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From our readers: Nurses leading from the middle


Nurse leaders are needed at all levels of the organization, especially in “the middle,” which is commonly used to describe mid-level management positions. Middle managers are essential to the organization because they link senior management and staff. Another important role that those in the middle perform is to interpret organizational strategy or the big picture in a manner that makes sense to the front-line staff.

The middle also includes leaders and emerging leaders in nonmanagerial positions. The middle also can refer to the spaces that exist between the service lines in the organization structure.

This article will discuss how leaders in the middle, whether they hold formal positions or not, implement effective organizational change. As stated by Porter O’Grady (2007), the leader lives in the space between action and potential, anticipating the next steps and translating the process for others.

Beyond organizational charts

Organizational charts define primary reporting relationships and the hierarchy of authority and accountability. The structure also determines which individuals get to participate in the decision-making process. However, much of the organization’s work gets done outside the boxes and lines of authority. According to Systems Theory, it is how the parts of the system interact that allows individuals and groups to achieve positive results when trying to implement change. The names in the boxes on the organizational chart represent the individuals who can access resources and remove barriers so change can occur. In other words, it is the leaders in organizational structures who are responsible for empowering others.

Most organizational change agents’ names are not found on organizational charts; it is the individuals closest to the work who know what change is needed and what change will work. An example is the development of the electronic health record (EHR). Changes to the EHR may have the chief nurse, medical, finance, and information officers involved, but it is really the staff who are the super users—doing the work and driving the change.

Another example of staff driven change is the implementation of bar code scanning for medication safety. Nurses know the work flow, so it should be the nurses who pilot and test the system. The organizational leaders need to remove the barriers and provide the resources to get the work done.

Power of shared governance

Shared governance structures support decision making at all levels, but even the shared governance organization charts do not demonstrate how the department’s work gets done. Governance structures need to be dynamic. In other words, the structures need to change to reflect the needs of the staff as well as the organization. It is in the spaces of the structure that committees and councils work together to improve care. Committee chairs have formal as well as informal conversations as the chairs remain accountable to the work that is within the scope of the committee’s charge. There is ongoing feedback and collaboration to close the loop on any changes implemented. There is a system of checks and balances in place.

An example of shared governance councils working together is the implementation of new clinical products. At our hospital, the Clinical Products Committee (CPC) evaluates, pilots, and approves product changes. The product conversion then moves to the Nursing Practice Council to address any practice and policy changes that are needed. Then the CPC chairs work with the Education Council and the vendor to provide the necessary information and training to staff.

In the background, the CPC chairs are driving the change through governance structure and communicating the plan out to the organization. Collaboration between the governance committees has been instrumental in empowering and demonstrates how nurses have the ability to move change through a complex system. In other words, staff should drive clinical excellence and the system’s infrastructure (governance structure) should be the system supported by management.

Professional practice

It is through the established structures and processes that staff are able to self-govern and participate in decisions that directly impact professional practice. Nurse staff satisfaction survey scores can demonstrate if structures and processes support nurses involved in leadership decisions and activities. The Practice Environment Scores (NDNQI Practice Environment Scales) represent that direct care nurses perceive their value within the organization as leaders.

For example, in our 2008, 2010, and 2012 NDNQI Nursing Satisfaction Survey results, Boston Children’s Hospital outperformed the mean scores to comparative academic organizations. These results also align with the philosophy that staff nurses and advanced practice nurses are clinical leaders.

Developing leaders

Managers should be leaders, but not all leaders have to be managers; there is nothing inherent in an organizational position that makes the person in a position a leader. There are abundant examples within organizations of nurse leaders in nonmanagerial roles. Staff nurses are perfect examples of nonmanager leaders. Staff nurses operationalize change at the point of care. Staff nurses as leaders is the foundation of professional advancement (clinical ladder), shared governance, and in the model of care.

Regardless of the nurse’s role, whether traditional or not, the question a leader must ask is how can one develop and encourage leadership at all levels. Leadership activities should be integrated into nursing job descriptions, performance evaluations, the professional model of care, professional advancement program, and philosophy. Also, during the hiring process, potential new hires should be assessed for leadership potential. Integrating leadership expectations into nursing foundational documents provide supportive evidence for the domains of Transformational Leadership, Structural Empowerment and Exemplary Professional Practice.

A nontraditional position

There are unique opportunities outside of the unit manager roles for nurses to practice in nontraditional roles. One such role is as project managers.
Project management is the discipline of planning, organizing, and managing resources to effect or bring about change. Nurses in this role work outside the normal nursing hierarchy and are change agents. Despite working outside the hierarchy, this role is able to integrate nursing and participate in interdisciplinary collaboration across the organization. This role provides a unique view of the organization; a horizontal vs. vertical perspective. Horizontal and collateral structural alignment is just as important as vertical integration when trying to implement change in an organization.

This mid-level role operates in the spaces that exist between the service lines and unit barriers (silos) and throughout all levels. Leading in these spaces is how the nursing organization gets connected and where influence and the work of change occurs. This project management role supports many activities and having a nurse in this type of role provides the clinical knowledge needed to access how changes will impact staff nurses as well as patients.
This role is nimble and can change based on organizational needs. This role can provide decision support, collect and analyze data, provide recommendations, manage and oversee organized projects as well as serve as a nursing resource and provide appropriate consultation to other departments. It is a role that can be delegated to take on many departmental activities; freeing up an executive’s time. This role can be key in assisting nurses from all levels in navigating the system by providing keys or access to other areas of the organization.

Role of change agents

Change agents such as project managers are effective and efficient if allowed the autonomy to implement and move change through an organization. Change demands that individuals outside senior management operate outside of the normal hierarchy. Nurses in nontraditional roles need to develope and maintain relationships as well as actively build social capital to be effective. Nurses working outside the normal hierarchy have many responsibilities and in most incidences have no direct authority over others who are relied upon to get the work done. Mastering communication is one way those in the middle gain mastery of influencing all levels of the organization. Through communication, the project manager develops informal as well as formal networking channels. These channels allow individuals to leverage expertise across the department as they gather and synthesize information.

Nurses in nontraditional roles demonstrate transformational leadership skills as they are able to move work through the system by maximizing structures and processes driving excellence in the organization. Nontraditional roles exemplify how nurses work autonomously to drive change as well as provide evidence how nurses can help drive innovations leading to more effective and efficient patient care.

Getting the work done

Nurse leaders must understand the essential characteristics and realities of creating structures to facilitate and drive change in an organization. To clarify, we are not discounting the importance of organizational structures but want to emphasize that much of the work of change gets done outside the usual lines of authority. Nurses can and do drive change and build extraordinary teams. Nurses in nontraditional roles can help organizational leaders cut through the noise because they are able to see things that others are not due to their horizontal integration into the organization. Some of the best leaders in an organization may be managing and leading change between the spaces and from the middle. The information provided demonstrates a professional practice environment congruent with Magnet criteria.

Lynne Hancock is project manager, patient care operations at Boston Children’s Hospital, and Diane Hanley is the associate chief nursing officer for professional practice, quality, and education for Hallmark Health System.

From our readers gives nurses the opportunity to share experiences that would be helpful to their nurse colleagues. Because of this format, the stories have been minimally edited. If you would like to submit an article for From our readers, click here.

Selected references

American Nurses Credentialing Center, Application Manual, Magnet Recognition Program, Silver Springs, MD: American Nurses Credentialing Center. 2008; p 24, 26, 28-29, & 32.

Kotter J. Leading change: why transformation efforts fail. Harvard Business Review Reprint. March-April 1995; 59-67.

Moore S, Hutchison S. Developing leaders at every level: accountability and empowerment actualized through shared governance. J Nurs Adm. 2007;37(12):564-568.

Pappas J, Flaherty K, Wooldridge B. Tapping into hospital champions–strategic middle managers. Health Care Manage Rev. 2004;29(1):8-16.

Porter O’Grady T, Malloch T. Quantum leadership: A resource for health care innovation. Sudbury, MA: Jones & Bartlett Publishers. 2007; p. 67

Stanley D. Role conflict: leaders and managers. Nursing Manage. 2009;13(5):31-37.

Schaffer R, Thomson H. Successful Change Programs begin with results. Harvard Business Review Reprint. January-February 1992; 80-89.

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