Practicing to the Top of Your License- Avoiding Elitism

Recently, I had an encounter with the family of the patient. Several family members were in the medical field and unfortunately, they were not happy with the care their loved one was receiving. They felt like the nurses were too slow and they had to wait for the nurses to get orders for over the counter medications. I explained that every medication we give, even if it is over the counter, requires a physician order. They responded by asking why the RNs weren’t practicing to the top of their licenses. I thought this was an interesting question and sought to examine the practice of my nursing staff. First, though, is to define it.

Practicing to the top of a license is a term we hear often now. What does it mean exactly? There are several definitions. Katherine Virkstis of the Advisory Board defines practicing at the top of a license as practicing to the full extent of one’s education and training. She goes on to say that nurses should not spend their time doing something that someone else can do effectively. Does this definition give RNs permission to refuse to do patient care tasks that they consider menial such as taking vital signs or giving a bath? As a nurse leader, I sometimes witness staff “delegating” tasks they consider to be beneath them. Nurses define for themselves which tasks are menial and which are not. Those “menial” tasks are important opportunities for assessment and developing caring relationships with patients.

In an article related to physician’s practicing at the tops to their license, Jennifer Adaeze Okwerekwu, describes the challenges of physicians who find themselves doing non-medical care rather than direct patient care. Okwerekwu states “As a doctor, I’m training to be at the top of the hierarchy….”. Once again, we are looking at differences in levels of practice as hierarchical and elitist rather than complimentary.

Another definition of practicing to the top of one’s license by Stephanie Allen is minimizing non-value-added (NVA) work which are tasks that do not “directly benefit the patient and are not necessary to delivering care”. She lists some of the NVA work as looking for equipment, waiting for phone calls and similar tasks. There are other non-licensed support staff that can answer the phone and look for equipment. I prefer Allen’s definition of practicing to the top of one’s license because it emphasizes value-added work, focuses on the patient, and doesn’t feel elitist. It is important to recognize that each member of the team has an important role that is essential to the care of the patient. Allen recommends several strategies to promote value added work in nursing which include reviewing nursing scopes of practice to ensure we aren’t inhibiting nurses from top of license work. Many times, tradition and ritual define our practice rather than actual scopes of practice.

When looking at nursing practice, it is important to make sure that we are maximizing our time doing patient care and building relationships with patients. It is also important to be sure that we are sensitive to the all the members of the care team and value everyone’s contribution rather than promoting an elitist stance.


Are You a Good Collaborator?

One thing that drives me crazy, in the realm of leadership, who are leaders who are part of a team, yet they refuse to behave as a team-mate or collaborate. These types of leaders live in relative isolation, make decisions independent of stake holders (and yes, team mates are stake holders), and demonstrate a lack of respect for others. They readily blame others for errors, yet hold themselves blameless. They dismiss the ideas of other team members because they feel others are inferior in ability and intellect. Sound familiar? We’ve all probably worked with people like this at some point in our careers.  So what makes a good collaborator?

Good collaborators are those who are able to build relationships with other team members through trust and the demonstration of success. They seek to build up the team and recognize each member’s strength and potential for contribution. It doesn’t matter what industry you are in- the ability to be a good collaborator is essential to the growth and success of your business, partnership, or department.  Here are some traits of a good collaborator. Is this you? Can you foster these traits in your employees?

  1. Positive attitude and openness to new ideas. Good collaborators have a genuinely positive outlook and are intrigued by new ideas. New ideas and fresh perspectives offer the potential for growth and innovation.
  2. Emotional Regulation. It is important for a leader or team member to be self-aware and control negative emotions. They must be able to stay calm, deal with difficult situations and manage to maintain good body language and facial expressions. This can be a difficult skill for those of us have particularly expressive faces, but with practice, this skill can be mastered.
  3. Humor. Humor is absolutely essential for a good collaborator. Humor can relax a tense situation, put others at ease and stimulates closeness between team members.
  4. Focus. Keeping focused on the task and on goals helps the rest of the team feel confident. Other benefits of focus include not wasting time and meeting deadlines, which also makes the team feel better about their work.
  5. Allow skepticism and dissention. Although they are sometimes difficult to listen to, dissenters and skeptics point pit-falls and issues that others might miss. However, if you are a skeptic, a dissenter or otherwise negative, you run the risk of being ignored or booted from the group, so choose carefully when you feel compelled to make a negative comment.

In order to be a great leader, you have to be a great collaborator. You also have to foster the collaboration skill in your team but building trust and relationships with them.


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Walk the Talk

This week, one of our nursing units was short staffed due to sick calls. The manager was asked to fill in as a staff member. I was shocked when the reply was “I can’t take patients because I haven’t been oriented to the unit.” This person has been the manager for over a year. Seriously, if you manage a group of people, get oriented and be prepared to step in and help. Your staff will appreciate it and remember that you helped. You will have instant credibility and gain the respect of your group. If you don’t, you will struggle with leadership and staff engagement. Get oriented! Be engaged in what your staff does everyday. Use this time to build relationships and demonstrate your empathy as well as your competence.

Motivation: Transcending Tragedy in the Workplace

I had a boss once who became annoyed with a perceived complacency about me and my staff. However, he had not communicated his expectations and by the time he did, he was so frustrated he directed me to discipline all my staff members and also threatened to fire me. His expectations were a high level of performance on some particular metrics. He gave us one month to improve our process metrics by 5% and maintain/increase them over the next few months in order to ultimately achieve 100% compliance. Process metrics that depend upon humans are almost impossible to achieve 100% compliance. Humans are fallible and make mistakes despite any process engineering. Therefore, achieving his expectations were very difficult. I refused to discipline my staff and negotiated with my boss to let me manage this issue my way (now that I was clear on his expectations), unless he had a better person in mind for the job. He was never a person to have a plan B, so he agreed. It is important to note that this was a highly public situation within the workplace. My boss told the board of trustees that we would be fired if we were not successful and our board was supportive of this action. The other employees were angry and accused my boss of fear-mongering and bullying. Our workplace had suddenly become a highly punitive environment.

Two weeks after we started working on this process a tragedy occurred in our workplace. An employee who had been terminated entered the building with firearms and open fired. The disgruntled employee shot at me and two others of my staff while we tried to assist an injured co-worker. The shooter and one other person were killed, one was severely injured and everyone else was highly traumatized. After the initial few days after the incident, my people starting asking questions about our project and deadline which was only 2 weeks way. Was this still a mandate? Would we still all get fired if we were not successful? As a leader, this was pivotal moment in my career. The decision I made would impact my career, my staffs’ careers, and their trust in me as a leader. Should I risk discussing the timeline with my boss? Should we just march on? These were all questions swirling around in my head along with a lot of anger and fear over the shooter situation.

My decision was to carry on. I felt it was important to give my people something to focus on rather than become paralyzed by all the emotions that we were all feeling. This was a risky decision. What if it was too much them? What if we failed? The truth is, we didn’t fail. We didn’t miss a single thing. We met our goal and exceeded it despite everything else. In the end, my staff gained a great sense of confidence and pride in their work. They became highly cohesive and gained a deep trust and respect for each other and for me.

This situation was probably the most poignant moment in my career to date and I learned several valuable lessons.

My boss was unreasonable, but he had the right as the CEO of the company to mandate performance. It took me a long time to reconcile that one.

Almost excellent isn’t good enough. This was my first appointment as an executive and my boss was not a good communicator. Never think that just because your boss doesn’t say anything to you about your performance, he is happy with it. Ask questions and over communicate. It is incumbent on you to make sure you know the expectations

Once you destroy the trust of your employees, you will never get it back. I worked very well with my boss for another few years, but I never trusted him again.

In a crisis situation, people need something to do and something to focus on in order to diminish their anxiety. In the end my people benefited from the confidence they gained by achieving goals in the midst of a huge tragedy. At that point it wasn’t about meeting our goal; it was about helping my staff get through a tough time.

It’s been 6 years since that awful day. That CEO eventually moved on to another organization as most CEOs do. The organization has moved on from the tragedy, but never really was able to regain the perception of a non-punitive environment.

My hope in sharing this story is that someone can learn from my experience. I replay this scenario often, still and always come away one more pearl I didn’t have before. Thanks for reading.

Women Who Travel Alone: A Reading List


My friend Mish is hiking the Appalachian Trail by herself. She hiked the northern portion first, and now she’s almost in Georgia. She’ll be home soon. In celebration, here are six stories about women who travel alone.

1. “A Little Honesty … On Safety and Solo Female Travel.” (Shannon O’Donnell, A Little Adrift, June 2013)

“I believe I have the right to travel, that despite criticism and skepticism that I can and should be on the road as a solo woman, that there are ways to travel with safety in mind. And even in the face of tragedies, I will encourage other women to travel, be that solo, with friends, or in a couple.”

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A Year With Nobel Peace Prize Recipient Malala Yousafzai


In one of our conversations, Malala told me that she once went to the theatre — a show called Tom, Dick and Harry in Islamabad — and loved it, so I got tickets for Hamlet at the Royal Shakespeare Theatre.

As it starts, she is wide-eyed. She jumps at the gunshot as the ghost of Hamlet’s father appears, and I hope it doesn’t trigger anything. A long and violent Shakespeare play may not have been the perfect choice — more than three hours is a lot for anyone to sit through, and both Malala and my son fell asleep. But they woke for the swordfight at the end.

Afterwards, she says she loved it. “I think it’s a good lesson,” she says. “Hamlet does to Laertes [killing his father] the same as what happened to him and it gets him nowhere. I don’t seek vengeance against those who tried to…

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Trust but Verify

Have you ever heard the phrase “Trust but Verify?”  Practicing this is essential to successful leadership, particularly if you are a new executive or manager. We all wish to have excellent employees who do everything right, who are totally engaged, who are avid team players, and who have a strong desire to achieve excellence. The truth is that about 10 percent of your employees will meet these criteria. Ten percent will be disengaged and the other 80 percent will be somewhere in the middle. You most likely can trust the majority of your employees to do adequate work. However, the bottom line is that you are ultimately responsible for the work they produce, particularly if that work supports outcomes that you are held accountable for. Your boss will find it unacceptable if you have errors in your work and blaming it on your employees’ lack of detail is equally as unacceptable. Here is an example from my own work. As a new executive I was just learning all the metrics I was responsible to achieve and I was dependent upon my director of quality to calculate and report these metrics to me. In turn, I reported them to my boss and also to our board of trustees. During this time I was just learning my role and I assumed (we all know what that means) that my quality director was detail oriented, totally engaged and team player. I took her report and presented at our board of director’s meeting. The board chairperson proceeded to point out every math error, every spelling error and every decimal that was out place. Not only did I look like an idiot, but so did my boss, the CEO of our organization. It was a tough experience, but from that I learned a valuable lesson that will be with me always.

So, how do you ‘trust but verify” without micromanaging and decreasing the morale of your employees?

1. Make your expectations clear- In detail, discuss what it is your want your employee to produce and exactly how you want it formatted. Make sure you are systematic in your approach so you don’t confuse your employee. Once you set your expectations, be consistent. It is impossible for employee to meet your expectations and produce a product that you can verify if the expectations are constantly changing.

2. Provide the right tools- Make sure your staff have the right tools to complete the job your asking them to do. If they need education or help, provide it.

3. Get feedback- Engage your employees and get their feedback on the tasks you give them. Use their good ideas to improve your product, report, or whatever the result is. Avoid making command decisions about their workflow. Be collaborative.

3. Sometimes you do have to micromanage- In order to hold someone accountable for accurate work, you will have to review  their work in detail, find the errors, point them out, and ask your employee to fix them. This is especially important if the employee is not detail oriented and has a history of error prone work.

4.  Make your sure play to your employee’s strengths- Do not give your big picture employee, detailed tasks to do. Do not ask a detailed person to produce big picture results.

Once you have provided all the tools and education, worked collaboratively with your staff and verify their work in detail. Over time, more trust and less verification will be required. That said, never forget that you are ultimately responsible and accountable for the work you delegate to your staff. It’s OK to make sure it is correct every time.

Welcome to the Women that Lead blog

Recently, I had a conversation with my daughter about women in leadership positions. She remarked how it was interesting that when she mentioned that our family had moved around a lot, people always asked two questions: “Is it for your dad’s job?” or “Are you a military family?” She found it interesting that people always assumed it was the male in the family that determined where we lived. It never occurred to people that perhaps the mother was the executive or maybe we all just had a wander-lust and moved around a lot. Both of these are true. 
This blog is dedicated to all the women in management and business that are working hard to advance their careers in a male dominated environment where the double standard still exists. It is my wish to pass on experiences, advice, and resources that I wish someone would have shared with me early in my career.