No One Should Carry 24/7 Accountability Alone

Lori Gunther and Nancy Travis came to our Belonging and Retention season to talk about one line. It appears in many nurse leader job descriptions, and it reads like an ordinary expectation: 24/7 accountability.

By the time we finished, it no longer sounded ordinary.

What 24/7 really costs

Lori is partner and CEO of Synova Associates, which works with nurse leaders in women's and children's health. She told me about a nurse leader she met during the pandemic. After 25 years with her organization, she had a new boss who made it clear she was accountable around the clock and could not leave town. She was wearing a heart monitor at the time, and it showed her heart going into an irregular rhythm during her one-on-ones with that boss. She eventually left for another job. Three years later, she still cannot submit a request for a day off without that fear returning.

Nancy has been a nurse for more than 40 years and a leader since the 1980s. She described the role as "monkey in the middle." Nurse leaders are told they cannot add a nurse to make an assignment safe because the budget won't allow it, then blamed when outcomes slip. Most absorb that stress themselves rather than pass it to their teams, because they know their nurses would leave.

Nancy is now teaching the next generation to push back. A nurse recently applying for her first manager role told Nancy she had been informed she must be available nights, weekends and holidays. Nancy's answer: "No, you don't." They talked through how to set boundaries before she ever started.

The scale makes it harder. Lori shared that the 220 nurse leaders attending one of Synova's events oversee more than 17,000 direct reports between them, and that a nurse manager averages around 46 direct reports.

Lori said it plainly: "It is absolutely unacceptable that we put that level of pressure and accountability on one person." When people tell her the 24/7 language isn't really meant literally, she answers that this is how it reads. And bedside nurses read it too. They look at their manager's life and decide they don't want that job.

Accountability without support becomes isolation

Accountability matters. No one is arguing that nurse leaders shouldn't own outcomes. The problem is accountability with no limits and no shared ownership. When one person is responsible for everything, all the time, the role stops being leadership and becomes endurance.

And yet nurse leaders stay. Lori surveyed the more than 8,000 nurse leaders in her network about what keeps them in leadership. About 65 percent said it was their team. Not pay, not their boss. Their people.

Lori also shared a moment from Synova's leadership program that stayed with me. Each participant fills out a mentor map. One leader with more than 25 years of experience couldn't name a single mentor. She had mentored countless others, but no one had invested in her.

Lead a team the way a nurse reads a room

Raelene Brooks, dean of the College of Nursing at the University of Phoenix, offered a model for what better looks like. She believes a leader should read a team the way a nurse reads a patient's room on entering it. She makes a point of asking quiet, analytical people for their thoughts. She has nurses journey-map a pharmacist's day, from the moment an order is entered, so they understand why a medication runs late instead of assigning blame. And she shows up consistently, so her team always knows what to expect.

When accreditors interviewed her leadership, alumni and faculty about working with her, the words that came back were empathy, caring, receptive and open. As Raelene put it, "You can't get a team of people to engage unless they feel like they're being heard, their thoughts are being understood and they are adding value to the work they're doing."

Three simple asks

Lori and Nancy's asks of the C-suite were simple, and that is what made them powerful:

• Round on your leaders. Executives round on patients and units. Do the same for the nurse leaders holding those units together, and make it safe for them to tell you the truth.
• Recognize good work. As Nancy said, if your leaders are getting recognized more outside your organization than inside it, there's a problem.
• Listen. Executives know the metrics. Ask why the metrics look the way they do.

None of these require a new budget line. All of them require attention. Lori practices what she preaches. Every Wednesday she spends hours holding babies in a NICU, simply to listen and learn from the people at the bedside.

You can watch On Call 24/7: The Accountability Nurse Leaders Carry with Lori and Nancy, and Transforming Nursing Leadership with Raelene, in the Belonging and Retention season.

Healthcare will not keep its nurse leaders by asking them to be more resilient. It will keep them by making sure they never carry the weight alone.

Want to explore these ideas further? Learn more about my work on leadership, identity and conviction at www.theglennllopis.com.