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The Ambivalent Leader: Reporting to the Lion or the Lamb
Julie has been the executive director of Maternal-Newborn Service for 5 years and
reports to a chief nursing officer (CNO). There are four other executive directors of service-
lines—Tim who is the executive director of Medical Surgical Services; Janice who is the
executive director of Critical and Emergency Services; Fred who is the executive director of
Surgical Services; and Gabriella who is the executive director of Rehabilitation and Out-Patient
Services. All of the executive directors with the exception of one are about the same age in their
mid- to late 30s or early 40s, educated with a Master’s in Nursing (MSN) level (except for Julie
who has a PhD in Nursing Leadership), and have significant clinical experience in their service-
line areas. Janice is in her late 20s, has a Master’s in Business Administration (MBA), and is also
quite experienced in critical care services.
The five executive directors work well together as a team, but do not respect the opinion,
direction, and leadership of the CNO who has been in her position for 30 years. The team
perceives her to be out of date, although the physicians at the hospital are quite supportive of her.
They often meet to determine ways they can work around her to accomplish their individual and
collective goals. The CNO reports to the CEO along with the chief financial officer (CFO) and
the chief operations officer (COO). The CNO, CEO, CFO, and COO have all worked together
for approximately 7 years. The rest of the executive team has little interaction with the executive
directors with the exception of the budget season when the executive directors work closely with
the CFO and COO to develop and negotiate the budgets and approved number of full-time
equivalents (FTEs) for each clinical area.
One summer, Julie goes on vacation, and while away, she receives a call from Gabriella
who informs her that huge changes have taken place. The president of the healthcare system has
terminated the CEO, and the CNO and has hired a new CEO. The new CEO was a CFO and
COO in his previous employment, but had no experience as a CEO. He has a Master’s Degree in
The reporting structure has also been changed. All of the executive directors, the CFO
and COO will all now report directly to the new CEO. There will not be a designated CNO since
all of the executive directors will fill that role. The new changes will take place immediately. The
communication to the organization and the public indicates, “Changes were needed to position
the organization for growth in current and future service-lines and expansion into new markets.
The CEO and CNO have decided to pursue other career opportunities.”
At first Julie is very impressed with the new CEO who is young, enthusiastic, and very
financially savvy. He meets with the executive team every Monday morning to review the
previous week’s performance in each service-line and to share plans for the upcoming week. He
meets with each of his direct reports once per month and reviews the budget, productivity,
patient outcome indicators, and satisfaction levels of staff and physicians. Julie seems to
appreciate the direct communication style of the new CEO.
After a few months, Julie detects a change. As budget constraints become more apparent,
the executive team is requested to tighten the belt. The proposed budget for the next year must be
cut 10% across the board, and the capital budget requests become very competitive. Although
Julie’s area has the greatest percentage of admissions and discharges as compared to the other
service areas, the reimbursement rates for her patients are significantly less than that of patients
in her colleague’s service areas. The way contracts have been negotiated for Medicaid and
Medicare patients, Julie’s areas actually loss money—the cost to provide the services for 48% of
the patients is more than the reimbursement rate. When this issue is discussed week after week at
the Monday report, Julie begins to see a change in the group dynamics among her colleagues.
Janice is emerging as the most powerful of the executive directors, and her areas contribute the
most to the revenue picture for the hospital. Janice often “hangs out” with the CEO and the two
of them meet daily at the end of the day. The other executive directors notice the change as well,
but no one feels it as much as Julie.
Julie never knows what to expect from the CEO. At one meeting he can be very kind and
supportive, but at the next meeting, he can be accusatory, belittling, and angry that her areas are
losing money—not because of productivity, but because of the revenue levels. He demands that
she decrease staffing levels to cut expenses, and Julie tries to explain that doing so would put the
areas out of compliance with required nurse-to-patient ratios. This rationale is not received well,
and more pressure is placed on Julie to reduce staffing expenses. The CEO wants her to change
the staff mix, use fewer RNs and add more nursing assistants to cut expenses. Some of the
meetings are brutal, and Julie often leaves feeling “beaten” and humiliated.
Julie feels so upset with the CEO, but after a few hours of reflective thinking after
meetings with the CEO, she blames herself thinking she should be more prepared, better able to
articulate the area’s needs, and better capable of managing the CEOs aggressive nature. She
dreaded meeting with him, but then when the next meeting came, he could either be absolutely
supportive and understanding or absolutely unsupportive and aggressive. She never knew what
to expect. When she spoke with her colleagues about their relationship with the CEO, they all
expressed that he was fine with them. She also met with the CFO to discuss her areas’ revenue,
expenses and productivity levels. The CFO is helpful and explains that the biggest problem is the
way the contracts have been negotiated and that the revenue level is not in Julie’s control. He
indicated that the hospital decided to negotiate a low rate for maternity and newborn services in
order to get a higher rate for critical care patients.
The situation began to escalate for Julie beyond the one-on-one meetings with the CEO.
He began to attack and belittle her in the Monday meetings in front of her peers, laugh at
comments she would make on any subject, and make a point of reminding her peers that Julie’s
areas were revenue losers. At one meeting, the CEO distributed an article that he liked from the
Harvard Business Review, but he did not give one to Julie. When she asked if he had another
copy for her, he answered, “What, little Miss PhD, I assumed you’d already know all about this.”
Her peers said nothing, but Julie noticed that they simply hung their heads, except for Janice who
was chuckling with her hand over her mouth.
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Julie, at wit’s end, finally confided to Gabriella that she was considering leaving the
organization. She felt absolutely defeated and could never predict what to expect from the CEO.
Gabriella listened carefully and then said, “Julie don’t you see what is going on here. You are the
classic abused woman. The CEO beats you up and you go away blaming yourself and promising
to be better. He then feels guilty and treats you better the next time, but the cycle continues over
and over. Now he is becoming more aggressive and humiliating to you in public. You have a
choice. You can leave, but you will never see this issue to closure and it might affect your work
in the future . . .or you can choose to break the cycle.”
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