Authority Without Rank: What a Nurse Taught Me About Leading

The best leader I have watched held no position that required anyone to follow her. She was a nurse. People followed her anyway, and the reason has stayed with me for most of my career.

Issue 027 of this publication described the death that started the prenatal program in Los Toros: a woman lost in 2009 to pre-eclampsia that became HELLP syndrome, and a community leader, related to her, who said enough. We will look after our own. That essay mentioned, in a single line, a nurse practitioner who had come through the Los Toros Foundation the year before and was present in some capacity when it happened. This essay is about her. I will not name her. She would not want the essay to be about her, which is part of the point.

The Obvious Move

I was connected to the Foundation's work at the time, but I was not yet part of the program, and I was not in Los Toros when the woman died. As I understand it, she was.

Look at who was in that community afterward. A family grieving a mother. A community leader who had just declared that the community would solve this itself. Health promoters who knew every household but had no clinical training. And one outside clinician, a nurse practitioner, who understood pre-eclampsia, HELLP syndrome, screening and referral better than anyone in that place.

The obvious move, the one most of us are trained to make, was for her to take charge. She had the expertise. She knew what a prenatal screening program needed to look like. She could have designed it, staffed it, and run it, and it would probably have been a competent program.

She did not do that. When the community leader said the community would look after its own, she took him at his word. She followed his lead. Her knowledge went into the program as support for a decision the community had made, not as the decision itself. Issue 027 described what came of that: a program led by promotoras, community health workers who lived in Los Toros and were trusted there in ways no outsider could be.

She never told me why. Nothing she said is what I carry. What I carry is what she did.

Authority Is Not Leadership

The distinction she lived out has a formal name. Ronald Heifetz, in Leadership Without Easy Answers (1994), separates authority from leadership. Authority is conferred: by a title, an institution, a credential, a role that gives you the power to direct others and the expectation that you will. Leadership is the work of helping a group face a problem it has to solve itself, and it can be exercised with authority or entirely without it.

The prenatal program in Los Toros was exactly that kind of problem. The community could not have a solution handed to it. It had to own the screening, the referrals and the trust, or none of it would last past the next visiting team. The nurse practitioner understood that her expertise gave her authority in that room, and that using it the obvious way would have undercut the very thing the community was trying to build.

Her authority came from somewhere else: from being present, from staying, and from making it unmistakable that the program belonged to the people who would carry it.

Issue 026 of this publication argued that community-based participatory research is a claim about who has standing to decide, not a gentler way of running a study. What she did in Los Toros was the same claim made in practice, before anyone had given me the vocabulary for it. Standing to decide belonged to the community. Her expertise belonged in service of that decision.

The cost of the obvious move would not have shown up at once. A program designed and run by a capable outsider can look excellent for years. It fails when the outsider leaves, because nothing in it was ever anyone else's. The community would have been the recipient of a good program rather than the owner of one, and the difference would have surfaced only after she was gone.

Where Medicine Goes Wrong

Medicine confuses expertise with leadership.

We promote people to lead because they are the best clinicians. The strongest resident becomes chief resident. The most productive researcher becomes division chief. The physician with the deepest knowledge runs the team. The assumption underneath is that knowing the most and leading well are the same capacity.

They are not. Expertise answers the question of what should be done. Leadership answers a different question: who has to do it, who has to own it, and what they need in order to do so. A clinician who mistakes the first question for the second will tend to solve problems for people that only those people can solve.

Nursing, at its best, keeps the two apart. Charge nurses and nurse leaders lead units where the work is done by many hands, and where the outcome depends on what happens when the leader is not in the room. That forces the distinction. You cannot lead a twelve-hour shift by being the most knowledgeable person on it. You lead it by knowing who carries what and making sure they can carry it.

The nurse practitioner in Los Toros brought that understanding to a community. She knew more than anyone there about the clinical problem. She also knew that her knowing more was not the same as the community owning the answer.

Who Leads in a Room

I run a residency program now. I hold real authority: I evaluate residents, shape their schedules, and sign off on whether they are ready to practice on their own. It would be easy to mistake that authority for leadership.

What I took from her is a habit of looking at a room differently. When I walk into a team meeting, a clinic huddle or a bedside, I try to see who the room actually follows. Not who holds the title. Who people look at when a decision is hard. Who the nurses check with before they page anyone. Who the residents trust when they are frightened.

Often it is not the person with the most authority. Often it is someone who has been present longest, knows the people best, and has made it clear that the work belongs to the people doing it.

When that person is not me, the right response is usually not to reassert the title. It is to do what she did in Los Toros: recognize where the leadership in the room actually is, and put whatever expertise I have behind it.

That is harder than taking charge. Taking charge is what training rewards. Following well, when you are the most qualified person present, is what she showed me leadership requires.

About the author

Peter Schindler, MD, PhD is an Assistant Professor of Medicine and Associate Program Director of the Community Health Center Family Medicine Residency Program at the University of Nebraska Medical Center. He practices at Winnebago Comprehensive Health System, OneWorld Community Health Center, and Nebraska Medicine. He completed a Primary Care Research Fellowship at McGill University and holds a BSN from the University of Wisconsin-Oshkosh, an MS and PhD in nursing from Emory University's Laney Graduate School, a Diploma in Tropical Medicine from the Liverpool School of Tropical Medicine, and an MD from the Medical College of Wisconsin-Green Bay. He is board certified by the American Board of Family Medicine. The Interprofessional publishes new essays every week at the intersection of medicine, nursing, and the clinical knowledge that lives between them.

Disclaimer. The views in The Interprofessional are Peter Schindler's own and do not represent the official positions of the University of Nebraska Medical Center, Winnebago Comprehensive Health System, OneWorld Community Health Center, Nebraska Medicine, or any other affiliated institution.