Today as I’m writing this, I’ve just wrapped up a long shift where I spent a lot of time in direct patient care. We weren’t short-staffed, but tension was high and I could see standards starting to slip from overwhelm. I’m glad I did it, and I’m confident it was the correct choice of priorities. However, it got me thinking about a difficulty many new nurse leaders face: how much patient care should a nurse leader actually be doing?
As a staff nurse, this is a question you never have to ask because your job is direct patient care. You get an assignment, you take care of the patients, and you go home; rarely do you get much say in the matter. When you transition into leadership, suddenly you are granted more autonomy to choose how to spend your time. It’s not immediately obvious what your priorities should be.
Many of us have also had the unfortunate experience of working for a leader who refused to assist the team with patient care. You might self-consciously fear becoming that kind of leader. Maybe you sense an implicit expectation from your team that you should be helping when things get busy. These concerns are valid; you need the trust and respect of your team to lead well.
Unfortunately, role expectations aren’t always straightforward, either. Many entry-level leadership roles involve a mix of patient care and administrative work. Even if your role is purely administrative, there is an ever-present awareness that you are indeed a nurse and have the skills and credentials to help with patient care. The difficulty is that your role now includes accountability for longer-term outcomes, so you have to find a way to balance your administrative, oversight, and strategic responsibilities with your desire to be helpful in the day-to-day. Leadership introduces this choice, and with it, responsibility for consequences.
Why a thoughtful answer matters
You might think the answer to this is self-evident: “I’m smart and experienced, and I know my specialty. If I see the need to jump in, I’ll know when it’s time.” That’s true. You’ve worked hard to build competency and solid instincts, and you should definitely trust them. However, if you are new to leadership, you need to recognize that your clinical instincts might deceive you in your new context. To expand on those instincts, you’ll need to engage with the non-clinical tasks of your leadership role and learn the nuances of this new environment. One of those nuances is adjusting your time-horizon.
As a leader, you need to elevate your perspective beyond today. Consider what happens if the unit suffers from ineffective or absent leadership. Could you choose patient care every day if these same conditions continued for the next 30, 60, 90 days or longer? How might that impact patient safety and team performance over time? These additional layers make the answer less obvious, and shooting from the hip wont help you navigate that tension effectively. A few principles have helped me think through decisions to step away from administrative work and dust off my clinical skills when necessary.
Principle 1: Its always a tradeoff
Saying “yes” to one thing generally means saying “no” to something else, and deferring or neglecting responsibilities always has consequences. Helping with patient care can be necessary but it carries a cost: you will need to put off other important work for a time while you attend to patients. For example, today I needed to draft a training plan for a new staff member starting soon. I can only postpone that for so long before it impacts patient care through ineffective training. Much of a leader’s work is similar in that the costs only compound the longer you delay or avoid handling things up-front. So consider whether your choice to work the front line will enhance or erode your ability to lead effectively in the future.
Principle 2: A leader’s core responsibility is leadership
A pilot can probably fill in for the flight attendant, but the inverse isn’t necessarily true. I am not equating nurses to flight attendants; the point is that the fundamental nature of a pilot’s role is to fly the plane, not take care of the passengers. Your role is fundamentally different from your staff. You are the pilot, and the plane won’t fly itself.
As a new leader, beware of this pitfall: patient care represents your comfort zone. In a healthcare environment where resources are virtually always stretched thin, it can be tempting to use patient care as a convenient hiding place from uncomfortable aspects of your role. Many critical leadership functions don’t have the same level of immediacy that patient care does, so it’s easy to procrastinate them in the face of “urgent” clinical functions. It may be tempting to reschedule meetings, procrastinate your budget, and defer planning until tomorrow. However, some meetings are important conversations aimed at root-causes (such as coaching an underperforming team member), a rushed budget can under-resource your team, and ineffective planning fuels dysfunction. While you can “be a nurse” and fill in for your team, they can’t do the same for you. Understanding and accepting this reality should inform your priorities. Stressed-out staff might not always understand or appreciate this perspective, but that doesn’t change the landscape you’re in.
Principle 3: patient care is still the point
I became a nurse to help patients; that didn’t change when I transitioned to leadership. While the impact as a leader is more indirect, I still see my role as caring for patients. I have met and worked with some leaders who feel that they “did their time” in direct care, and have somehow earned their way out of such duties. I firmly disagree with that line of thinking; I am here to help the patients, regardless of my title or seniority. As leaders, we are responsible for the care delivered under our oversight, so sometimes the best contribution we can make is to participate in that care directly. Good reasons to step into patient care include when there is a clear threat to patient safety or a standard of care without your intervention. Another is identifying a critical skill or behavior issue with a team member and the need for hands-on coaching.
However, there are other situations where our direct involvement is not the best way to serve the patient. For example, if you’ve been away from the bedside or direct care for some time, your proficiency in certain areas may not be to the same level as some of your staff; could the patient(s) be better served by freeing up the person with the requisite skill set? Sometimes, your best contribution as the leader is to help install a more systematic process to handle future occurrences rather than simply react to the immediate problem. In some cases, taking on care as the leader robs your team of a valuable opportunity to build competency or resilience. In any case, consider what is the best (or safest) way to meet the patients’ needs with current resources, and accept that that might not always be the most visible way to help.
No easy answers
We’re wrestling with one of the difficult realities of being a leader: there are no right answers, only tensions and tradeoffs. Your core responsibility to lead strategically sits in tension with your accountability for delivery of care. The choices you make about providing direct care will always be some kind of transaction between these. Navigating that tension is the challenge of leadership.
Should you participate in patient care as a leader? Probably yes. Sometimes no. Definitely depends.
When, and how often? That’s up to you. It’s situational.
That doesn’t mean it’s a guessing game, just that you need to be armed with clear principles, sound priorities, and the courage to make a call and own the consequences.
I hope the principles I’ve shared here will help you decide intentionally and feel good about the choices you make.