NURS 721 Week 1 Discussion Board Forum 1 on Level Three Leadership Example

Discussion Board Forum 1: Leading Below the Surface

NURS 721 Leadership, Policy and Ethics, Discussion Board Forum 1

Thread by [Student Name]

The hospital, the units and the classmates replied to are composites written for a model discussion.

Two years ago my four medical-surgical units introduced bedside shift report. We trained every nurse, posted a script at each nurses' station, and the managers audited ten handoffs a week. Compliance reached 80% within a month. Six months later it had fallen below 30%, and nurses were again giving report at the station before walking past the patients' doors. Last year we tried again with a new script, a laminated badge card and recognition for the unit with the highest audit scores. The result was the same, only faster. Reading Clawson this week, I finally understood why.

Clawson (2012) describes three levels at which leaders can influence people. Level One is visible behavior, what people do and say. Level Two is conscious thought, the reasoning people can explain. Level Three lies beneath both: the values, assumptions, beliefs and expectations, which Clawson calls VABEs, that people hold, often without stating them, and that drive their thoughts and behavior. Leaders who work only at Level One can produce compliance while they are watching, but lasting change requires engaging people at Level Three. Both of our rollouts were pure Level One. We changed the script and counted the behavior. We never asked what nurses believed report was for.

When I finally asked, in a series of small conversations with night and day nurses, four beliefs surfaced. Report is for nurses, a protected time to speak frankly about patients and families. Patients will hear things that frighten them or that they should not hear. Bedside report takes longer, and the off-going nurse is already late. And, most revealing, "management cares about the audit, not about us." None of these appeared in our training, and our audits reinforced the last one. We had tried to change what nurses did at the bedside without ever learning what they believed about the conversation.

The evidence suggests that how leaders engage matters for outcomes. A systematic review of 12 reviews covering 85 outcomes found that relational leadership styles, transformational leadership above all, were the most studied and were linked to beneficial staff outcomes, especially job satisfaction, while patient outcomes were less often measured (Hult et al., 2023). Another review of 23 studies found that transformational leadership affected nurses' work environment through mediators such as structural empowerment and commitment, and that nurses did not perceive their managers' transformational behavior as excellent in any included organization (Ystaas et al., 2023). Our rollouts used none of the relational behaviors these reviews describe. We announced, trained and audited, but we did not empower the councils, invite nurses to shape the script or share the reasons behind the change in terms that mattered to them.

For the third attempt, I plan to begin at Level Three. Each unit's practice council will hold conversations about what report is for, using the nurses' own concerns as the agenda. We will agree on what can be said at the bedside and what will be shared away from it, address the time concern by measuring it, and replace punitive audits with peer observation. Jesus taught that a good person brings good things out of the good treasure of the heart (English Standard Version Bible, 2001/2016, Luke 6:45). Behavior flows from what lies beneath it, which is as true of a nursing unit as of a person.

Reply to Angela

Angela, you described servant leadership as the style you most want to practice as a new manager, because it puts the needs of staff first. Your instinct has support. A 2026 meta-analysis of 57 studies found a moderate positive relationship between leadership and nurses' job satisfaction, with an overall effect of 0.39, and transformational and authentic leadership showed the strongest positive correlations, while toxic and task-oriented styles were negatively associated with satisfaction (Ozen & Kantek, 2026). Servant leadership belongs to the same relational family. Clawson (2012) would push your thinking one step further, though. Serving staff well requires knowing what they value and expect, which is Level Three work, and good intentions at Level One can misfire if they rest on a manager's assumptions about what staff need. On my units, we assumed nurses wanted recognition for high audit scores; they wanted to be asked. One practical approach is to begin each new manager role with individual conversations, asking every nurse what makes a shift go well and what gets in the way, before changing anything. How do you plan to learn what your staff actually value before deciding how to serve them?

Reply to Marcus

Marcus, your story about a manager who posted error rates by nurse name on the break room wall was difficult to read. It also illustrates what happens when leadership damages Level Three beliefs. A systematic review of 16 studies identified 31 outcomes of toxic leadership in nursing, grouped into five themes: satisfaction with work, relationship with the organization, psychological state and well-being, productivity and performance, and patient safety outcomes (Labrague, 2023). The review called the evidence modest, but the direction is consistent: when leaders humiliate staff, nurses learn to hide errors rather than report them. Clawson (2012) would say the manager changed staff beliefs about whether it is safe to be honest, and that belief will outlast the manager. Rebuilding that belief takes more than a new manager. Leaders have to show, repeatedly and visibly, that honesty is safe, for example by openly discussing their own mistakes at staff meetings and responding to reported errors by fixing systems rather than blaming people. I wonder whether your unit has since tried anything of that kind, and whether reporting has recovered.

References

Clawson, J. G. (2012). Level three leadership: Getting below the surface (5th ed.). Pearson.

English Standard Version Bible. (2016). Crossway. (Original work published 2001)

Hult, M., Terkamo-Moisio, A., Kaakinen, P., Karki, S., Nurmeksela, A., Palonen, M., Peltonen, L. M., & Häggman-Laitila, A. (2023). Relationships between nursing leadership and organizational, staff and patient outcomes: A systematic review of reviews. Nursing Open, 10(9), 5920-5936. https://doi.org/10.1002/nop2.1876

Labrague, L. J. (2023). Toxic leadership and its relationship with outcomes on the nursing workforce and patient safety: A systematic review. Leadership in Health Services. Advance online publication. https://doi.org/10.1108/LHS-06-2023-0047

Ozen, T. A., & Kantek, F. (2026). Relationship between leadership and job satisfaction in nurses: A meta-analysis and moderator analysis. BMC Nursing. Advance online publication. https://doi.org/10.1186/s12912-025-04174-7

Ystaas, L. M. K., Nikitara, M., Ghobrial, S., Latzourakis, E., Polychronis, G., & Constantinou, C. S. (2023). The impact of transformational leadership in the nursing work environment and patients' outcomes: A systematic review. Nursing Reports, 13(3), 1271-1290. https://doi.org/10.3390/nursrep13030108