Deviating in white: Rebel nurse leadership in the nursing practice

Abstract

Nurses are frequently confronted with situations in which they must deviate from organizational rules and regulations when these rules do not align with their professional standards and beliefs concerning delivering high-quality healthcare. Nurses exhibit leadership qualities by taking actions in suboptimal conditions that are in the best interest of their patients and a positive work environment. Eline de Kok's thesis is centered on the practical implementation of this positive deviant behavior and rebel leadership by nurses in their practices. In total this thesis contains five studies; The first study involved a descriptive qualitative study to understand how nurse leadership could be stimulated within the nursing practice by evaluating the Dutch Nurses Association's Excellent Care Program. The second study entailed a scoping review to provide an overview of the perspectives on deviating nurses in the literature and to identify the characteristics of deviating nurses and the factors that stimulate or hinder rebel nurse leadership practices. Based on this study a new definition of rebel nurse leadership is proposed which supported all further research of this thesis. The third study was exploratory in nature, offering insights into nurses' experiences of rebel nurse leadership in their daily practices from a leadership-as-practice perspective. The fourth study was conducted to gain insights into how nurses took on the responsibility during the COVID-19 pandemic to reshape their work environment in response to the highly changed organizational structures. Finally, a multiple case study was conducted in two Dutch hospitals to identify the most common "lived" experiences and dilemmas encountered by nurses and nurse managers in the context of rebel nurse leadership practices. Overall, it can be concluded that rebel nurses are successful in pushing the boundaries, challenging established norms, and thinking outside the conventional framework without losing the support of their colleagues and management. They strive to find elegant and efficient solutions and ultimately reshape their practices. The practices of rebel nurse leadership are characterized and influenced by five key aspects: 1) the internal conflict, 2) the power of reflection, 3) knowledge, experience, and skills, 4) the impact of networks, relationships, and collaborations, and 5) the collaborative efforts of nurses and managers. This thesis describes the significance of rebel nurse leadership in driving innovation in healthcare and enhancing the quality of care and the work environment for nurses. Nevertheless, it also highlights that these practices are often complex, often take place out of the sight of others, and frequently remain in quick fixes. Consequently, the potential of rebel nurse leadership practices in healthcare remains underutilized and hampers the implementation of elegant and efficient solutions into sustainable change. To harness their potential more effectively, there are opportunities for collective reflection, learning, and action concerning the impact of rules, agency, feedback, frameworks, and professional tensions within the nursing practice.