Betrayed Trust Article Review
Order Description
Read the attached article and answer each question attached in the other document. APA is extremely important, including headers. There is only one scholarly article required to support the answers. We were told we can take any direction we wish with the paper, as long as it directly pertains to the attached “Betrayed Trust” article.
Betrayed Trust Discussion
Please answer all discussion questions below and submit to the Drop Box. Use one scholarly article to support either a leadership, ethical or legal issue. Use APA format

Page 38 of your text discusses the management functions of:

Planningencompasses determining philosophy, goals, objectives, policies, procedures, and rules; carrying out long- and short-range projections; determining a fiscal course of action; and managing planned change.
Organizing includes establishing the structure to carry out plans, determining the most appropriate type of patient care delivery, and grouping activities to meet unit goals. Other functions involve working within the structure of the organization and understanding and using power and authority appropriately.
Staffing functions consist of recruiting, interviewing, hiring, and orienting staff. Scheduling, staff development, employee socialization, and team building are also often included as staffing functions.
Directingsometimes includes several staffing functions. However, this phase’s functions usually entail human resource management responsibilities, such as motivating, managing conflict, delegating, communicating, and facilitating collaboration.
Controlling functions include performance appraisals, fiscal accountability, quality control, legal and ethical control, and professional and collegial control.
D1. Based on your review of the article, give an example of each function

D2. What is the role of a Hospital Board?

D3. What potential legal issues were threats to the organization?

Were these intentional or unintentional acts?
Was it subject to trial in civic or criminal court?

D4. The CEO uses a systems theory framework to understand the culture of the organization and to rebuild the organization.
Was this the right strategy for the organization?
Could it be sustainable after the CEO’s departure?

D5. If you were to identify one key element that led to the dysfunction of the organization. What would it be and why?

D6. Using this case study give one example of an ethical principle? Why?

D7. Based on your leadership style, what would you have done differently?

D8. Please list any other leadership and management functions that you identified in the article.

Vol. 36, No. 1, pp. 63–80
Copyright c 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Betrayed Trust
Healing a Broken Hospital Through
Servant Leadership
Deborah A. Yancer, MSN, RN
An investigative reporter with The Washington Post broke the news of a no-confidence vote by
the medical staff of a hospital in the suburbs of Washington, District of Columbia. The chaos that
followed created a perfect storm for needed change and offered the rare opportunity for unbridled
deep and creative collaboration. Issues the hospital faced as a result of this crisis and subsequent
events that tested the authenticity of change are summarized. This article focuses on the approach
used by the registered nurse chief executive officer (RN-CEO) to humanize the hospital, viewing it
as though it were a patient and leading a clinical approach to organizational recovery and health.
The relationship that developed between the medical staff leaders and the RN-CEO was pivotal to
the hospital’s recovery and evolved as a hybrid of servant leadership. Outcomes achieved over a
7-year period and attributable to this relational model are summarized. Finally, the RN-CEO shares
lessons learned through experience and reflection and advice for nurses interested in pursuing
executive leadership roles. Key words: no-confidence vote, recovery, servant leadership, trust
MIRACLES HAPPEN, as clinical professionals
we know that. We have been
blessed to see patients recover when healing
was not thought possible and our efforts inadequate
to the challenge. Miracles can also happen
in the health and recovery of a hospital.
When a hospital falls from grace in the eyes
of the community it serves, people look for
someone to place their trust and confidence
in. A building does not engender confidence.
But people can. And so when we hold up a
leader, confidence in the hospital can be nurtured.
But the path to recovery can be long
and unpredictable. When trust is betrayed, it
is more difficult for people to invest in new
Author Affiliation: Independent Consultant,
Lincoln, Nebraska.
The author thanks the past presidents and other medical
staff leaders of Shady Grove Adventist Hospital for
their leadership and sage advice as they, along with the
author, laid down the path to the future.
The author declares no conflict of interest.
Correspondence: Deborah A. Yancer, MSN, RN
([email protected]).
DOI: 10.1097/NAQ.0b013e31823b458b
relationships and risk disappointment again.
This is true for each of us and so, too, for
people bound together by a common work.
A HOSPITAL IN CRITICAL CONDITION
In 1999, Shady Grove Adventist Hospital
(SGAH), a 268-bed acute care hospital serving
a rapidly growing community in the suburbs
of Washington, District of Columbia, was
the subject of a breaking investigative story
in The Washington Post, a reputable national
news source. The premise of the article, and
the series that followed it, was that patients
were dying at SGAH because of poor leadership
and the medical staff had issued a noconfidence
vote (NCV). Although the source
was not named, it was attributed to medical
staff speaking on behalf of hospital nurses and
staff. Perhaps, more damaging was the slow
decline in personal confidence that physicians
and staff shared with family and close
friends. When the story went public, all those
comments added credibility to the concerns.
Confidence was lost from the inside of the
hospital out to the community. All venues of
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
63
64 NURSING ADMINISTRATION QUARTERLY/JANUARY–MARCH 2012
local media carried the story over the intervening
months. In fact, for several years, any
news about the hospital was prefaced by reference
to the troubled time.
The good intention of medical staff leaders
to herald the need for change spiraled out of
control and caused many unintended consequences.
Public scrutiny placed an additional
burden on all engaged in delivering or supporting
care at the already faltering hospital.
Everywhere hospital staff and physicianswent
in the community they were questioned and
subjected to name-calling. The hospital’s staff
and physicians were battered in the cross fire
of accusations and suspicion. It was a fearful
time, with great uncertainty about the future
of the hospital.
Patients continued to come to the hospital,
with newspapers in hand, and challenged
even the most basic care processes. Regulatory
agencies (The Joint Commission and
the Maryland Department of Health) also arrived
immediately and conducted concurrent
reviews. Temporary management was put in
place at the hospital and the parent health system,
Adventist HealthCare, Inc, whereas the
system board (there was no hospital board
at the time) worked to respond to the immediate
situation. Conflicts between board
members and medical staff were aired in
the media. The hospital was subsequently
placed on conditional accreditation by The
Joint Commission, and its deemed status with
the Centers for Medicare & Medicaid Services
(CMS) was threatened. Conditional accreditation
was a designation that had not been previously
used, and its meaning and path to resolution
were unclear. Many people in the community
misunderstood the designation and
believed the hospital had lost its accreditation.
Since the hospital had recently achieved
the highest Joint Commission rating, the
health system formally appealed the decision.
Meanwhile, the health system board considered
potential management options including
affiliation, contract management, or recruitment
of new leadership. Interim leadership,
with assistance from consultants, worked to
stabilize the hospital and set priorities. Efforts
during the interim period, while well
intended, were in some cases off point, bringing
focus and energy to change initiatives inappropriate
for a hospital in crisis. For example,
work began on the development of
a clinical ladder for nursing. Although nurses
were interested in the development of a system
to recognize their clinical expertise, this
work would have no value unless the hospital’s
performance and reputation were first
restored.
Themedical staff leadership, to their credit,
took seriously their involvement in selection
of the next hospital leader. They articulated
what they wanted in a leader and what
they believed the hospital needed. The medical
staff president and president-elect participated
in the selection interviews and pledged
their support moving forward. No formal
methods for medical staff engagement had existed
prior to the NCV. Contact with hospital
and health system leadership had been predominately
transactional. Meetings were held
on an as-needed basis with individual physicians
or groups. Distrust had grown as people
had different accounts of commitments
made, and many described an absence of relationship
with administration. The medical
staff desired relevant involvement in shaping
the future of the hospital.
Many barriers existed in the hospital that
would need to be overcome, including but
not limited to the following:
• Significant findings from regulatory agencies
with tight timelines for improvement.
• Frequent unannounced surveys by
discipline-specific and hospital accrediting
and regulatory bodies.
• Damaged credibility with the community.
• Weariness of hospital staff and physicians
before the NCV worsened under intense
public scrutiny and suspicion of coverup.
• Broken trust; people described feelings
of deep disappointment and betrayal.
• Vacant, consolidated, and eliminated executive
and management roles.
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Betrayed Trust 65
• Acting or inexperienced leaders; some
had experience only at SGAH and lacked
requisite formal education.
• No hospital board and limited connection
between the community, the hospital,
and the health system board.
• Communication had been messy, with
conflicts and disagreements reported in
the media; “no comment” responses to
inquiries deepened community distrust.
• Hospital financial performance had declined
to a loss position; expenses for
consultants and interim leadership were
unbudgeted.
• An entrenched view of the prior leadership,
like a mantle, would be inherited
by the new hospital leader.
• People interpreted responses and actions
through the filter of prior experience.
• People were reluctant to try again since
their prior efforts had gone unheeded.
• The uncertain future of the hospital
made retention and recruitment of qualified
and experienced leaders and staff
difficult.
Over the next several years, significant internal
and external events provided additional
challenges to the hospital and tested forward
progress (given next). Media coverage of selected
(*) events and investigations produced
a layering type of impact on the hospital and
its people. Keeping hope for recovery alive
was perhaps the most important and daunting
leadership challenge.
• The community was growing rapidly and
with it, needs for health care services
• Service-line competition was increasing
with 4 other hospitals in the service area
• Patient boarding and ambulance diversions
among county hospitals reached a
crisis point*
• Significant near misses and sentinel
events were self-reported, and the error
rate in the hospital appeared to increase
as a result of increased reporting*
• Members of the community notified The
Joint Commission and the State Board of
Health of their concerns about care delivery,
resulting in additional inquiries and
on-site reviews*
• An intensive care unit nurse was suspected
of hastening the deaths of patients
at SGAH; investigations were conducted
concurrently by the hospital, the
police, and the Maryland State Board of
Nursing*
• A disgruntled former employee was arrested
and sentenced to prison after
bringing a concealed shotgun to the hospital
in search of his supervisors*
• Various threats to the community required
hospital attention or response, including:
• The Pentagon attack*
• Anthrax exposure threat at the Shady
Grove post office*
• Reports that hospitals were targeted
for dirty bombs
• Random DC sniper attacks, gunmen
arrested in hospital service area*
At the time, living the experience, each
day was filled with urgent issues and more
work to be done than we had staff to satisfy.
The environment was dynamic both in
the hospital and in the broader community. It
was easier to see what was working against,
rather than for, the hospital’s recovery. The
hospital continued to serve the community
and experienced growth in volume and services
while doing the difficult work of making
changes rapidly and in full public view.
For the purposes of this article, we will focus
on the collaboration between the hospital
president (registered nurse chief executive
officer [RN-CEO]) and the medical staff
officers (past president, president, presidentelect,
secretary, and treasurer). Certainly, contributions
from the health system leadership,
board members, medical staff, hospital leaders
and managers, employees, and volunteers
were all critical to the recovery of the hospital
and are recognized.
RN-CEO, THE NEW HOSPITAL LEADER
During the selection process, it had become
clear that the next hospital leaderwould
need a broad base of health care experience
and an ability and interest in providing
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
66 NURSING ADMINISTRATION QUARTERLY/JANUARY–MARCH 2012
hands-on, just-in-time leadership. Turning the
clinical and financial performance of the hospital
would require expert communication
skills, a strong personal presence, a sense
of urgency, and the ability to inspire confidence.
The new leader would become the
face of the hospital and would need to be
comfortable dealing with adversity and conflict.
Motivation for success must be deeply
ingrained, and the leader must be mission
driven.
In June 2000, the newly appointed CEO
for Adventist HealthCare, Inc, announced the
selection of a new hospital leader (RN-CEO)
for SGAH. I had been selected to fill the role.
I was living in Tennessee at the time and
would make the move to Maryland to assume
my duties. I had 25 years of experience as a
nurse, with 20 years in progressively responsible
hospital executive positions including experience
in both chief nursing officer (CNO)
and chief operating officer (COO) roles. While
most of my experience was in mid-size, private,
not-for-profit, faith-based hospitals and
health systems, I had served as COO in a
large teaching hospital and carried interim
responsibilities during organizational transitions.
My experience included working at every
level within the hospital hierarchy, leading
department and division turnarounds, and
collaborating with other health system executives
during hospital reorganizations, consolidations,
and mergers.
My leadership perspective had been built
upon a systems theory framework, beginning
with my education in a baccalaureate nursing
program and continuing in my first role
as a primary nurse in the intensive care setting.
It was in that first role as a nurse that I
discovered that work conditions matter and
that patients care depends on the effective
integration of effort across departments and
disciplines. I quickly discovered that clear
accountability and the existence of healthy
relationships are requisite to good patient outcomes.
As a staff nurse, I witnessed horrific
patient care as the result of fragmented care
processes and the divorce of responsibility
from accountability. Within 2 years of beginning
practice, I felt a deep calling to directly
influence care conditions and moved from a
staff nurse role to a unit-level management
position. My personal mission in that first
management role and every role leading up
to my appointment as the president of SGAH
was to create conditions where good people
could give great care.
My motivation for moving from a direct patient
care role to a management role was to
change what was happening at the bedside. I
explored ways of involving staff in decisions
about patient care and began implementing
staff engagement models. Soon after taking
my first position as CNO in 1980, I heard
Tim Porter O’Grady speak about Shared Governance.
Over the next decade, I served as
CNO in 3 different organizations in Michigan,
Missouri, and Nebraska:
• Introducing shared governance in each
organization
• Applying learning from the prior
experience
• Deepening my understanding of the
complexity of culture change
I learned that improving performance
in nursing, engaging and empowering staff
nurses, and strengthening effectiveness of
nursing leadership contributed to improvements
in patient care but in limited ways.
To really impact patient care, influence across
the hospital was required. During this time, I
completed a clinical master’s degree in nursing,
an unusual academic path for a nurse
executive. A more typical path would have
been a master’s in nursing administration or
a master’s in health care or business administration.
However, by that point in my career,
I had significant executive-level experience
and had learned business skills on the
job. Given my passion for improving patient
care, I had chosen to pursue graduate level
education in clinical nursing and to further
strengthen my understanding of patient care,
a hospital’s core mission. I chose to specialize
in women’s and children’s health, the only
clinical area in which I lacked experience. In
this way, I broadened my understanding of
clinical specialties.
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Betrayed Trust 67
This combination of clinical education and
administrative experience offered a balance in
perspective thatwould prove an important advantage.
Although this would be my first time
in a permanent CEO position, there was confidence
that my deep experience in hospital
operations, engagement models, success with
turnarounds, as well as leadership presence
and style would be a good match for the challenges
the hospital faced. Many people asked
me then and since, why I would be willing to
take on such a responsibility and risk failure?
As I visited the community and interviewed
for the position, I had seen a great community
that needed its hospital. This was work
worth doing. My decision to accept the position
came with a deep sense of calling to help
ensure that the hospital would be able to continue
its mission of service to the community.
I had a strong faith that the outcome would
not rely solely on my effort, knowledge, or
skill. Like all the work we do in nursing, I believed
I could make a difference by joining my
efforts with that of others. As a clinical professional,
my courage came from that internal
well that nurses and other professionals routinely
draw upon in providing clinical care. It
is what we are prepared to do.
THE HOSPITAL AS PATIENT
But how should I lead? Where would the
work begin? It was like being confronted with
a critically ill patient and determining where
to put your first effort. I observed that much
of what was needed was the exact opposite
of what had been happening. For example,
the initial response to the media inquiries
about care had been “no comment,” a literal
fuel for the fire of public scrutiny. From
themomentmy appointment was announced,
I made myself available and was willing to
comment even if the response was “I don’t
know, but I will find out.” I was responsive
to the hospital’s need for permanent leadership
and traveled to the hospital before my
official start date to address staffing shortages.
Every conversation became an opportunity to
learn from people about what had happened
and what it meant to them. People described
the disappointment and hurt they had experienced.
It was important to understand the
way people in different parts of the hospital
had experienced the gradual breakdown of
trust and how that played out, near and distant,
to the patient. It was valuable to understand
the meaning that individuals and groups
made of their experiences and to consider
how that would affect their behavior moving
forward. All the hospitals problems were
rooted in disconnection and broken trust.
It took 6 months to begin to see an impact.
It was like bailing water out of a sinking
boat. There were many small changes, and
how something was done, often proved more
important than what was done. I looked for
opportunities to be responsive in early and
meaningful ways to signal a new beginning
and that people would be valued and heard.
For example, 2 major capital investments
were made in response to physician and staff
feedback, a new computed tomographic scanner
for the high-volume emergency department
and an additional emergency generator
with wiring mapped throughout the hospital
to support critical patient needs.
Early on, it was difficult to get people to
believe that they would be heard, as these urgent
requests had been made before. It was
the fragile beginning of rebuilding trust. Like
priming a hand water pump for a well, there
is no water unless you first pour some in.
So, too, with trust, when people have been
disappointed repeatedly and trust is broken
or betrayed, they stop trying and give up
hope of any response. Apathy is a learned response.
To change this situation, the leader
must gift trust, modeling consistent and continuous
behaviors that deepen with repetition
so that trust can be reborn one relationship at
a time (Table 1). I leveraged my personal and
professional experiences with trust betrayal
and tragedy. I had learned through these experiences
that we cannot control what happens
to us but we can choose the response
we will give. That became my mantra as I
met with individuals and groups. I began to
help people look at what had happened, take
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
68 NURSING ADMINISTRATION QUARTERLY/JANUARY–MARCH 2012
Table 1. Leadership Behaviors to Rebirth
Trust
Gift trust
Be vulnerable and transparent
Use presence and voice
Listen to understand
Communicate openly and directly
Do what you say
Admit mistakes
Be accountable
Lead as an equal
lessons from it that could inform their future,
and put the history and pain behind them.
I used stories from my own experiences to
communicate that I understood the pain of
broken trust. Trust betrayal, like loss, must be
experienced to truly understand it. I was able
to recognize wounded spirits and create space
for healing to occur.
My visibility and availability as the hospital
leader was critical, especially in the first
3 years of my tenure. My calendar was filled
with face-time and I constantly juggled priorities
in response to situations and problems
that continually bubbled up. One strategy I
used to extend my presence in the hospital
was a weekly voice mail. An e-mail was sent
to communicate that a new voice mail message
was available and staff could call a dedicated
phone number at their convenience,
from home or work, to hear the 1- to 2-minute
message. This simple experiment proved to
be a very powerful use of voice and virtual
time. It became a best practice, with the following
benefits:
• Other audiences, including physicians,
volunteers, community members, and
family of staff, accessed the messages.
• People felt connected and that they had a
direct line with me as the hospital leader.
• Rumors were reduced, and finite energy
and attention were better focused.
• Reliable direct communication signaled
transparency and reduced power games
over access to information.
• The hospital had a simple and easy way to
communicate quickly, making it possible
to communicate before information was
in the press.
• During regulatory surveys, daily reports
of progress and requests for changes
could be communicated.
• Appreciation was expressed for the important
work each person was doing to
support the care and caregivers, highlighting
examples throughout the hospital.
• People reported that they felt they knew
the RN-CEO, even if they had never met
me. (This impact was attributed by staff
to knowing the sound of my voice.)
Hospitals are complex organizations with
interdependencies within and among professional
and support staff. I had learned that lesson
many times. As a CNO, I had experience
strengthening the performance of nursing and
still having poor care result. In hindsight, this
is not surprising. It would be like setting a
broken leg and expecting your patient’s heart
to heal. My desire to become a COO and a
CEO had been born out of that recognition.
To impact patient care and to create conditions
where good people can give great care,
you must be able to influence the whole organization.
My view of the hospital had shifted
from an organizational context to a human
context. My leadership perspective had been
shaped through the interplay of education,
experience, and exposure to theoretical constructs
over my entire career. I had benefited
from opportunities tomakemistakes, to begin
again, and to adjust my approach on the basis
of situations or new learning. Until, as I began
my work as RN-CEO at SGAH, I viewed the
hospital as though it were a patient (a collection
of humans, with human characteristics).
This was not a decision, rather a natural progression
that I began to give voice to and be
intentional about.
I applied a clinical model to leading the hospital
and found that knowledge I had gained
while pursuing my clinical master’s degree
was directly relevant in my role as hospital
leader. Family theory could be applied when
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Betrayed Trust 69
using a human construct for the hospital and
was remarkably similar to organizational theory.
My knowledge and experience as a nurse
and as a clinically rooted executive gave shape
to a clinical approach that I used to support
the hospital’s recovery (Table 2). Just
like patient care, leading a hospital through
a turnaround requires intuitive skills and the
courage to test interventions and pursue other
optionswith a sense of urgency. Situations are
dynamic and ever-changing, like in any living
system. I had to stay close and project confidence
that together we could make the difference
needed, regardless of the number of
problems that surfaced within the hospital or
changes that impacted the hospital from the
external environment.
People seemed to value my nursing background
but often referred to me as a “former”
nurse. I repeatedly had to correct this misunderstanding.
I believe that nurses sometimes
add to the public’s confusion by discounting
roles that are not involved in direct patient
care. We need to give voice to the value that
clinical preparation and experience bring to
patient care and leadership roles in hospitals.
The hospital had difficulty attracting and retaining
well-qualified CNOs. In fact, the position
had been vacant for some time prior to
the NCV. It was unclear whether CNOs were
risk averse and put off by the significant challenges
at SGAH, or in some way intimidated
by an RN-CEO. While at SGAH, I came to understand
that my nursing experience should
inform my practice as the hospital CEO but I
should take care not to eclipse the CNO as the
organization’s nursing leader. My role as RNCEO
was to be the voice of patients and their
families and all who serve them. This was an
important role shift for me to understand.
Because of my breadth of experience as a
nurse and a hospital executive, I was able to
do parts of various roles as needed early in
my tenure when many important roles were
Table 2. A Clinical Approach to Leading Hospital Recovery
Continuous use of the nursing process
assess whole patient (hospital)
sample at the point of care and move outward, checking processes and interfaces
continuously learn and teach
engage the patient (the hospital people) in the healing process
leverage fluency in clinical language (a language of healing)
Therapeutic presence and listening
personal presence required for relationship to develop
create space for listening, listen to understand
help people process and mine meaning from the unfortunate experience
invite people to have their future be informed by this meaning
urge people to leave the wreckage behind and move forward
Bring a single-minded focus to mission and set priorities
meet people (patients, families, staff, physicians, community) where they are
clarify mission “why we do what we do”
use Maslow’s hierarchy to prioritize change efforts, delay work until appropriate time
minimize use of external resources
Author new culture of the hospital
position communication as universally available
be trustworthy and transparent
value all people and help them see their relevance to patients
model accountability and build it into processes and systems
expect people to lead from where they are, staff and management
continually learn and always seek feedback and improvement
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
70 NURSING ADMINISTRATION QUARTERLY/JANUARY–MARCH 2012
vacant. I also worked closely with individuals
and teams to push for results in short time
frames. Although the role