DNP 899 Module 5 Leadership Development: Decisions and Conflicts Example

Leading Without Authority: Decisions and Conflicts in a Maternal Depression Screening DNP Project

Student Name

Doctor of Nursing Practice Program, Aspen University

DNP 899: DNP Project Capstone

Instructor Name

Month Day, Year

Leading Without Authority: Decisions and Conflicts in a Maternal Depression Screening DNP Project

A DNP project is often the first time a nurse leads a change across a whole team without any formal authority over its members. My project asked a pediatric practice to screen every mother for depression at her baby's early visits and to connect positive screens to its social worker that day. None of the medical assistants, clinicians, the social worker or the front-desk staff reported to me. This paper examines four decisions and two conflicts from the project, what the evidence on leadership suggests about them, and the habits I will carry forward.

Decision One: Whom to Invite First

Before writing the protocol, I had to decide whom to involve first. The obvious choice was the practice's lead pediatrician, whose support would carry weight. I chose instead to start with the social worker and the lead medical assistant, because their work would change most and their concerns were least likely to be heard otherwise. Kotter (1995) lists failing to build a strong enough guiding coalition among the common reasons change efforts fail, and I read that as a reason to build the coalition from the people doing the work, adding the pediatrician third. The protocol that resulted was more practical than one designed from the top, and the medical assistants treated it as theirs.

Decision Two: Whether to Pause

In the third week, the screening rate fell because two medical assistants were out sick and the others were rushed. I considered pausing the program for a week. Instead, the team agreed to screen only at the 2-month and 4-month visits that week, keeping two of the four visit ages the professional recommendation lists, and to resume all four the next week (Earls et al., 2019). The decision protected the habit of screening without overloading the staff, and it taught me that a partial pause can keep momentum better than a full one.

Decision Three: A Missed Safety Screen

In week six, a chart review found that a mother had marked the self-harm item on the questionnaire and left the practice without a same-day assessment, because the score had been entered after the visit ended. The social worker reached her by phone that afternoon, and she was safe. I had to decide how to respond. Rather than looking for someone to blame, I brought the event to the next huddle as a system failure, and the team changed the workflow so the medical assistant flags any positive self-harm item to the clinician before the infant's examination begins. No further delays occurred. The decision tested whether I would treat a serious lapse as a learning event, and I believe that choice is why the team reported the next near miss themselves.

Decision Four: When to Stop Adding

As the program settled, staff suggested additions: screening fathers, screening for anxiety, adding a food insecurity question. Each was reasonable. I decided to add none during the project, explaining that changing the program midstream would make it impossible to evaluate, and to record each suggestion for the practice to consider after the evaluation. Saying no to good ideas was harder than saying yes, and it mattered for the integrity of the results.

Three of those suggestions are now on the practice's list for the coming year.

Leading Upward

Leadership in the project also ran upward, toward the practice manager and medical director who controlled time and money. Early on, I sent them long updates that they did not read. After the first month, I switched to a five-line message every two weeks: screens completed, positive screens, handoffs, one problem and one request. The requests became specific, such as two hours of medical assistant time for a refresher or approval for video handoffs on days without the social worker, and both were granted within days. The lesson was that leaders above me needed the same thing as the team around me: short, honest information and a clear ask.

Two Conflicts

The first conflict was between the social worker, who wanted every positive screen to receive a same-day meeting, and two pediatricians, who worried about delays for families waiting in a busy clinic. The resolution came from data: in the huddle, I showed that most handoffs took under 15 minutes and that the longest delays happened when the social worker was paged late. The fix, paging at the time of screening rather than at the end of the visit, satisfied both. The second conflict was with myself. I wanted the project to look successful, and there was a temptation to describe the rescreening results as improved maternal outcomes. My committee challenged that phrase, and accepting the challenge was a small act of leadership in its own right.

What the Evidence Suggests

Across 129 studies of nursing leadership, one systematic review linked people-centered styles, among them transformational and supportive leadership, to more satisfied nurses and healthier workplaces, and linked task-centered styles to worse results in a number of studies (Cummings et al., 2018). My decisions leaned toward the relational: involving the people doing the work, treating errors as system failures and resolving conflict with shared data. The review cannot tell me whether those choices caused the program's success, but it suggests they were consistent with the approaches most associated with healthy teams.

Habits to Keep

Four habits will come with me. Start with the people whose work changes most. Bring errors to the team as system problems. Resolve disagreements with data that everyone can see. And protect the integrity of an evaluation by postponing good ideas that would change what is being measured.

I have written them on the first page of my planner.

Conclusion

Leading this project meant making decisions without authority, under pressure and sometimes against my own wish to look successful. The decisions that worked best were relational and grounded in shared information. They are the basis for how I intend to lead in the role that follows the degree.

I will test them in my next role.

References

Cummings, G. G., Tate, K., Lee, S., Wong, C. A., Paananen, T., Micaroni, S. P. M., & Chatterjee, G. E. (2018). Leadership styles and outcome patterns for the nursing workforce and work environment: A systematic review. International Journal of Nursing Studies, 85, 19-60. https://doi.org/10.1016/j.ijnurstu.2018.04.016

Earls, M. F., Yogman, M. W., Mattson, G., Rafferty, J., & Committee on Psychosocial Aspects of Child and Family Health. (2019). Incorporating recognition and management of perinatal depression into pediatric practice. Pediatrics, 143(1), Article e20183259. https://doi.org/10.1542/peds.2018-3259

Kotter, J. P. (1995). Leading change: Why transformation efforts fail. Harvard Business Review, 73(2), 59-67.