It is undeniable that being a nurse leader – from shift or team leader to chief nurse – is a role that requires complex skills. I have been reflecting this month, following the recent media reports of significant patient harm, which have been frequently linked to the criticism of nursing leadership. This does raise questions regarding what our profession and wider teams need to consider to support those in nursing leadership roles, as well as how we support and encourage aspiring nurse leaders to realise their potential and make a difference.
At a journal club recently, we considered an article by Kelly et al (2023), which explores the challenges and opportunities facing executive nurse directors (ENDs) in the UK and identifies factors to strengthen their role and support more effective nurse leadership. This was a study that I had participated in, and feel that the findings could be considered across all nursing leadership roles.
The study participants described a uniquely complex role with a broader scope than any other executive board member, with seven themes (see panel) for consideration identified as outlined below, including examples of direct quotes from the study group.
Preparation for the role
With no formal career path into nurse leadership identified, ENDs shared the view that shadowing senior roles was one example of invaluable support, referencing role models who were crucial to developing individuals.
‘The gap's big, so I think there's less opportunity for senior nurses now to cut their teeth on a smaller organisation that's a bit more manageable and get to grips with at executive level working with the board.’
Length of time in role
Participants also recognised the benefits of longevity in the role, as well as the possible disadvantages, such as becoming complacent. Also noted were the critical support networks that developed over time to support success.
‘I think the longer [that] directors of nursing are in post the better known and more successful they tend to be.’
Role expectations
The study shared examples of breadth of role beyond that of the wider team, with a thread running through the responses. These aligned with thoughts such as:
‘So, there's very little you can actually touch in the health board that the nurse director can't legitimately say [that] she or he's got an interest in and I think that view, I know that view, is shared by my executive team.’
Managing complexity
Although the ENDs discussed the many complexities of the role, they also stated that being able to prioritise issues was an important skill in managing effectively, as was knowing when to delegate and when to take control of an issue:
‘You are constantly re-visiting what those priorities are, and I think that's become more challenging.’
Status
ENDs perceived that medical dominance could be a challenge within the executive board, as there was a perception that the medical advice and voice could override that of nursing:
‘I think what is not clear or what's not been standardised is what that nurse brings to it and what to expect … (so) there needs to be this recognition of what exactly the nursing director as an executive brings to the board, how it's recognised.’
Being political and Influencing
ENDs reflected on the need to influence matters over which they may have little direct control, such as budgetary issues. This, it was felt, could be done more successfully through the building of relationships and alliances.
‘Well, I have a set of values and behaviours that I frequently remind myself of and will not deviate from which sometimes puts you in conflict. But over the years you learn ways in which you manage that before you get into a board room situation. So, for me it's always about relationships and how you have relationships with the front line and your occupation on the board and everybody in between.’
To conclude, a point underlined by the study is that ENDs are key to the transmission of nursing values and the delivery of safety and quality in healthcare settings. To strengthen their role, Kelly et al (2023) advocate that both challenges and enablers should be recognised and addressed at an individual, organisational and professional level, as I reflected at the beginning of this column.
The considerations shared can be applied at all levels of nursing leadership, particularly in the context of supporting the retention of valuable nurse leaders.
Themes identified as key to the role of executive nurse directors
- Preparation for the role
- Length of time in role
- Role expectations
- Managing complexity
- Status
- Being political
- Influencing