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Leading nursing beyond 2020 – the challenge and the opportunity

2020; Wiley; Volume: 28; Issue: 4 Linguagem: Inglês

10.1111/jonm.13022

1365-2834

Alistair Hewison,

Healthcare Quality and Management

In the last months of 2018, a number of reports concerning health care leadership in England were published. In October, the NHS Leadership Academy published the findings of a survey of chief executives which explored their views of the attractions and barriers to clinicians becoming chief executives (NHS Providers/NHS Leadership Academy, 2018). Then, in November, the Faculty of Medical Leadership and Management (2018) produced Barriers and enablers for clinicians moving into senior leadership roles, followed just under fortnight later by a review of the key challenges facing executive leaders in the NHS: Empowering NHS leaders to lead (Kerr, 2018). This coincided with a speech by the Health and Social Care Secretary Matt Hancock on 28 November in which he argued that good NHS leadership starts with culture change (Hancock, 2018). This need for effective leadership of health and social care has been a familiar refrain in health policy in England from the Darzi Review (DH, 2008) to the Berwick Report (2013) in which the role of leadership in improving quality was emphasized, and more recently the NHS Long Term Plan (NHS, 2019) with its commitment to strengthen and support good, compassionate and diverse leadership at all levels—managerial and clinical—to collectively deliver greater value for the NHS and for patients. It is clear leadership remains an issue of concern in health care; however, it is also clear that there is still much to do. This need has also been identified as an international concern with a global independent commission on the education of health professionals for the 21st century concluding high-quality professional leadership is crucial for progress in improving health and developing effective health systems globally (Frenk et al., 2010). Yet how to achieve such aspirations is less clear. The World Health Organization (World Health Organisation, 2020) has designated 2020 as the year of the nurse and midwife to coincide with the 200th anniversary of the birth of Florence Nightingale. As part of this, a Nursing Now global campaign to improve health by raising the status and profile of nursing is in progress (https://www.nursingnow.org/). It aims to engage with nurses, governments, partners and stakeholders globally to achieve the ‘triple impact’ of improved health, greater gender equality and increased economic growth (APPG, 2016). It is a social movement with an active network of 266 Nursing Now groups in 89 countries (as of June 2019) working to influence global and national policy (https://www.nursingnow.org/). However, there are significant challenges that will need to be overcome if these aims are to be achieved. For example, although women make up 70% of the total global health and social care workforce, only 25% of health system leadership roles are occupied by women (Newman, Stilwell, Rick, & Peterson, 2019). This is the result of many barriers to nursing leadership that marginalize and exclude female nurses from decision-making roles. These take the form of gender discrimination, bias and stereotyping which serve to limit opportunities for skill development, perpetuate the gender pay gap and result in unequal treatment of men and women in the health workforce (Newman et al., 2019). In an effort to redress this imbalance, Nursing Now issued the Nightingale Challenge (https://www.icn.ch/news/nightingale-challenge-inspires-next-generation-nurse-and-midwife-leaders-during-2020-year) to every health employer around the world to provide leadership and development training for a group of their young nurses and midwives during 2020. The aim is that 20,000 nurses and midwives aged 35 years and under benefit in 2020, and that at least 1,000 organisations participate. Although this is a laudable aspiration, health systems worldwide are under extreme pressure and securing commitment to meet this target will be difficult. Also, leadership development activity is only part of the solution. Fundamental changes in health and social care organisations are needed which take account of local contexts and combine expert support, organisational development and leadership development founded on evidence, if such change is to happen (West et al., 2015). In addition, urgent political action is needed in many nations, particularly with regard to resource allocation, if health and social care systems are to meet the pressing challenges presented by an ageing population, multi-morbidity (James et al., 2018) and a shrinking workforce (Liu, Goryakin, Maeda, Bruckner, & Scheffler, 2017). Returning to the aim of Nursing Now to support nurses at every level to develop their leadership and quality improvement skills and knowledge, so they can lead and manage change, could be seen to place additional demands on an already hard-pressed workforce, because many practitioners would argue that clinical work is difficult enough without the addition of significant leadership responsibilities. However, if notions of ‘traditional’ leadership are set aside and new approaches considered, the huge potential for nursing leadership could be realised. For example, the old model of ‘heroic’ leadership by individuals is limited, and if leadership is to progress and meet the needs of patients and staff, then a focus on developing the organisation and its teams and leadership across systems is required, rather than relying solely on individual leaders (The King's Fund, 2011). With regard to nursing leadership, there are several areas of enquiry/development that hold promise for the future and if harnessed could empower nurses as leaders to realize the goals of Nursing Now. These are summarized below and set out an agenda for research and action that has the potential to help ensure 2020 becomes a turning point for nursing leadership. If clinical staff are to have an impact on the care patients receive, there is a need to engage with leadership because it has been found to influence the culture that affects quality, safety and the working environment (Mannion & Davies, 2018). Indeed, some argue that engaging in leading and managing systems of health care, be it at the level of the team, department, unit, hospital or health authority—is a professional obligation of all clinicians (Swanwick & McKimm, 2011). Four approaches are summarized below that hold promise in terms of enabling nurses to meet this professional obligation. Adopting a focus on compassion can provide a bridge between clinical practice and clinical leadership. Compassionate care for patients and staff should be the foundation of all health and social care (Hewison & Sawbridge, 2016) and it has been argued that to harness the power of leadership in health care, there is a need to develop and support clinical leaders (Imison, 2018). Compassionate, caring and inclusive leadership (Edwards, Till, & McKimm, 2018) may be what health and social care need; however, if this vision is to become a reality, then the approach needs to be developed, tested and evaluated to contribute to the evidence base for clinical leadership. Compassion can be interpreted in a number of ways (Singh, King-Shier, & Sinclair, 2018), and ensuring that leadership maintains a focus on an inherently complex concept is by no means straightforward, but such an approach is vital to serve as a corrective to the corrosive and negative effects of austerity and command and control approaches which can result in incivility, and has a destructive effect on the workplace and patient care (Armstrong, 2018). Some exploratory work has been conducted in this area (Hewison et al., 2018; Hewison, Sawbridge, & Tooley, 2019), however, much more is needed to determine its benefits for patients and staff. Another recent strand of work that could inform understanding of the leadership role of nurses is leadership as practice (Raelin, 2016). This has emerged from the premise that no one knows the practice better than the practitioner who must negotiate and arrange that practice. Also, many practitioners work in teams that are interfunctional and interdisciplinary, yet not necessarily co-located (Raelin, 2011). Leadership as practice redirects attention from what (extraordinary) individuals [leaders] are, to what ordinary people do as they engage in leading (Crevani & Endrissat, 2016). It is experiential, interactive, situated, embodied, sustained and relational—in sum a new kind of engagement with self, others and world (Carroll, Levy, & Richmond, 2008). In thinking about how to develop leadership in a group, including nursing, there is a need to find ways to bring more of the unconscious and unreflective into the conscious and intentional domain and investigate instances of failure, dissonance, crisis and obstruction in the workplace (Raelin, 2015). In this way, new insights on nursing leadership can be generated and fresh approaches developed to meet the coming challenges noted earlier. Elements of this line of enquiry can also be found in Allan's study of the invisible work of nurses (Allen, 2015). Using Actor Network theory (Allen, 2018) as part of an ethnographic study of the reality of nursing, she found that it is nurses that are mainly responsible for managing emergent organisation and this work is important in ensuring the quality and safety of patient care. However, although nurses are often referred to as the ‘glue’ in health care systems, we know little about the work that this involves. She contends that too often prescriptions for nursing have arisen from armchair theorizing about what nurses should do rather than research into what they actually do, and an understanding of how this role function is shaped by the contexts in which they work is needed (Allen, 2015). This suggests that more research to investigate the reality of nursing leadership in context would provide useful data to inform the development of this area of practice. One further perspective that may yield a new way forward for nursing leadership research and practice is Strengths-Based Nursing Leadership (Gottlieb & Gottlieb, 2017; Gottlieb, Gottlieb, & Shamian, 2012). It is defined as a value-driven philosophy of nursing that is focused on understanding, uncovering, discovering and releasing biological, intrapersonal, interpersonal and social strengths to meet challenges in care and enable achievement of team and system goals (Gottlieb & Gottlieb, 2017; Gottlieb et al., 2012). It is designed to guide system transformation, placing the family at the centre of care and create environments to empower strength-based care (Gottlieb et al., 2012). It is founded on eight principles incorporating the ideals of empowerment and equity (Gottlieb et al., 2012). The intention is that this provides a model for nursing to create a more holistic, humanistic, integrated, health-based system (Gottlieb et al., 2012). Work is underway to enable clinical managers and leaders to work through a strength-based lens, to build communities of caring and create safe workplaces for nurses and all health care workers (https://www.mcgill.ca/nursing/article/transformational-mcgill-nursing-research-project-awarded-2-million-dollar-grant). The findings from this study, combined with research in the other three areas, will be vital in uncovering the contribution and potential of nursing leadership. Investigation of nursing leadership using new perspectives and approaches that take account of the reality of practice rather than outdated notions of what leadership should be represents an exciting opportunity to advance nursing leadership. It has been argued that at a system-level, collective leadership cultures for high-quality, compassionate care extend beyond the boundaries of specific organisations and provide the basis for the creation of such cultures across the whole system, forging an interdependent network of organisations that work together to deliver high-quality care (West, Eckert, Steward, & Passmore, 2014). In recognizing that organisations cannot work in isolation to achieve the best possible care, it follows that their cultures need to be conducive to interdependent working within and across the system (West et al., 2014). Yet there is much to be done before this can be achieved. For example, Newman et al. (2019) recommend that more research is needed to investigate the intersection of gender with other axes of stratification and exclusion that may inhibit women's opportunities in nursing leadership. Also, the continued recommendations based on male-dominated ‘hero’ accounts of leadership (Ford, 2016; Idelji-Tehrani & Al-Jawad, 2019) do little to acknowledge the emergent nature of leadership created by the interaction between people, practice and structure (Woods, 2016). For all its importance, nursing remains underappreciated and its full value unrealized (The Lancet, 2019). The exploration of nursing leadership, in context, centred on its emergent and contingent nature holds the promise of revealing how best to enable ‘nurses at every level to develop their leadership and quality improvement skills and knowledge, so they can lead and manage change’.