Leadership Challenges

The critical nature of nursing leadership in a competitive service

The successful service of modern times relies on a committed workforce aligned, single-mindedly, behind a good strategic plan. Perhaps more important than the plan itself is the ability of the team to pull together towards its attainment. Motivating people towards a distinct goal or vision is very much the realm of transformational leadership and yet in healthcare we have tended to stick very much with the more hierarchical, autocratic styles. Furthermore, despite the vital nature of aligned consistent activity, we have also grown different vertical streams of hierarchy (medical, nursing, allied, management etc), with each having comparatively little influence over the others. Nursing has remained more ‘standalone’ than any other stream. Given that nurses make up 30% of the workforce, it is vital that nursing adopts the same drive for effective leadership that is currently expected of medical staff, despite (especially in) the current economic climate.

Competing hierarchies

Nurses and doctors need to work handin-hand to deliver successful clinical care but also to deliver against the ever more pressing business objectives that services are setting themselves. In the same way that doctors have resisted direction from management in matters they consider to be their responsibility (for instance, direct clinical care), so too have nurses engaged in the same resistance both with their medical counterparts and management too. The ability to largely self-govern, although comforting in turbulent times, brings with it a heightened need to exhibit strong, selfless leadership towards making the service, not just nursing, successful. Exactly the same must be said for doctors, allied professionals, support services, management and all. We’re not suggesting that it doesn’t exist but having separate hierarchies raises the potential for inadvertent inertia arising largely out of a failure to agree on the ‘best’ course of action.

In a commercial organisation, even a matrix organisation with a flat management structure, there is explicit control of the many by the few at a business unit (service)level. Even though staff of many levels may be involved in devising the strategic plan, ultimately, the business unit director, with accountability for results, retains the ability to instruct a direction and get the team moving i.e. if he (or she) senses inertia or stalemate occurring, he can overcome it in the interests of moving forward. In healthcare, failure to agree between different parties is common, even within distinct streams. As the healthcare economy heats up, giving rise to more aggressive competition, inertia is likely to be the fastest killer of competitiveness, leading to service financial distress and even obsolescence. Under these conditions, hierarchies have to ensure that they collaborate not compete, if services are to survive and thrive.

Leadership in nursing

Leadership in the most modern healthcare form, involves setting a direction designed to deliver success for a service, its staff and patients alike and then mustering support, enthusiasm, commitment and aligned activity towards that direction. A service must have only one strategic direction or plan, however many service goals go to make it up. Consequently, all staff need to be able to reach agreement on the way forward for them, being equally mindful of the huge potential cost whilst agreement remains outstanding. No strategic plan tends to mean that activity is confined to the day-today delivery of healthcare with insufficient focus on the future. It is imperative that nursing leaders help their teams understand the consequences of this in modern times and the important of working collaboratively within a Trust, not just within nursing.

It is often said that management is doing things right whereas leadership is doing the right things. Whereas nurses adopt the utmost professionalism in delivering their healthcare roles, it is the role of nursing leadership to ensure that they are focused on the right things. For instance, nurses have the predominant influence on how a patient experiences a service. Patient experience is becoming a key determinant of future service fortune, both financially and strategically. It is up to nursing leadership to focus nursing attention on their role in delivering this strategic imperative, helping nursing teams to understand the cause and effect relationships that lead to service success or stress. The same could be said for cost improvement, where nurses have tremendous potential to contribute. Again it is imperative of nursing leaders that they show fellow nurses how CIP leads to financial sustainability, stability and ultimately to their own job security, not to mention protecting patient care, instead of allowing teams to resist CIP in the inadvertently misguided perception that this is in the patient’s best interests.

Ultimately, nursing needs leaders with the leadership knowledge and skills necessary to win the hearts and minds of their fellow nurses, coupled to a high degree of understanding about the environment in which they operate, as well as the utmost altruism to ensure that the right things are done. This involves adopting the intellectual flexibility to see beyond the immediate pain of a system in stress, developing the insight necessary to identify the true underlying issues and the propensity to come forward to the table as equal peers, committed to determining a compelling direction for a service. That represents leadership in its grandest form.

The Nursing Leadership Challenge

For many reasons, nurses have struggled to receive the same degree of professional development afforded to medical staff (which is still largely insufficient). Development has tended to be focused on the work and not the person, or in attaining competencies driven by the Knowledge and Skills Framework, leaving a deficit in leadership & management skills across all levels of nursing. Although opportunities for leadership development are increasing, nurses will be playing catch up for many years to come. However, the nature of something described as ‘imperative’ is that it does not afford the luxury of time. Consequently, nurses must develop modern, proactive, insightful leadership now,almost concurrently with engaging in the strategic challenging facing almost every service.

Time creates a second challenge to leaders in healthcare, consistent across all leaders, not just nursing ones. Leadership is about working ‘on’ rather than just ‘in’ and yet few leaders have the capacity to truly lead. Effective organisations, even when requiring leaders to conduct a ‘day job’ alongside their leadership role, recognise that the organisation is weaker if leaders are stretched to the point of only working within. In nursing, most leadership is devoted to operational leadership and the organisation of healthcare delivery. This needs to be re-balanced to allow nurses to contribute fully to the strategic effectiveness of the service. Whereas ‘walking the floor’, visible, operational leadership remains vital in nursing, it cannot fill the vital nature of a sound strategic input.

Time is not the only challenge. Funding remains woefully inadequate to properly equip nursing leaders with the skills and insight necessary. Nursing must find innovative ways of gaining leadership knowledge and skill, coupled to healthcare market insight. The carrot is competitiveness, leading to successful, robust and prosperous services, whilst the stick to nurses, services and Trusts alike is that failure to succeed in this vital baseline carries with it untold risk across all aspects of a service. Service success in the modern environment is so much more than the outcome and it is going to take exceptional levels of nursing leadership to deliver these wider aspects through a workforce that remains committed but under-developed.

Author: Andrew Vincent Managing Director, Medicology Ltd

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Leadership Challenges

The critical nature of nursing leadership in a competitive service