Nursing leadership is required to inform the strategic direction of Aotearoa New Zealand’s health-care system and play a key role in establishing change that is patient, whānau and family centred, evidenced-based and cost-effective.
Nursing leadership is about influencing others to accomplish common goals. It is complex and multifaceted - providing support, motivation, coordination and resources to enable individuals and teams to achieve collective objectives.
Executive nursing leadership works when:
- Nurses have wide health sector knowledge and relevant experience to work across the health, social and psychological continuum of care
- Nurses are responsible for line management and professional oversight of nursing staff
- Nurses have responsibility and authority for financial management of the nursing workforce and the resources necessary to be responsive and effective
- Nurses have consistent titles across the sector
- Nurses have consistent reporting across the sector (eg director of nursing to chief executive)
- A leadership succession plan is developed and followed
- There is a consistent approach to national benchmarking (eg using nurse- sensitive indicators from a national nursing DHB dashboard), including the development of agreed primary health care nursing indicators
- There is a consistent approach to data management (including a minimum dataset) relating to nursing employment, retention, and deployment.
5.1 What is needed of nursing leadership?
Research conducted by Dr Aisha Holloway confirms that nursing across the world requires a critical mass of nurses that have:
- Capability and capacity to shape, develop, support, and drive forward evidence-based health and social care policy
- Political, strategic and advocacy skills to secure and sustain a credible position at the highest level of policy development within government
- The highest standards of research education to support the evidence base, across the local, national, and international political and health and social care contexts
- The ability to identify understand and work with key stakeholders both within and external to nursing
The national context of nursing leadership here needs to be considered in light of the challenges facing nursing internationally.
5.2 The international context
Nurses throughout the world hold leadership positions in WHO, government, academia and health-care organisations – leading, teaching, researching and shaping policy. Aotearoa New Zealand nurse leaders are held in high regard internationally.
New Zealand nursing leadership must respond to the trends affecting provision of nursing services.
Trends identified in recent works such as the White Paper by the All-Party Parliamentary Group on Global Health include:
- Changing work roles in response to changing health needs
- The shifting emphasis towards closer to home community care
- Critical emphasis on disease prevention and health promotion
- Client engagement with health workers is seen as essential in improving access, quality and costs
- The increasing role of technology
- Knowledge of what works is at a premium as countries struggle to achieve the goal of good access, high quality and value for money.
Examples of New Zealand nurses and midwives at the forefront of international leadership:
- A New Zealand midwife leads the International Confederation of Midwives, an organisation representing 400,000 midwives in 113 countries
- Until recently, the chief executive of the ICN was a New Zealand nurse.
- Three New Zealand nurses were awarded Florence Nightingale medals in May 2017 - the highest international nursing distinction
- The WHO chief nursing officer, Elizabeth Iro, is from the Cook Islands and has worked as a nurse and midwife in New Zealand.
Internationally there is a consistent call for greater and sustained nursing leadership
Nursing leadership in Aotearoa New Zealand and across the world is faced with similar trends and challenges, as the context of health-care delivery changes and evolves. Challenges include:
- Predicted nursing workforce shortage
- Changing population demographics
- Persistent health inequity
- Pandemic disease responses
- Antimicrobial resistance
- Impact of climate change and natural disaster management
- Promotion of human rights.
5.3 Leadership in the NZNO Strategy for Nursing
Leadership is an essential component of any nursing role. Understanding and obtaining knowledge of leadership attributes and skills is an important part of any nurse’s development. For the sake of clarity, this section on leadership has been divided into governance, executive leadership, clinical leadership and point-of-care leadership; however there are overlaps and interdependencies between each.
Women in Aotearoa New Zealand currently tend to be under-represented in governance roles within health and all sectors of the community. Nursing remains a female-dominated profession at 92 per cent female and eight per cent male. Nurses, including Māori nurses, are also under-represented on health and social care boards.
Nursing Council of New Zealand workforce statistics (2015) show that over 41 per cent of nurses in Aotearoa New Zealand are aged 50 years or older. There is an opportunity to harness the skill, knowledge, experience and wisdom these nurses have acquired in the health and social care system and in their communities by encouraging them to participate in governance.
There is little encouragement, information, process, training or general guidance for nurses who want to develop governance roles and skills. NZNO will create a governance toolkit to improve this situation.
- Develop a governance toolkit to provide the required information and guidance for nurses interested in governance roles in health and social care in Aotearoa New Zealand. The toolkit will have a factual and practical focus. NZNO has the unique ability to combine its expertise in professional nursing and its robust legal structure to produce this toolkit. To support this work, NZNO will develop closer working relationship with the Ministry of Women, the Institute of Directors in New Zealand, National Council of Women and the Māori Women’s Welfare League.
5.5 Executive leadership
Leadership, governance and practice are central to the nurse executive role. This is reflected in the critical accountabilities of strategic vision, organisational decision-making, practice innovation, and professional development and accountability.
The nurse executive role impacts on nurse performance and client safety, thereby making a significant contribution to organisational and population health outcomes.
The nurse executive in Aotearoa New Zealand:
- Follows a patient-centred philosophy and has the ability to convey the patient experience from “ward to board”
- Positively contributes to and /or leads service co-design and new models of care
- Interprets and applies the required standards and competencies, and is accountable for endorsing legislative and regulatory processes related to nursing
- Ensures that robust workforce data is measured, reported and actioned
- Is accountable for human and fiscal resource allocation for nurses
- Creates, supports and sustains a safe and healthy work environment by promoting management practices that support nurses’ health, safety and well-being
- Understands the complex challenges facing nursing
- Has extensive knowledge of the broader health system
- Manages clinical/management tension by utilising creative and empathic models of leadership
- Demonstrates strategic leadership to advocate for health equity and improving Māori health at local and national level.
Nurses require the authority to lead. Nurses are responsible and accountable at every level of their practice, profession and organisation but lack authority in relation to health-care decision making, distribution of resources and budget control. Impasses occur when a leader lacks authority, yet is accountable for results. This often leads to organisational stagnation, and frustration for the leader.
NZNO will use a partnership approach to:
- Prepare a leadership manual for DHB and other relevant chief executives on NZNO expectations of the nurse executive role
- Evaluate the proposed state services leadership programme to be rolled out to DHBs from 2018-2020
- Conduct a two-day political leadership seminar - “Impact and Influence” - for executive nurse leaders across all health sectors
- Advocate for the executive nurse leader role to be mandated in DHBs and report directly to the chief executive
- Conduct/facilitate a stocktake of primary health care nursing leadership roles within DHBs, PHOs, aged care and national service providers
- Create a nursing leadership infographic for distribution to health facilities and public places, eg libraries
- Recommend to relevant agencies that executive leadership rounds are consistently undertaken in each DHB or equivalent agency
- Work with DHBs to create a national director of nursing dashboard to track progress of critical nursing outcome indicators and health workforce information. This will use data from the CCDM core data set, and other relevant information.
5.6 Clinical leadership
Charge nurse managers (or equivalent roles across the sector) are responsible for managing people, systems, processes, the environment and resources to enable a high standard of patient care. The position is also accountable for budget setting, budget holding and business planning. These responsibilities ensure the safe effective running of an efficient ward/unit.
The charge nurse manager (or equivalent) is a pivotal role in clinical leadership. However, two thirds of nurse managers are frustrated and report low job satisfaction.
Who becomes a charge nurse manager (or equivalent)?
Nurses coming into the charge nurse manager position have usually demonstrated very good clinical skills and knowledge and have a temperament and work history that demonstrate leadership qualities. These attributes are important. However, leadership in a complex, fiscally-constrained and dynamic clinical environment also requires formal, ongoing coaching and support to enable charge nurse managers to effectively lead the ward/departmental team.
Barriers to leadership
- Many charge nurse managers do not have access to formal leadership education or ongoing mentoring and coaching. Starting in the role is often made more difficult by limited orientation or nurses beginning the role after the position has been vacant for some time.
- Leadership programmes in health are ad hoc and inconsistent in their programme content and methodology. There are a limited number of programmes, they have small classes, and programme entry is not always fair and equitable.
- Many charge nurse managers have a nursing staff of 30+ and a budget in excess of $3 million, along with the accountability of providing safe, effective care for those who use the service, but receive inadequate support and training for this responsibility.
It is imperative a consistent leadership and “know the business” programme is formally provided to charge nurse managers, either before or within six months of starting in the role. Follow up support (external clinical supervision, coaching etc.) is also critical. Such a programme should also be offered to associate charge nurse managers.
5.7 Point of care leadership
Leadership at the point of care encompasses two key areas of informal leadership by nurses:
- Leadership that engages others in clinical practice change, practice research, quality improvement or evaluation; and
- Leadership where clinical nurses play a key role in decision-making and development of a treatment plan.
- Point-of care-leadership is different from other types of leadership because it relates directly or indirectly to care, with leadership undertaken in all environments by point-of care-nurses who are not in a formal leadership role.
Point-of-care leadership is the source of future nurse leaders. If this leadership is acknowledged and enabled, it is both motivating and sustaining for the nurse, and results in safe patient care and positive work environments.
Individual, organisational and systemic support is required for nurses to best exercise point-of-care leadership.
Many nurses demonstrate excellent point-of-care leadership, though they may not recognise this, associating leadership only with formal roles.
- Create a compendium of information outlining the features of point-of- care leadership
- Use its website to create awareness of leadership opportunities for point- of-care nurses nationally and internationally
- Emphasise positive point-of-care leadership and its outcomes in health workplaces.
5.8 New Zealand nursing leadership - areas that require focus
Māori nursing leadership
Historically, Aotearoa New Zealand has produced outstanding nurse leaders. The tensions of walking in two worlds has been extensively noted and articulated through generations of Māori leaders. The disease management focused western model of health care challenges the holistic model of well-being and cultural practices. Our noted Māori nursing pioneer, Te Akenehi Hei, clearly identified this issue and it is still a reality for many Māori nurses today.
Early Māori nurses were pioneers for change. Originally trained to work only within Māori communities, their courage, knowledge and resilience - while trying to uphold cultural practices - helped to alleviate many deaths from disease during the 1900s. This training, and the desire of many young Māori women to work with Māori has steadily increased. However, the low number of Māori nurses in all areas of the health sector means their roles demand leadership responsibilities for which they have little formal preparation, training and resourcing.
Funding for Māori-specific leadership programmes must be assured and increased to offer Māori nurses the best opportunity to work within a Māori world view to improve the health of Māori and all New Zealanders.
The development and sustainability of Māori nursing leadership is a key strategy to ameliorate Māori health inequity and provide the greatest support for the Māori nursing workforce.
Te Akenehi Hei (1877-1910)
In 1909, Te Akenehi Hei became the first Māori nurse to be both a registered nurse and midwife. Like other Māori nurses she was sent into rural and often isolated areas where there were outbreaks of epidemic diseases and hardship. Hei herself later died of typhoid. Hei and her colleagues’ tenacity, endurance, passion and advocacy for nursing and their people helped halt Māori population decline in the early 1900s.
Although she noted the challenges of training under a western model of nursing and maintaining cultural ideologies, Hei realised the art of balancing health care and public health education without compromising one’s values.
In many ways Hei was a woman before her time and an agent for change. She challenged cultural competencies and awareness in healthcare and pioneered district nursing. She was a courageous leader and inspired many others to take up nursing during this time.
At the time of her death, the success of her work within Māori communities was recognised by the government and notable health professionals.
The Te Akenehi Hei Toputanga Tapuhi Kaitiaki o Aotearoa, NZNO Award acknowledges the significant contributions Hei made to nursing and Māori nursing, and is awarded biennially to a recipient who demonstrates leadership, engagement and contribution to the community.
Dr Irihapeti Ramsden (1946-2003)
Ngai Tahu/Rangitane Māori nurse, philosopher, writer and educationalist.
Irihapeti Ramsden was a nurse, anthropologist, educator and author who strived to help people understand how their own culture impacted on others. Best known for the development of Cultural Safety – an educational framework for the analysis of power relationships between health professionals and those they serve.
Cultural Safety has been part of the New Zealand nursing and midwifery curriculum since 1992 and is now part of nursing practice throughout the world.
Ramsden was awarded the NZNO Te Akenehi Hei Memorial Award. The Te Akenehi Hei Memorial Award for significant contribution to Māori health is the highest honour that can be awarded by Te Runanga.
Primary health care nursing leadership
Primary health care nursing leadership is currently patchy. Not all DHBs have invested in it and only some PHOs have a designated nurse leadership role. As more services are devolved to primary health care, there is a greater need for robust primary health care nursing leadership, and an agreed leadership training programme to underpin such leadership.
Aged care nursing leadership
Some of the large aged-care corporate organisations have realised the importance of nursing leadership and some have developed bespoke leadership programmes for their staff. However, it is important that medium and small facilities have access to leadership programmes. In contemporary nursing, leadership competency is essential for organisational performance and improved patient outcomes.
Outstanding leadership in the aged-care sector is required because:
- Residents’ health needs are becoming more acute and complex.
- The RN’s role is often autonomous and can be isolated from peers and related support
- The RN’s is working with a skilled but unregulated workforce
- The RN’s role is expanded, especially out of hours – eg, the RN is the first responder to acute and or emergency situations, is responsible for infection control, and oversees all staff and the physical environment while on duty.
Different initiatives throughout aged care and other health services demonstrate collaboration, usually in relation to sharing clinical expertise, eg, access to gerontology nurse practitioners or clinical nurse specialists employed by DHBs.
Mental health and addictions leadership
Mental health and addictions services in Aotearoa New Zealand are under tremendous strain and this imposes greater demands on nursing leaders. Services are mostly delivered in the community and through multiple NGO, DHB and private providers. There are many community support workers providing a good service; however there are few RNs supervising this workforce. Workforce training is variable. RNs often have little access to frontline leadership and management education. This must be addressed.
NZNO will use a partnership approach to:
- Conduct a stocktake of leadership programmes and the number of nurses who have undertaken such training. The stocktake would rely on voluntary participation of the organisations involved.
5.9 Current situation - the paradox
Nursing leadership is directly related to improved patient health outcomes. International and national research has established the significant contribution that quality nursing care makes to improved outcomes for patients.
“Healthy work environments, supported educational opportunities, effective nursing leadership, and enabling legislative and contractual arrangements hold the key to supporting nurses to provide quality care to patients” ~ Report from the National Nursing Organisations to Health Workforce New Zealand, 2014.
Decimation of Aotearoa New Zealand nursing leadership occurred in the 1990s, with the majority of nursing leadership roles disestablished or severely curtailed. Recovery from this leadership vacuum has taken two decades.
In the last two years this attack on nursing leadership has recurred in 20 per cent of Aotearoa New Zealand DHBs.
E Gilbert, 2017.
The above diagram reflects the stages of instability/stability associated with organisational restructure. The shaded oval area demonstrates the areas of suboptimal activity and lack of forward focus pre- and post-restructure. This reflects the amount of time that momentum and leadership cohesion is lost.
The effects of restructure on organisational culture is well known and is generally regarded as a blunt instrument in terms of organisational productivity and performance.
“How very little can be done under the spirit of fear” ~ Florence Nightingale