Kate Khair, MSc, RN, RSCN.
Clinical Nurse Specialist - Haemophilia
The history of nursing is ‘littered with hierarchical baggage. From Nightingale up to the present day, nursing has often been saddled with so-called leaders who have merely maintained the status quo. Leaders, it is said, are people that have an ability to make others follow them…’ (Rowden, 2000).
Nursing has traditionally been seen as vocational profession, with the public’s perception of nurses as ministering angels at the bedside. Media images have reinforced the impression of nurses being concerned solely with the delivery of care. However, although nursing continues to be influenced by patient needs, nurses are becoming more involved in clinical decision making, executive and political management, as well as academic study and research-based practice.
Patients and their families rightly expect high standards of care from professional nurses but this is not always the case. Cunningham and Whitby’s study (1997) illustrates this dilemma. Their three-year study identifies the skills that promote effective leadership in senior nurses and examines how these skills influenced nursing at the bedside. After taking part in action learning programmes, nurses became more effective communicators, their confidence increased and they improved their ability to explore, question and support their actions. This research acknowledges that nurses are aware of the need to develop their roles as professionals who are involved in all aspects of care management and delivery.
Nurses have now begun to recognise the need to develop their role as clinical leaders, although they have been slow to do so when compared with their medical colleagues (Berragan, 1998). Reasons for this could include a lack of suitable role models or the current clinical grading pay structure, which keeps clinical nurses at the bedside while allowing less clinically motivated nurses to move into management or education (Buckingham, 2000).
Thus there appears to be a continued resistance to the development of nurses into leaders. But as recognition of the contribution that nurses make in society becomes apparent both within and outside nursing, traditional views, roles and practices will have to change.
Paediatric nurse specialists
Far-reaching inquiries (Kennedy, 2001) into events at children’s hospitals in the UK looked at issues such as organ retention and problems with surgical outcomes. While commending aspects of good practice, they have questioned the quality of service delivery and professional accountability within paediatric care in the NHS (Box 1). The investigations have highlighted several failures in the system, such as the traditional code of silence, the myth of professional infallibility, the general lack of comprehensive error-reporting systems and the fears of potential whistle-blowers.
Such events highlight the extended role that the paediatric nurse specialist (PNS) can play in clinical decision-making and the delivery of care to this susceptible patient group (Jones, 1995). However, the literature continues to describe nurses in the traditional role of delivering care at the bedside, omitting their increasing part in management and decision making (Antrobus and Kitson, 1999).
Health-care professionals are becoming more involved in making decisions about a child’s care through discussion and agreement on treatment plans with colleagues and parents, but many continue to pay lip service to the child’s wishes.
Research suggests that involving children in planning their medical care and potential treatment options is more likely to ensure their co-operation, in turn leading to improved health outcomes (Alderson, 1990). Lansdown et al (1996) state that children and young people ‘should have all the information they need to enable them to participate in their own health care’. Elliott and Watson (2000) say that children appreciate it when their fears are ‘recognised, understood and dealt with in some way’. This can be done through activities such as ‘acting out’, awarding bravery certificates and/or play therapy.
In London, the Stepney Community Nursing Development Unit found that even very small children were capable of providing powerful testimony about their lives and what they would like to change. The children understood that traffic, drugs, cockroaches and violence dominated their lives (Stepney Community Nursing Development Unit, 1995).
Children’s nurses must recognise that they play a pivotal role as advocates for the child and family. This is enhanced when the nurse listens to and comprehends the child’s views, plays an integral part in planning and explaining care, and promotes care delivery and management as part of a multidisciplinary team.
The NHS Plan (Department of Health, 2000) is based on the concepts of investment, reform and the needs of the patient. Following consultation on the government document, the public highlighted several priority areas for development, such as the need for more staff with new ways of working and high-quality patient-centred care. However, the report does not specifically address improvements in paediatric care, even though children and young people make up 25% of our population and face increasing problems with chronic illness and mental health.
The Children’s Task Force was created in the wake of the The NHS Plan, with the aim of delivering improvements in paediatric services through the creation of a National Service Framework for Children. By focusing on national standards and guidelines it intends to improve care delivery to children and their families (Brook, 2001). Nurse leaders should take advantage of the core goals of The NHS Plan by taking on new ways of working and adopting a leading role in the provision of high-quality patient-centred care for children.
Leadership in children’s nursing
Today, nurses can dramatically shape politics and policy. However, involvement in strategic areas of authority and responsibility requires effective nursing leadership that must be embraced both by nurses and their colleagues. To be involved in change management, clinical nurse leaders must be involved in making decisions related to that change (Pinkerton and Schroeder, 1988). Nurses will always work as direct care-givers within clinical practice, but they can also contribute actively to the nation’s health by participating in policy development at local, regional and national levels.
Antrobus and Kitson (1999) examined contemporary nursing leadership in the context of health policy, describing the profile of an effective nurse leader irrespective of nationality or health-care system. Common themes were identified in the skill repertoire of the future nurse leader (Box 2). ‘A leader is someone, irrespective of professional background and level within an organisation, who has influence over other people’ (NHS Confederation, 1999). To find their place within the management system nurses must identify their role and perspective of leadership.
Politics shapes nursing, so nurses must understand the influences and demands of society and lead colleagues in the shift towards more contemporary roles. Adoption of a leadership philosophy allows the nurse leader, through increased motivation and belief in a common purpose, to empower colleagues at all levels, by facilitating personal growth and development.
A transformational approach to leadership seems appropriate to paediatric settings. Girvin (1998) describes transformational leaders as visionary, inspiring, innovative and entrepreneurial. Many nurses, especially in paediatrics, where flexibility in care provision is vital, consciously or unconsciously adopt a transformational approach to their leadership style. The approach works best in small teams that have a defined client group and that function within a larger organisation.
The common belief that a multidisciplinary philosophy creates open and honest communication with a proactive rather than reactive approach to decision making and care provision is supported in the literature (Madge and Khair, 2000). The final children’s hospital inquiry report, Learning from Bristol (Kennedy, 2001), recognises this and recommends continuing joint educational programmes and team-based appraisals to enhance this.
The transformational model of leadership, therefore, not only provides power and inspiration to the individual and the team within which the person works, but also empowers the user.
Slowly, leadership in children’s nursing is changing. In Britain the advent of nurse-led services, particularly for children with chronic or long-term disorders, has promoted a holistic continuum of care that concentrates more on the needs of the individual and his or her family than the preceding medical models (Daley, 1996). This philosophy has enabled children to voice their opinions and make informed choices about health care and treatment. Children are now actively encouraged to participate in policy making for the development of services. With the support and encouragement of clinical nurses who are taking on a more active role in change management, the views of children and young people can also be acknowledged.
Cantwell (1989) recognises that children can act independently when they are given enabling rights, such as the right to freedom of expression and association. Throughout the world, children’s needs are developing on a continuum, changing over time. When PNSs work in partnership with each other and with children, well-planned comprehensive and co-ordinated services are promoted. By encouraging children to vocalise their opinions it can become possible for individualised services to be created, uniting all aspects of planning, care delivery and the involvement of outside agencies.
Over the past 10 years, nurses in the UK have been encouraged to become leaders. However, the pitfalls associated with this process, such as the failure to recognise the importance of teamwork, negotiation and change management skills, have not been acknowledged and, as a result, training and support have not been provided.
The changing health-care system and our role in it are a constant challenge, which we have been given little or no preparation to manage. To encourage clinical nurses to take a more active role in leadership, and in recognition of the lack of a clinical career structure beyond the role of clinical nurse specialist, the Government has created a new nursing role, that of nurse consultant, announced by Tony Blair (Brindle and White, 1999).
Nurse consultant posts will demand nurse leadership and change-management skills at the highest level. Nurse consultants must support and inspire colleagues, improve the quality of care and develop professional practice. This is achieved through clinical governance, providing expert input, working to secure quality improvement, including influencing other disciplines in the wider organisation and across organisational boundaries. The aim is to help deliver better services.
Blair’s announcement pre-empted the launch of a pilot study by the UKCC designed to assess higher levels of practice (1999). In consultation with users and providers of health care, the council recognised that some nurses, midwives and health visitors were implementing innovative practice at advanced levels. The pilot is being formalised and will eventually become a registerable qualification. While recognising the level of competence of some clinical nurses in the NHS, the UKCC is also aware of users and the need to offer them safeguards and validation of the quality of services.
Registration at a higher level of practice will ensure that not only will nurses be recognised for their contribution to health care at national and international levels but that, through education and information, the public can be assured of this. Alongside this initiative, the Bristol Royal Infirmary Inquiry (2000) recommended that good practice should be identified and disseminated to ensure that the public and media were genuinely and constructively informed. The report suggested that timely information be given to patients and carers, and that feedback from patients should be encouraged and their views acted upon.
In 1994, the UKCC ascribed higher levels of clinical decision-making to specialist nurses, whose skills can be developed via a range of activities (Box 3). The authors believe, however, that there is a difference between nursing within a specialty and being a nurse specialist, and it is perhaps the recognition of innovative intervention and leadership that differentiates the two. The UKCC Higher Levels of Practice pilot study, where active involvement from consumers, outside agencies and lay people in the assessment of candidates is mandatory, have supported this concept.
Health-care systems worldwide are constantly developing, as successive governments introduce improvement initiatives and innovative practices.
At present, fiscal and ethical decision-making in UK hospital trusts is the responsibility of an executive and chair at board level. Current practice suggests that decision-making partnerships should be formed with clinicians. In the most general sense, they should include staff from medical, nursing and allied professions, to allow all health-care workers to take responsibility for accountability both individually and at trust/ corporate level.
Clinical governance continues to rely on overall accountability remaining with management. Leadership, in this context, hinges on the principle of involving everyone who has an interest in health services within a local focus, developing effective relationships and creating dialogue (Malby, 1997). In practice, the nurse using leadership skills within a model of shared governance may be best placed to provide a seamless service for the patient and family, ensuring the provision of appropriate information and involvement in decision making with regard to specialist paediatric care.
This vision is further supported internationally by the World Health Organization’s Expert Committee on Nursing Practice (1996). It states: ‘Because of their in-depth knowledge and experience, they (nurses) have much to offer in the areas of health-care assessment and policy development.’
It is clear that the developing skills of the PNS as leader incorporate the ability to assess and implement the philosophy of clinical governance, and ensure equity and high quality of service delivery to all. Other models of leadership could, arguably, also be used - the most common of these models being transactional leadership.
Leadership is an evolving process, with continuous development both by the individual and within the system. The changes in the nursing profession and the NHS reforms have led the Government to demand effective leadership from clinicians and managers throughout the NHS. Nurses are not the only group to recognise the importance of this shift in culture, other professions are also preparing to play a more active role in planning and delivering care. Nurses, however, must not rely on others to lead this change but remember their responsibility to patients and play an active part in reform.
There is no doubt that within the scope of clinical nursing in the UK there is a need for nurses with a range of skills, from those delivering care at the bedside to political movers and shakers, who can be leaders not only of nurses but also their colleagues in the multiprofessional team. Leadership and management are not the same, and nurses do not have to take on a management role to become leaders. However, when nurses recognise the extended part that they can play within these roles their contribution will enhance and improve the service offered to NHS users.
Leadership in paediatric nursing enables colleagues to meet the challenges of the changing NHS, as well as empowering children and their families. Paediatric nurses as leaders must encourage and take the lead in child empowerment with regard to health-care planning and delivery, paving the way for adolescent and adult involvement in the NHS services of the future. To this end, the responsibility of the PNS undertaking a leadership role includes raising children’s rights on political and social agendas: locally, nationally and internationally through involvement of the wider community and appropriate use of the media (Boyden, 2000).
It is therefore obvious that the aim of leadership is not only to achieve cultural change but also to bring about that change (Manley, 2000). Leaders in nursing have been described as either the ‘visionary plant’ or the ‘shaper’ (Rowe, 1996).
These roles involve collaboration within multidisciplinary teams to provide an improved service for patients and families. The PNS is therefore best placed to adopt the mantle of leadership in children’s nursing, as the client group places increasing responsibility on these nurses. They are in an ideal position not only to recognise children’s needs and acknowledge their requests and demands but also to promote a specialist service in the NHS.
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