‘Balance your books then cover your ass’ – why nursing leadership needs to change

We need to focus on the job in hand. Nurses by Shutterstock

Having recently completed a 50-year career in nursing and health research and development I am often asked to talk to newly graduating students. At one such event recently, I shared with them some examples of how nursing has changed over the lifetime of my career and how it will dramatically change in theirs. This often raises a lively conversation.

The nursing profession in England, as elsewhere in the world, has gone through significant transformation. Now a graduate profession, nursing has become more evidence-based, more nurses carry out research and are self-employed or work for agencies and subject to more public criticism for an occasional lack of focus on its most vulnerable patients. And a series of public inquiries that have found nurses guilty of poor care have hammered its reputation.

A number of papers in a recent special edition of the Journal of Research in Nursing (JRN) broached the subject of whether nursing was in crisis – the recurring themes that emerged were leadership, the focus of nurses’ work, the impact of failing national economies and a need for strategic engagement by nurses into healthcare systems.

Leadership issues

When I talk to those entering the profession, their most consistent concerns relate to the public opinion of the profession. But it is professional leadership that appears to be of greatest concern to nurses starting out – and, in the course of my research, I repeatedly hear the view from junior nurses that senior nurse leaders, despite donning blue uniforms and “walking the floor” are difficult to speak to and unapproachable.

Baroness Audrey Emerton – the only nurse sitting in the House of Lords – said in a recent article that she didn’t think “we have our leadership training right at all”. She suggested that despite leadership courses being widely available they were clearly having little impact on nursing practice.

Senior nurses are called executive nurses, though some don’t refer to themselves in this way. Their dislocation from our own Royal College of Nursing (RCN) is very disappointing, even though the organisation has tried to engage with the profession’s leaders and leadership though the establishment of the RCN Executive Nurse network. However, the Royal College has some work of its own to do in order to work more effectively with the most senior nurses, as its focus on pay and conditions alienates many of them from more active engagement with the RCN.

Wider interests

Sadly for the profession, some of those who occupy our most senior nurse executive posts actively ape general management models that embrace secrecy and elitism and establish “closed organisations” for their own ends. In my own editorial for the JRN I attempted to raise this debate. This formation of cabals within the profession means that organisational reputation and corporate image will inevitably over-ride professional nurse leadership responsibilities.

For a clear articulation of where this leads, author and philosopher Ray Tallis describes an emerging set of loyalties for doctors, a picture in which the ethical demands of the Hippocratic oath have degenerated into “first balance your books then cover your ass”. This has a powerful resonance for nurses too and has surely contributed to present problems in finding and keeping executive nurse appointments.

The resolution lies within our own profession; no one but nurses can change it and some senior nurses must now step up to the plate, to help to prepare a next generation of leaders and put developing the profession before a selfish and misplaced corporate drive for particular employers. However, it will not get any easier for the nursing profession and its leaders any time soon.

A wider threat

In the UK, delivery of healthcare still rests in great part on our globally admired National Health Service. It is loved by people who use it, by the clinicians who work in it and, as we approach a general election, by politicians who have all (without exception) declared this love by offering increases in finance and workforce numbers.

These declarations offer important insights into an inherent problem: because the NHS is loved and politicians recognise its importance, there is a continuous temptation for politicians of all parties to criticise, reorganise and then re-structure healthcare services. The most recent manifestation in England is the Health and Social Care Act 2012, which has changed the commissioning and delivery of services towards those with clearly vested interests.

Responses from professional associations and royal colleges have been muted, with one or two honourable exceptions led by the Royal College of Nursing (RCN) and the Royal College of General Practitioners (RCGP). Others such as the Academy of Medical Royal Colleges and the NHS Confederation have been missing from the debate. This is lamentable and will come back to haunt us all in due course.

Equally as disturbing is a European Parliament proposal (the Transatlantic Trade and Investment Partnership or TTIP) that will open up English healthcare provision to the predations of private healthcare companies in the US and elsewhere, making us liable for the “access and trading rights” of privateers.

There is little evidence that this offers any advantage – and the drive for shareholder dividend may well over-ride the importance of clinical nurses being marshalled by a strong executive nurse who actively leads their profession. The importance of such leadership and its positive effect on patient safety has been repeatedly demonstrated by research in Magnet hospitals in the US, where awards are given for nursing excellence.

Our much-loved NHS is clearly at risk and nursing and its senior leaders must find a place to comment loudly and with purpose if they are to lead us through such a difficult period.