ACN Nurse Leadership White Paper FINAL
ACN Nurse Leadership White Paper FINAL
Contents
Introduction 4
Defining leadership
Patient outcomes
Financial performance 9
Retention 10
Challenges
11
Bibliography
12
Citation: Australian College of Nursing (ACN). 2015, Nurse Leadership, ACN, Canberra.
ACN 2015
Introduction
Australias health care system faces a number of complex and interconnected challenges in providing
high-quality, innovative and cost-effective care into the future. These include an ageing population
increasingly affected by chronic disease, rising health care costs, technological change and the need to
improve the equity and accessibility of the health care system, including for Aboriginal and Torres Strait
Islander people. The need to maintain and, in some cases, improve safety and quality will be an ongoing
priority. These issues are likely to play out within a context of economic uncertainty and nursing workforce
challenges, as health care organisations and governments seek ways to contain the costs of care delivery,
improve productivity, and recruit and retain skilled staff. This will require change in the way health care
is delivered, models of care and the role of all members of the health workforce.
Nurses1 will be a key contributor to Australias ability
to meet the challenges described above. The nursing
and midwifery workforce represents more than half of
all registered health practitioners (HWA 2014; AIHW
2014) and accounts for a significant proportion of health
services expenditure. Nurses work across all sectors and
settings of the health care system and are integral to the
delivery of a range of health services, from communitybased primary health care to inpatient care in the tertiary
sector. Nursing is a diverse discipline which encompasses
a range of overlapping roles, including:
delivering clinical care
patient care coordination
driving safety and quality improvements
health service development and systems management
research and education.
As a profession, nurses take a holistic, patient-centred
approach to care. Nurses assess and monitor changes in
patients health status, develop care plans, deliver clinical
nursing interventions, support patients self-care and
evaluate patient outcomes. Nurses are often the frontline
of health care delivery. As a result, they play a critical
role in identifying and responding to changes in patients
health status, preventing adverse events and supporting
patients throughout their care journey.
Workforce projections indicate that without reforms there
will be a significant shortage of nurses into the future
(HWA 2012), making it critical that retention strategies
are implemented to enable the nursing workforce to
continue to meet the needs of the Australian population.
The availability and appropriate distribution of a nursing
1
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Defining leadership
At its heart, leadership is broadly accepted to be about influencing others to accomplish common
goals. In nursing literature, it has been described as a complex and multifaceted process which involves
providing support, motivation, coordination and resources to enable individuals and teams to achieve
collective objectives (Davidson et al. 2006; Wong and Cummings 2007).
Management and leadership are distinct concepts,
although in practice there is significant overlap and
interconnection between management and leadership
roles. Management is centrally concerned with operational
aspects of planning, organising and monitoring service
delivery. In contrast, leadership is fundamentally about
creating a long-term strategic vision and enabling people
to work towards change. It involves developing a shared
sense of mission; tackling political, organisational and
resource barriers; and inspiring and motivating others
(Kotter 1996).
Effective management in complex environments requires
leadership, but leaders are not necessarily managers.
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Knowledge of health
care systems
Societal
Nurse
Leader
Models of care
Strategic
contributions
to health
care policy
Informed &
experienced
perspectives on
health care
Effective
health outcomes
Economic
Organisational
culture & structure
Clinical
leadership
Patient outcomes
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leadership, in particular, tends to support nurses selfefficacy and sense of competence in the workplace
(Salanova et al. 2011).
Leaders play an important role in driving change in
nursing units, including both cultural and practice change.
Researchers have pointed to nurse organisational leaders
key roles in creating positive practice environments which
support patient safety, particularly at the level of the nurse
unit leader (Duffield et al. 2011). Nurse leaders at the unit
level can role model behaviours such as mentoring and
demonstrate their commitment to creating a learning
environment by valuing feedback from patients and staff
and encouraging professional development (Metcalfe
2010; White 2011). They can also lead improvements in
service delivery which support a shared interdisciplinary
focus on the patients goals rather than a siloed approach
to care delivered by different interprofessional groups
(Keenan et al. 2014). Strong clinical leadership at the unit
level is also needed to drive changes in nursing practice
within evidence-based practice models (Lusardi 2012).
Researchers have suggested that emotionally intelligent
leadership may be able to address dysfunctional
workplace relationships by modelling organisational values
and managing conflict. Nurse leaders who are focussed
on outcomes and targets to the exclusion of people
and relationships may be slower to address a culture of
bullying and are more likely to attribute workplace conflict
to individuals rather than organisational practices and
policies (Hutchinson and Hurley 2013). Leaders are able
to change workplace culture by modelling professional
behaviours, socialising new members, using effective
conflict resolution techniques and implementing a zero
tolerance culture for violence and bullying (Tomey 2009).
Financial performance
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Retention
Organisation structure
& leadership
Nurse
Leadership
Improving health
outcomes
Maintaining productivity
& cost effectiveness
of health services
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10
Challenges
The importance of nurse leadership positions has been recognised internationally in a number of key
documents including the Institute of Medicines report, The Future of Nursing and the report of the Mid
Staffordshire NHS Foundation Trust Public Inquiry (the Francis report). Despite the recognition of the need
for nurse leadership at the highest levels, nurse leadership positions are not always secure within health
care organisations and the wider health system. Nurse leaders currently occupying formal leadership
positions at all levels sometimes lack the resources, visibility or formal authority to be optimally effective.
This section briefly outlines the key barriers that exist in
relation to ensuring that nurse leaders are able to make a
maximal contribution to driving change from ward to board.
A critical challenge is to ensure that health care providers
maintain nurse leadership positions at appropriate levels
within organisational structures (Kings Fund 2009). In the
current economic climate, there is a risk that the redesign
of health care organisations management structures
may result in the removal of nurse leadership roles at the
executive level, as happened in Canada in the mid-2000s
(Storch et al. 2013). There must be organisational support
for visible and influential nurse leadership roles at the level
of the nursing unit, middle management and the executive
leadership team. In a system that is facing workforce
challenges, financial imperatives and questions, at times,
on the quality of care, the key contribution that nurse
leaders can make must not be ignored. For those in nurse
leadership roles there are other threats that undermine
their capacity to contribute to the fullest possible extent.
At the unit level, the most significant threat is underresourcing of the role. Nursing unit managers may find
that there is a mismatch between their perceived authority
and their actual influence within the organisation, which
can undermine their ability to lead. The ability of nurse
unit leaders to balance conflicting demands and provide
effective leadership depends not only on their preparation
for leadership roles, but also on the organisational support
and recognition they are given in terms of time, resources
and personnel.
An excessive administrative burden can draw nursing
unit managers away from clinical leadership, mentoring
and communicating with their teams, which reduces their
capacity to provide day-to-day leadership and develop a
strategic vision for the unit (Locke et al. 2011). In 2008,
the Report into Acute Care Services in NSW Public
Hospitals (the Garling Report) noted, with concern, that
Australian College of Nursing | Nurse Leadership White Paper
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