Directors of nursing: Caught between a rock and a hard place?

1 August 2014

Are today’s directors of nursing “disempowered” and “disconnected”? Kerri-Ann Hughes’ PhD research attempts to “make sense” of where (and if) nursing power sits in New Zealand’s public hospital system.


Once upon a time, there was one nurse to rule them all and she was called ‘matron’.

Matron (or principal nurse as the role came to be known) was part of the traditional triumvirate of hospital management power – the hospital administrator, the medical officer, and the matron.

While ‘matron’s’ actual power in that triumvirate may have been more mythical than reality, the health reforms of the late 1980s and 1990s saw the triumvirate thrown out to be replaced by a chief executive (CEO) and a generic management structure built around services delivered and not the health professionals who delivered them.

So out also went the operational line of reporting from the nurse at the bedside up the nursing chain of command to the principal nurse. Sitting at the top of the traditional hierarchy, the matron or principal nurse had been not only nursing’s professional leader but also often held the purse strings and decision-making powers for the nursing workforce.

Researcher Kerri-Ann Hughes says the shift to directors of nursing (DoN) under the new “managerialism” climate “disempowered” nursing. Nursing still had professional reporting up and down to a top nurse, but the operational reporting – and with it, usually the budget and decision-making powers – now went via service managers up the line to the chief executive. The hospitals’ nursing leader appeared to have been largely sidelined to a professional and clinical advisory role.

Hughes, a nurse and teaching and research fellow in Massey University’s School of Management, decided to focus her PhD research on “making sense” of the modern director of nursing role and how it fitted into the decision-making process of public hospitals from a management and nursing perspective.

“The loss of senior nurse leadership was one of the major casualties of the reforms and this loss of leadership becomes one of the factors that influences the visibility and authority of nursing leadership during the period of this research (2006 to 2012),” says Hughes in her thesis.

Hughes first wrote a paper exercise comparing 13 of the DHBs’ overall organisational structure charts with their nursing structure charts and found in nearly all cases the structures bore little relationship to each other. The charts left the impression that nursing was “siloed” within the organisation and the DoN’s status in the leadership structure was “ambiguous”.

She then went on to survey DHB DoNs and CEOs (see sidebar for more details) to get their own perceptions of the DoN’s organisational role and responsibilities.

This didn’t make things that much clearer. Hughes says while the perception given by the DoNs was that they had a voice at the executive decision-making level, the comments by the CEO indicated that the ‘voice’ of the DoN was regarded predominantly as an ‘advisory voice’.

Too often, she got the impression that many “DoNs struggled to be heard” and “they weren’t visible in the board room”.

About half of the DoNs had faced having their roles restructured in the previous five years; one had faced “disappointing” talk of disestablishing the DoN role and another said they had been demoralised by being left “hanging” for months.

Hughes also found that while most DoNs had strategic oversight of the hospital’s spending on nursing – very few had operational budgets per se, and in most cases, it was only a nursing department budget covering professional development and a small unit of staff, such as educators and associate directors of nursing.

Instead, it is the service managers who have the operational budgets that feed down to the charge nurse managers and the RNs. Hughes says this leaves DoNs with a “huge disconnect” between their professional oversight role of operational budgets and their power to influence what is happening at the coalface.

One DoN reported frustration at dealing with service managers with no clinical background who did not consult them over decisions “potentially affecting clinical outcomes” or “being overruled due to fiscal concerns”.

The CEOs spoke positively about the working relationship with their DoN, but again, they most commonly described the role as a professional and clinical advisory role. Despite this, a number of CEOs also expressed an expectation that DoNs be accountable for nursing resources and one CEO said a “greater balance between clinical and financial accountability was needed”.

The contradiction was not lost on Hughes. The managerial model that had “disempowered” and “disconnected” nursing – by taking away responsibility at the operational reporting level and budgetary control – still wanted accountability.

She says having both professional and operating reporting lines going through to a nursing leader and full financial accountability is the definition of a professional practice model of nurse leadership outlined by the research-backed Magnet hospital process. The Magnet process has identified nursing leadership has the ability to impact on patient outcomes.

It is also interesting that the DoNs in her research talked of their first priorities for nursing being “safe professional practice”, “safe staffing”, and “patient safety”.

“The focus on safety implies that practice and staffing are unsafe, and given the regulation and educational standards nursing has as a profession, the perceptions of ‘being in an unsafe situation’ is a damning indictment of how the organisation is operating,” writes Hughes in her conclusion.

Talking to Nursing Review two years on from her initial research, Kerri-Ann believes there are signs that things may be changing and improving on the nurse leadership front.

“With the focus on more frontline staff and the bringing back of clinical governance … you are starting to get more influence for nursing coming through with the new clinical structures being put back in place. [There is also] the emphasis on quality.”

“As a researcher, I believe there needs to be support to (the) nursing voice, not only clinically but also strategically, due to the complex environment in which nursing is operating.”

“It’s about getting them heard in the boardroom and making their voice count,” says Hughes. “Probably some of them would say ‘that’s happening for me’.”

Kerri-Ann would like to see that become the accepted norm for nursing leadership in the future and not the exception.

DHB DoN and CEO research findings 2006–2012

  • 17 out of 20 DHB DoNs took part in survey
  • Average age was 45.5 years
  • Average time nursing 16+ years (6 years as DoN)
  • 13 DoNs had a Master’s degree or PhD
  • Of the then 19 DHB CEOs surveyed, there were 10 responses (2 from COOs)
  • 3 CEOs came from a nursing background and 1 from a medical background.