Thrown in the deep end: learning nursing leadership the hard way

1 November 2012

Sonia Gamblen talked to 13 clinical nurse managers about the often ad hoc and haphazard path from bedside nurse to ward leader. Her research findings prompted a call for improved leadership and management training for nurses and her own local solution.

Being thrown in at the deep end has always been a questionable way to teach someone how to swim.

But nurse leader and researcher Sonia Gamblen found that nursing in New Zealand – and internationally – is little better in the way it prepares nurses for leadership roles.

Her Masters in Management research project was prompted by observing that clinically trained nurses were expected to suddenly become managers simply courtesy of a title change. While senior nurses progressing into advanced clinical practice roles were encouraged, and often funded, into further training, their colleagues moving into management were often as not just thrown in at the deep end.

“So it would strike me that often the sister (clinical nurse manager) positions were struggling in some ways. Some did it quite well, while others would struggle,” says Gamblen. “And it all seemed to be about chance, personality, or networking ability whether they sunk or swam.”

Not their chosen path

She set out to identify the leadership and management requirements for nursing by talking to 13 clinical nurse managers (CNMs) about their own career pathways and preparation for the role.

“The (CNM) position carries responsibilities that are many and varied and include standards of practice, recruitment, staff retention, role modeling, appraising, disciplining, budgeting, materials management, general maintenance, and staffing often over the entire 24-hour day, 365 days a year,” summarises Gamblen in her research report. The CNMs are also often involved with wider organisation decision making and service development, so their position is crucial to both the running of the organisation and patient outcomes.

But she found that all but two had landed in their CNM roles by chance rather than consciously setting out on that pathway – often through ‘acting up’ while somebody was sick or falling into the role as they were the ward’s quality or roster person.

For example, one participant was asked to step in to cover for a CNM vacancy in a short-staffed ward going through “challenging times”, and described her acting role “as bit of a firefighter dealing with issues as they cropped up … I didn’t think I would ever be a manager”.

The participants also often belonged to the generation that had nursed in the 1990s when nursing leadership roles, like charge nurses and directors of nursing, had been stripped out of the health system, leaving them with few role models.

One started as staff resource nurse in a ward stripped of its charge nurse, but found her role kept growing and growing. Another, when asked about the stresses of the CNM job, recalls starting when the ward was seven FTE (full-time equivalent) nurses down.

Crossing over to the ‘dark side’

The international literature shows that nurses are often promoted into CNM roles based on their clinical nursing abilities, and sometimes, length of service, but it is rarely linked to management qualifications or leadership ability.

Making the move from a clinical to a leadership role can also be a lonely one, with Gamblen saying nurses often talk about it as ‘crossing over to the dark side’.

Being promoted into management was “rarely mused over with relish or excitement” or much time put into thinking about whether they had the ability or skills to do the job; but it was seen as an achievement and a chance to “make things better for the team”.

Gamblen says most of the CNMs she spoke to said their promotion “just happened” or “just evolved”, but when spoken to further, it was clear a number had also felt the need to step up into the role to fill a leadership vacuum or because they were worried somebody else would “mess it up”.

Many enter the job with little understanding of the change in skills needed from being an RN working on the floor to permanently managing and leading a team – the result can be a shock.

“I was terrified when I first started and lost about 5kg through nervous energy; I had a total lack of confidence in myself. I hadn’t had any training or done any extra study around management style,” one participant said. The lack of support once in the position was also “voiced time and time again”.

Overall, Gamblen found that preparation for the role of CNM was “generally ad hoc and retrospective and is certainly not standardised”.

She believes nursing can do a whole lot better.

Valuing, and training for, leadership

At present, nurses are being sent mixed messages about the value of leadership.

There is a government emphasis on clinical leadership but little-to-no back-up in funding or training for nurses wanting to pursue that career path. For that matter, there is no clear career path.

Gamblen says her own health management masters was not eligible for Health Workforce

New Zealand funding but was supported by her district health board.

“All the [HWNZ] postgraduate funding is really geared to clinical development rather than leadership and management.”

Likewise, the Nursing Council’s competencies requirements are geared towards the clinically practising nurse with four ‘quite vague’ competencies for nurses working in clinical management roles. Gamble says this belittles the role of CNMs and other senior nursing positions: “Specific competencies would show more status and respect.”

Gamblen believes HWNZ and the Nursing Council need to reassess what training they fund and approve to become better aligned with government expectations of clinical leadership roles.

There also needs to be set management and leadership competencies and a clear, equal status pathway for nurses wishing to pursue management roles. Training and education for such roles should be a mix of postgraduate learning, practical skills acquisition, experiential and opportunities for ‘shadowing’ leader role models.

Local CNM training answer

On the local front, Gamblen has put her research findings into action by developing a leadership programme for clinical nurse managers at Tairawhiti District Health Board.

Since March, the CNMs have been heading off-site as a group for the regular education sessions.

The DHB has worked with a local training provider to come up with sessions on a range of skills from managing complaints and computer skills to budgeting and staff appraisals. The facilitators work with the CNM’s service managers, so the managers know what is being taught each session and can ensure it is relevant to the DHB’s internal systems.

“Their managers then meet with them [CNMs] afterwards and coach them through some of the linkages between what they’ve learnt in the sessions and some of the problems manifesting on the ward,” says Gamblen. “It’s like a workshop where they practise some of the scenarios.”

She says the training has been well received by the CNMs, particularly working with managers to put their learning into practice.

It is also a positive step up from the past, with CNMs telling her during her research that they gained the essential skills for the role by “trial and error”, “on the job”, or “by making mistakes”.

Gamblen would like to see the day that clear career paths, training, and competencies are available for nurse managers, so stepping into leadership roles isn’t so often an unexpected plunge into the ‘deep end’ – and more nurses can emerge swimming, not spluttering.

Call to make director of nursing positions mandatory for all DHBs

Memories of when New Zealand stripped its nursing leadership in the 1990s are still fresh in many nurses’ minds, Gamblen found during her research.

The UK-trained nurse started her research just two years after arriving in New Zealand in 2006 and became aware of the “somewhat fragile and precarious environment in which senior nursing positions operate in

New Zealand”.

Her research project was written up before she herself stepped up into an acting and now permanent director of nursing position at Tairawhiti District Health Board.

She believed then, and still believes, that role modeling is important and that it should start at the top by making the director of nursing (DoN) position a mandatory requirement for all district health boards.

“In New Zealand, there has only been a DoN for each of the 20 DHBs since 2007, so that shows how young the role is really in New Zealand.”

It also shows how fragile the role is.

“We’ve only got them now because the group of DHB chief executives value the DoN position, but should political persuasion dictate otherwise … who knows?” says Gamblen. “You’ve always got to have a chief executive, but you don’t have to have a director of nursing.”

Gamblen says in the UK, it is a requirement to have a director of nursing on a health service’s board of directors. She believes

New Zealand needs to put something similar in place and that the DoN role should have designated managerial and leadership functions rather than just professional influence.

Sonia Gamblen was recently confirmed as director of nursing for Tairawhiti District Health Board after acting in the position for 18 months. She carried out this research project for her Masters of Management degree (health services management) while associate director of nursing.