Paths to nursing leadership

TERESE BONDAS P hD , RN

Senior Lecturer, University College of Borås, School of Health Sciences, Borås, Sweden

Introduction

Nursing leadership is exposed to various organiza-

tional, economical, scientific and political demands. It is

concerned with the care of vulnerable human beings

and human encounters in health, pain and agony, and

close to matters of life and death. Nursing leadership

occurs in an environment that has become more and

more technological and complicated (Bondas 2003). It

seems to be an eternal task for the nurse leader to create

a balance between a caring patient, family friendly,

employee attractive as well as an economical effective

and smoothly operated health care organization. The

patients need to know that they will get the best poss-

ible known care, receive up to date information, and

also participate in care according to their ability. They

want to know who is responsible for their care (Ehrat

2001). Brandi (1998) metaphorically described nurse

executives on the managed care battlefield. However,

professional nurses are seldom in need of �commando-

management� but, instead, they need possibilities and

support to practice and develop nursing (Mahoney

2001, Bondas 2003).

The matters concerning the educational requirements

for health care leadership positions, and the rights to

administrative authority, have not been settled since the

Correspondence

Terese Bondas

University College of Borås

School of Health Sciences

S-501 90 Borås

Sweden

E-mail: [email protected]

BONDAS T . (2006) Journal of Nursing Management 14, 332–339

Paths to nursing leadership

Aim The aim was to explore why nurses enter nursing leadership and apply for a management position in health care. The study is part of a research programme in

nursing leadership and evidence-based care.

Background Nursing has not invested enough in the development of nursing lead-

ership for the development of patient care. There is scarce research on nurses� motives and reasons for committing themselves to a career in nursing leadership.

Method A strategic sample of 68 Finnish nurse leaders completed a semistructured

questionnaire. Analytic induction was applied in an attempt to generate a theory.

Findings A theory, Paths to Nursing Leadership, is proposed for further research.

Four different paths were found according to variations between the nurse leaders� education, primary commitment and situational factors. They are called the Path of

Ideals, the Path of Chance, the Career Path and the Temporary Path.

Conclusion Situational factors and role models of good but also bad nursing lead-

ership besides motivational and educational factors have played a significant role

when Finnish nurses have entered nursing leadership. The educational requirements

for nurse leaders and recruitment to nursing management positions need serious

attention in order to develop a competent nursing leadership.

Keywords: analytic induction, nursing career, nursing leadership, nursing management,

qualitative approaches

Accepted for publication: 14 September 2005

Journal of Nursing Management, 2006, 14, 332–339

332 ª 2006 Blackwell Publishing Ltd

days of Florence Nightingale (Gould et al. 2001,

Mahoney 2001). Duffield and Franks (2001), in their

review, describe a lack of formal preparation for the

transition and development of clinical nurses into

management positions. Many first-line nurse managers

lack appropriate educational qualifications to do their

jobs effectively. In Finland, 1-year educational pro-

grammes in administration have been arranged for

nurses since the 1950s. These programmes ended when

the university education in nursing science began in

1979. It was then possible to earn a master’s and a

doctoral degree. In the last few years, the university

colleges have arranged courses in health care adminis-

tration that vary regionally between 20 and 40 weeks,

but there are no separate degrees awarded. A back-

ground in nursing has been an important factor, and

still is a necessity for leadership positions at the ward

level in public health care organizations (Sinkkonen &

Kinnunen 1999, Academy of Finland 2003).

An effective clinical leadership requires competence

in research and knowledge of nursing care (Atsalos &

Greenwood 2001, Cook & Leathard 2004). It is also

seen as important that nurse leaders develop an under-

standing of a multiprofessional and transcultural care.

The nurse leaders need to have a clear understanding of

the priorities and the key stakeholders whom they serve.

Cooperation and communion within, and outside the

organization is desirable when it has an impact on the

prerequisites for care and valuing nursing (Duffield &

Franks 2001, Bondas 2003, Jones & Cheek 2003). A

pledge to identify and nurture a strong nursing leader-

ship has been set out. The purpose of this study is

therefore to explore why nurses enter leadership and

apply for a management position.

Previous research

There is scarce research on nurses� motives and reasons

for committing themselves to a career in nursing lead-

ership. Nursing leadership has an effect on both the

quality of care and on the organizational culture. There

is, however, a shift away from the core of nursing, the

provision of patient care (Duffield & Franks 2001).

McKenna et al. (2004) in their study of community

nursing, conclude that the traditional subservient cul-

ture of nursing is blamed for the perceived inability to

nurture strong leaders and there is a reliance on lead-

ership from General Practitioners (GPs). Community

nursing participants felt that they are either pushed into

management positions or that those nurses who become

leaders leave practice. Allen (1998) studied perceptions

and beliefs about leadership development by inter-

viewing 12 nursing leaders. Five important factors were

self-confidence, innate leader qualities, a progression of

experiences and successes including education, influence

of significant people who expressed confidence in, and

encouraged the nursing leaders, and finally personal life

factors such as family reasons with a daytime job or

finding a less strenuous position. For future nurse

leaders, they recommend reinforcing self-confidence,

acting as role models and mentors, creating opportun-

ities for progressive experiences and successes and fos-

tering continuous learning. All 12 participants

described a sense of self-confidence that had developed

since childhood with additional attributes of risk-taking

and education. Natural leadership tendencies and easily

getting involved were described by eight participants,

but only two nurse leaders described a desire to change

and improve nursing.

Purpose

The purpose of this qualitative study, which is a part of

a wider study in nursing leadership and evidence-based

care, is to explore, from the nurse leaders� perspective, their experiences of entering nursing leadership and

applying for a management position in health care.

Data collection

Data were collected using a semistructured self-reported

questionnaires developed by the researcher, based on a

pilot study and previous research. It has eight open-

ended questions that are focused on becoming a nurse

leader, and content relevant to nursing leadership and

administration. In this study, only the questions that

concern entering nursing leadership, and applying for a

management position in health care, are highlighted.

Demographic data about age, position, years of work-

ing life and education were also collected. A self-report

measure was chosen in an effort to avoid the problems

that could come with the structured interview where the

researcher’s presence might hinder the participants to

articulate the ways in which they conceptualize and

understand their own world (Johnson 2004).

Ethical considerations

The researcher tried to avoid exploitation of partici-

pants, acknowledging their vulnerability and respect for

them as persons. Ethical principles were applied. These

principles included the protection of human rights: the

rights to be informed of the study, the right to freely

decide whether to participate or not, the right to

Nursing leadership

ª 2006 Blackwell Publishing Ltd, Journal of Nursing Management, 14, 332–339 333

withdraw and informed consent (Orb et al. 2000). Each

participant was given an information sheet, in addition

to a verbal explanation and a possibility to ask ques-

tions about the study. Anonymity, meaning that par-

ticipants� identities were not revealed, was applied.

Participants

A strategic sample of 68 Finnish nurse leaders, from

both rural and urban parts of the country took part in

this qualitative study. The selection of the participants

was directed by the principle that the informants taken

together should give a broad picture of the area under

study. The participants answered the questionnaire at

the beginning of leadership courses held at four uni-

versity colleges, one university and one hospital. The

courses in which the participants were enrolled were

short continuation courses for nurse leaders or leader-

ship courses that were part of a master’s education. The

nurse leaders joined the courses with or without finan-

cial or other support from the organization where they

were employed.

The participants were all active in leadership posi-

tions as ward sisters or nurse executives in different

private and public health care organizations. Only five

of them were men, and this reflects the percentage of

men (7%) in nursing in Finnish health care organiza-

tions (Tehy 2005). Participants� educational back-

ground varied, all had a nursing background. A few

(5%) had completed master programmes, and 71% of

the informants had participated in various courses in

leadership and administration that had not led to a

degree. Additionally, 24% of the participating nurse

leaders did not report administrative education at all,

besides their nursing education. Participants� experi-

ence, as leaders, varied between 3 months and 26 years.

The age of participants was ranging from 25 to

55 years. The health care organizations where they

were employed had between 4 and 500 staff positions.

Only 5% of the nurse leaders were in positions with

authority, equal to chief doctors. The great majority,

95%, occupied middle management positions and

answered to the chief doctors. The unit leaders reported

to the nurse executives.

Data analysis

In this qualitative study, analytic induction was applied

to examine a number of cases to determine the char-

acteristics of a specific phenomenon (Johnson 2004).

The method is influenced by the constant comparative

method for grounded theory (Glaser & Strauss 1967).

Analytic induction is a set of methodological procedures

that attempt to systematically generate theory grounded

in the empirical world, and to focus on the variations of

a phenomenon, and not on its quantity. Analytic

induction consists of four phases. In the first phase,

access was gained to the primary phenomenon of

interest, i.e. nursing leadership and evidence-based care,

by using questionnaires. In the second phase, the phe-

nomenon was defined as the following research ques-

tion: why do nurses enter nursing leadership and apply

for a management position? Moreover, variations were

identified by reading and re-reading the data. An

in-depth comparative analysis was performed within

and between the data from different participants,

looking for both common and differing characteristics.

Variations were then categorized in terms of shared

characteristics and differences in cases. In the third

phase, a provisional list of case features, common to

each delineated category, was identified. Any deviant

cases that lacked case features, common to the cases

initially put in the same category, were re-examined. If

there were differences, the categories or case features

were modified to accommodate the findings. The case

features, shared by more than one category, and case

features unique to a category were examined. Shared

case features were regarded as necessary, but not suffi-

cient, for generating a category. In contrast, unique case

features were sufficient. In the fourth phase, a taxon-

omy of categories was constructed, and case features

elucidated to facilitate the theoretical development, best

explaining the collected data. This taxonomy was then

presented in a matrix. A matrix is essentially the cros-

sing of two lists, set up as rows and columns, and dis-

played as a table (Miles & Huberman 1994). Each row

and column was labelled, with rows representing the

unit of analysis. The columns represent the character-

istics that were found pertinent to the research ques-

tions. The matrix thus provided visibility to the process

of data analysis and enabled the theory generation.

Findings

The findings show that there were variations in the way

the nurse leaders had entered leadership and considered

applying for a management position. There were dif-

ferent patterns called Paths to Nursing Leadership

positions. The path was chosen as a metaphor to depict

the nurse leaders� descriptions. The path is not a simple

and smooth way forward; it is thickset but unique in the

area. The person has to make some