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WORLD PULSE: Global leadership challenges of nurses
Perspectives from members of RNL’s International Advisory Board

Nurse leaders from 14 countries were recently named to the International Advisory Board of Reflections on Nursing Leadership (RNL). To enhance the magazine’s global relevance, members of this board will be asked to respond periodically—for publication—to questions posed by the editor about significant nursing issues in their countries or global regions. In this first poll, advisory board members were asked the following two-part question: What are the leadership challenges of nurses in your country (or global region), and what is being done to address those challenges? Below are their responses.

— James E. Mattson, editor, Reflections on Nursing Leadership.

 

Lorraine Ferguson

Lorraine Ferguson, Australia
Health care in Australia is both privately and publicly funded. Universal public health care is available for all citizens, and a private hospital system can be accessed through personal health insurance. As in other developed countries, the public hospital system is large, strained by excess demand and limited resources. The health status of indigenous Australians is of grave concern.

Nursing in Australia is a two-tiered system with registered nurses, who are prepared at the undergraduate bachelor of nursing (or equivalent) level, and enrolled nurses, who complete a 12-month vocational education program. In many facilities, particularly in the aged-care sector, nursing staffing is supplemented by assistants in nursing. Many health care issues that are of concern globally are also of concern in Australia. These include:

• increased demand for all types of acute and chronic health services;

• need for improved efficiency, to increase access and throughput and to meet demand;

• recruitment and retention of all health care professionals;

• shortage of nurses in the workplace—in particular, in specialty areas such as critical and emergency care, midwifery and mental health—also of nurses willing to work in rural and remote areas;

• aging nurse work force.

All these issues impact nursing work and the health care system’s ability to recruit and retain highly educated, experienced and motivated nurses, this at a time when there are many career paths and challenging professions available and the nursing work force is predominantly female.

Leadership challenges for nurses in Australia need to be addressed through a number of avenues, including:

• Cultural reform in the workplace to reduce bullying and harassment, introduce shared governance frameworks and focus on improving quality and safety in patient care;

• Improved recruitment and retention measures, such as innovative marketing initiatives, family-friendly workplace policies, professional and leadership development support, succession planning, and public recognition of nurses as professionals in their own right and members of multidisciplinary teams that deliver health care;

• Work force and work practice redesign—currently, a focus on implementing new models of care and service delivery, redesigning services, changing skill mix and work roles to meet future health needs of communities, and making nursing more rewarding to improve retention;

• Bedside clinical information systems/nursing informatics systems that positively impact nursing work and nursing communications, and contribute to patient safety and quality of care.

Maureen Dobbins

Maureen Dobbins, Canada
Leadership is one of the most crucial attributes in nursing, with the potential to facilitate and/or hinder significant improvements in evidence-informed practice, quality improvement and quality of work life. A recent Canadian study found that leadership was the only statistically significant factor—organizational or individual—associated with sustaining implemented best-practice guidelines in nursing (Davies et al., 2006).

I think leadership challenges faced by nurses are multifaceted. They include such factors as limited training and capacity-development activities to facilitate leadership skills, limited opportunities to assume these roles, and competing demands on time as a result of more acutely ill patients and nursing shortages. I also believe that these factors predominate, from frontline nurses to senior management positions.

To address these challenges in Canada, two initiatives come to mind: The Executive Training for Research Application (EXTRA) program, funded by the Canadian Health Services Research Foundation, and the Swift, Efficient Application of Research in Community Health (SEARCH Canada) program, funded by several community partners including the Alberta Heritage Foundation for Medical Research.

The primary goal of EXTRA is to develop individual skills and competencies in research use, build organizational capacity to use research to manage and guide health system change, and foster interprofessional collaboration. The target audience for the program is health service professionals in senior management positions, including nurse executives. Participants in the program act as important agents of change within their organizations and the health care system.

The primary goal of SEARCH, from which EXTRA is developed, is to help health organizations make best decisions through development of people, relationships and information. This intense, two-year cohort experience combines learning opportunities through face-to-face modules, intermodule work and application of knowledge to practice-based projects.

Both programs have had an important impact on development of leadership skills among nurses in Canada. It is hoped that similar programs will be implemented across the country to increase the number of nurses exposed to these opportunities.

Reference:
Davies, B., Edwards, N., Ploeg, J., Virani, T., Skelly, J., & Dobbins, M. (2006). Determinants of the sustained use of research evidence in nursing: Final report. Ottawa, Ontario, Canada: Canadian Health Services Research Foundation & Canadian Institutes for Health Research.

Claudia K.Y. Lai

Claudia K.Y. Lai, Hong Kong SAR, China
There is no shortage of students joining the nursing profession in Hong Kong. However, in addition to a large number who had already retired in recent years, a staggering number of nurses opted for voluntary retirement after the Severe Acute Respiratory Syndrome (SARS) epidemic. Exacerbated by the developing private health services sector, the shortage of manpower has become intense, leading to staffing and morale problems. In an unusual response, Hong Kong nurses took to the street last month to protest their work situation to the government and to the Hospital Authority, the publicly funded independent body that manages all public hospitals in Hong Kong. How local nurse leaders guide the profession forward has thus become an important challenge.

The shortage is even more acute in long-term care. Hong Kong came close to establishing one level of entry into the profession—the baccalaureate degree. Regrettably, in response to the outcry over the nursing shortage in long-term care, the government approved reinstatement of enrolled-nurse programs in schools. (Enrolled nurses in Hong Kong are similar to licensed practical nurses in the United States.) This was a serious setback to the goal of establishing the bachelor’s degree as the entry point into the profession.

Another challenge for local nurse leaders is to have advanced nursing practice recognized and regulated. The Hospital Authority has made a tremendous effort to promote development of advanced practice nursing roles—e.g., nurse consultants, nurse practitioner positions—yet, to date, responses from clinicians have been lukewarm.

To achieve these objectives, nurse leaders need to lobby, because manpower planning is funded and regulated by the government. We have one nurse in the Legislative Council who represents the health care constituency. We will also have to lobby other legislative councilors for support. Local nurse leaders in the tertiary education sector and professional bodies are studying the nursing shortage and its impact on clinical services. Both are helping the voices of nurses to be heard. Our universities are collaborating with public and private sectors to develop degree programs to prepare nurses for working at different levels. Professional associations are also striving for development of advanced programs in their own specialty areas.

The planning of an academy of nursing to draft legislation for advanced nursing practice is underway. Nurse leaders from more than 20 professional organizations are uniting to move this cause forward.

Lisa Willers

Lisa Willers, Germany
The greatest leadership challenge facing nurses in Germany is empowerment. Nursing programs—typically three years of hands-on and theoretical learning—prepare new graduates to enter the work force with highly practiced skills as well as the necessary assessment and critical-thinking skills. Unfortunately, these nurses are never really given the chance to fully utilize this in-depth education. Doctors and residents are on staff around the clock in hospitals throughout Germany. Accordingly, many practical skills, such as IV insertion and almost all assessments, are performed by these doctors.

The struggle to empower nurses to fully use their skills is met by many obstacles, as doctors and residents continue to cling to traditional roles. However, with substantial health care costs and decreasing reimbursements, hospitals are being forced to evaluate their everyday processes, i.e., wound care, patient transport and scheduling of procedures, and their outcomes, i.e., lengths of stay, staffing demands and quality of care. To improve these processes and outcomes, hospitals are starting to initiate programs such as “discharge management” and “case management” that provide nurses with new roles and responsibilities and challenge the way the system works and the way the people within the system think.

Laura Morán Peña

Laura Morán Peña, México
The main nursing challenges in Mexico are:

• To have enough qualified human resources in nursing to increase health care coverage, especially among the most vulnerable populations.

• To increase the number of nurses who are pursuing or have completed graduate studies. This will provide, for universities and for nursing practice, better resources for innovation and evaluation of health care and nursing systems.

• To improve working conditions for nurses in health services, to make the profession more rewarding and to discourage migration.

• To promote usage of current telecommunication technologies by nurses and to encourage nurses to learn and speak a second language.

To address some of these challenges, Mexico’s Permanent Commission in Nursing, associated with the Health Ministry, seeks to encourage collaboration among collegiate nursing organizations and also with national and international associations in Latin America. This collaboration facilitates setting of guidelines with regard to nursing education and regulation of professional practice. The major universities in Mexico are developing graduate programs in nursing including, through cooperation with foreign universities, development of the doctorate in nursing.

Claudia Gamel

Claudia J. Gamel, Netherlands
One challenging area for nurses in the Netherlands—as well as other health care professionals and administrators—is patient safety. Associated problems and challenges are outlined in various reports, including Keeping Patients Safe: Transforming the Work Environment of Nurses (Page, 2004). In the Dutch nursing literature, numerous examples portray clinical nurse leaders and their patient safety initiatives. One example is the Safety First Program in a Dutch children’s hospital, which consists of four subprojects directed at 1) incident reports, 2) dangerous situations, 3) complication registration and 4) crew resource management. Another initiative is the fall prevention program developed for use by community nurses, which received a national nursing recognition award in 2005.

In addition to these clinical initiatives and strategies, nurses are also challenged to take a leadership role within national evolving programs such as the Hospital Certification for Safety Management Systems (in Dutch, the “VMS project”). The Netherlands Centre for Excellence in Nursing (abbreviated “LEVV” in Dutch) demonstrates organizational leadership by developing practice and research programs targeted at patient safety. A conference recently hosted by LEVV focused on promoting patient safety and attaining practice indicators in the areas of fall prevention, medication monitoring and decubitus. Both clinical practice leadership initiatives and organizational leadership strategies are being utilized and are essential for maximizing patient safety.

Reference:
Page, A. (Ed.) (2004). Keeping patients safe: Transforming the work environment of nurses. National Academies Press: Washington, DC.

Karien Jooste

Karien Jooste, South Africa
A major challenge for nursing in South Africa is to present a united platform to provide excellence in nursing education, research and practice. Firstly, a single framework for governance of nursing education is needed. Secondly, nurse leaders need a recognized forum to discuss important documents and to position themselves in international nursing organizations, African nursing organizations, and within and between different nursing organizations in South Africa.

In South Africa, nurse leaders need to be part of and consulted in new developments and initiatives taken with regard to health care delivery systems. Nurse leaders are involved in various nursing organizations throughout the world, such as the International Council of Nurses, Commonwealth Nurses Federation and International Confederation of Midwives, but collaboration, coordination, networking and feedback amongst these role players are absent.

The Department of Health recently launched the National Human Resources Plan to ensure that there is a sufficiently trained work force to deliver health care to all, although some nurse leaders are of the opinion that there are several obstacles to achieving an effective nursing strategy for the country. Furthermore, leaders in the younger generations need to be developed to empower them for national and international leadership roles. (It should be noted that, as in other countries, South Africa has leaders in both public and private sectors who pursue excellence. Dr. Manto Tshabalala-Msimang, the minister of health and leader of the overall health sector, has been ill for the past few months. Recently, Jeff Radebe has been appointed acting minister of health.)

Since 1995, the heads of departments of nursing in South Africa have met yearly to speak with one voice about the health needs of the country and to take the lead in directing and developing nursing practice, research and education. Universities with medical faculties have affiliated with the Forum for Health Science Deans (FHSD), gaining the respect of the minister of health and minister of education in South Africa.

A partnership among nurse leaders, the Department of Health, the Department of Education, the professional nursing association and the South African Nursing Council is a priority in addressing the challenges faced by nursing in South Africa. The Department of Health has sought to establish a national leadership and coordinating structure within health research, based on the principle that such an initiative should represent all members of the broad research community. The Department of Health has established the Hospital Revitalization Program, a comprehensive initiative to improve hospital infrastructures in all provinces and to strengthen the management and leadership capacity at those hospitals.

Adelaida Zabalegui Yárnoz

Adelaida Zabalegui Yárnoz, Spain:
Current Spanish health care is being influenced by trends that have a strong impact on the nursing practice. Major factors affecting health care in our European context are demographic changes and cultural diversity, biotechnological developments, economic and sociopolitical globalization, increased level of patient knowledge and decision-making, cost maintenance and reduction policies, and population mobility. In addition to such factors, the increasing complexity of nursing care in Spain is influenced by aging of our population, heavy patient loads for nursing staffs (1:15), instability of nursing staff positions, and a new nursing education framework (bachelor’s, master’s and doctoral levels.)

Although nursing in Spain has evolved enormously over the last 25 years, at present, nurses are hired only at a university diploma level. The new educational structure allows nurses to acquire all the competencies needed to cope effectively with health care challenges and changes. However, it is necessary for Spanish nursing associations and organizations to assume a more assertive and focused role to promote nursing visibility and representation in health care decision-making, and to take a more proactive approach to developing nursing as a true profession that reflects its academic competencies.

Marianne Gustaffson

Marianne Gustaffson, Sweden
The big leadership challenges for nurses in Sweden are:

• To encourage involvement of patients in their own care, and increase decision making by patients;

• To overcome hierarchical barriers that hinder involvement of nurses in decision-making processes;

• To advance evidence-based nursing practice.

In addressing these challenges, Swedish nurses need to:

• Strengthen and increase their professional knowledge;

• Create possibilities for development and a “learning climate” within health care organizations;

• Increase education at all levels with regard to leadership and management theories and strategies;

• Recruit, in collaboration with universities, PhD-prepared nurses to all specialities within hospitals to work with staff members and students.

Tony Leiba

Tony Leiba, United Kingdom
For mental health nurses in the United Kingdom, one leadership challenge is empowerment of service users. This concern requires changes in how mental health care professionals and volunteers, the mental health system, caregivers and families engage with users of mental health services. Issues of empowerment and involvement of mental health service users, caregivers and families with regard to services provided by mental health care professionals require thoughtful development. There are philosophical, practical, financial and ethical considerations.

The chief nursing officer’s review of mental health nursing (Department of Health, 2006) emphasizes the need for mental health nurses to ensure empowerment of mental health service users through incorporating principles of the recovery approach in every aspect of their practice. This means working toward goals that are meaningful to service users, being positive about change, and promoting social inclusion for mental health users and caregivers. These principles need to be reflected in training for mental health nursing and in organizational policies.

Empowerment requires understanding the perspectives of mental health service users and mental health nurses. Any such analysis must also address the concept of power within mental health systems, institutions and organizations. Furthermore, there should be recognition that mental health nurses and mental health service users must unite to pursue forms of knowledge that challenge the current hegemony of the medical and scientific elite.

Reference:
Department of Health. (2006). From values to action: The chief nursing officer’s review of mental health nursing. London: Author.

Karen Hill

Karen S. Hill, United States
The following are significant leadership challenges for nursing that impact nurse leaders on local, regional and global levels.

In 2006, the average age of a nurse in the United States was 46.8 years. This has implications for retention of staff nurses due to physical requirements of the job, for nurse leaders in regard to succession planning, and for nurse faculties, which are reported to have an average age of 55 years.

Nurse leaders need to collaborate with staff nurses to develop and implement new models and mechanisms of care delivery that support retention of senior nurses at the bedside, while promoting innovation, evidence-based practice and sharing of outcomes. One action that can be taken at many levels is to implement recommendations contained in documents such as Wisdom at Work: The Importance of the Older and Experienced Nurse in the Workplace (2006), recently published by the Robert Wood Johnson Foundation (RWJF), that identify best practices for hospitals to retain bedside nurses over age 45. To produce replicable data for implementation, RWJF has allocated grant funding of multiple national pilot studies to advance implementation of these practices.

Within their administrative realms, many nurse leaders are not exposed to the components of nursing practice. Moreover, leadership curriculums in graduate programs do not consistently expose students to preceptor and mentoring opportunities with nurse executives, networking that is needed for nurses interested in pursuing executive practice. Nurse leaders are interested, however, in supporting the growth of others within the profession, and such opportunities need to be expanded.
           
As they continue striving to meet market needs, schools of nursing in most states have done a good job of adding capacity for undergraduate programs. Within each program, priority must be given, however, to developing plans to ensure that faculty members are being mentored and to identify, from within the student body, those who can transition into roles within the nursing education community at large.
           
Balancing the rising costs of quality health care with diminishing reimbursement is a constant challenge for nurse leaders at all levels. Nurse leaders are working to quantify the value of nursing care and to relate the cost of this care to demonstrable patient outcomes, information that is now available to the public. Increasing scrutiny of these benchmarks will, I hope, support nurses—from staff nurses to advanced practice nurses—in advocating for optimal patient care.

Reference
Robert Wood Johnson Foundation. (2006). Wisdom at work: The importance of the older and experienced nurse in the workplace. Retrieved June 22, 2007, from http://www.rwjf.org/files/publications/other/wisdomatwork.pdf. RNL