Understanding leadership in community nursing in Scotland: The ...

Haycock-Stuart, Elaine, PhD, RHV, RM, RGN;Baggaley, Sarah, BSc, SCM, RHV, RGN;Kean, Susanne, PhD,...
Community Practitioner; Jul 2010; 83, 7; ProQuest
pg. 24

Understanding leadership in
community nursing in Scotland
Introduction
HS;
kllult
PlIO, RHV, 11M,RGN
SenIor 1ecIurer,IMiIIIsIty 01 dInburgh
IEIIIIIIe

.....

.....,

Nursing

BSc. SCM, RHV, RGN

leadership

.....c.-

or define exactly what

leadership

recent policy identifies

of multiple

reforms.

the qualities

AIootnoct
1IIert Is limited evidence an:eminC ieadeBIIlp in
communllr nursing. NItS policy also tails to clarify and
deIIne what IeadenhIp Is, tI10ufI regarding ~ as key
to dMIopIng sara andhigII quallIr care.
This paper repor1s the ftndl"" 01 a """"n:h study.
thai aimed to IdaIIIIIJ how leldelsblp Is pereaIved
and~bJCOII1RIIIIitr_andto

aims.'7,'
dependent
patterns

enacts

In communllr nuosli1g. Mixed

quaIIIaIMI metIIods .... usad IIIIoIvIng 31 Individual
Intarviews and 111"" locus fOIl"" wItb communllr
nurses and nuoseleadefs (n-39) In 111"" health
boanIs In ScoIIand. FIndIICs IndIcata the laadelShijl
quaIIIIas vaIuad bJparticipanls.1I1duding
the Importance of leaders' vlslbitllr_ Team IeadeIs In particular
.... ~fDrtheirvisIbIIItJ
and clinical leader~
andpmfessionaIlaadelShlp
was less

carelO,1I

dMIopment

so acIing as a banIef to the development

1111 profession. The ~
vision was often not
avIdant,

claar to communIly _

and they ~

01

In

dIIIIrtng W8JS III1h the sIrataIfas and action plans

senior nurse IeaderI. New leadefshlp roJes. like

of

cMnat. need tina to ewoIIe andnew Ieadars need

spece and the educ:IIIon to dMIop 1eadenhIp.
Future laadars In communllr nurslni need to focus be!
Ond cllnlcalleadarship. ansutingthal good leadership Is a process requiring Int8nIapendence btIween
leaders and follooars.

are

adding

involves goal attainment.

nursing.
clinical
responsiabout

Research

that it is the

nursing

grades
nurse

of

leadership

nurses. 12,13

leaders

require

their activities

across

It seems

that

different
that

congruence

and their values and beliefs

yet available for community

of individuals

is not

nursing.

study that aimed to:

Identify

how leadership

experienced
Examine

and

community

policies10,14.15
of good leader-

involving

being

in community
nursing leaders
in frontline
community
nurses in

interviews

written

boards

and

then

transcribed

was approved

ethics

departments

health

where

an understanding

matters

and the policy emphasis

on improving

leadership,

the

quality

that
of

focus
in

Following

all semi-structured

consent,

development

Despite

three

inter-

views and focus groups were digitally voice-

and

leadership

and

in Scotland.

developed
Scotland.

methods

nurses and leaders in

with a total of 39 participants

The study

is

in

nursing.

community

recorded

this

recent

development

Method

understanding

how

between

leadership

and

nurses

This study used mixed qualitative

ship for quality care. However, there is little

of

is perceived

by community

the interaction

policy

three health
of recent

to achieve a common

Purpose

31 individual

Background
the importance

is a

influences

This paper reports the findings of a research

groups,
publication

'Leadership

an individual

acute

between

in order to be effective - this evidence

suggests,

process whereby

roles

leaders

shape

Leadership

goal' (p3).21

community

of nurse

involves influence

As Northouse

values

beliefs

to be central components:
is a process

of

nursing.

for.2

the following

within

group

so that

but

patient

from the acute setting indicates

and

is complex,

are considered

to those

is aiming

occurs in a group context

is a lack of research

in community

Leadership

development
leaders

organisation

to this transfor-

have taken on increasing

leadership

the

leadership

in different

Leadership

skills are

within community

bility. There

that

result

Leadership

new leadership

dimensions

otherwise

ntight

the conceptu-

within an organisa-

of leadership

quality

vision

alisation

care

leadership
Leadership

is necessary for

it

the leaders to be clear about

Leadership

to deliver

the

new

reinforces

PrrIai_, 2010; 83(7): 24-8.

primary

in
to

leadership.16-19

nursing

Consequently,

in recent policy reflect transfer-

and behaviours

mational leadership, which is considered

some studies as particularly
suitable

and

How

have emerged
nurses

as

nursing.
of

nursing.

Current
roles

reconfigured.

as being essential

mation

as care shifts

changing

is redefining

identified

nursing

to the community.

policy

community

The

Commrmity

complex.

signalled

identified

tion.

community

responsibilities 23,7,8

_lnethel_~_poIIcyand
IeIdeIsbIp

more

from hospitals

services

is

to policy drivers and changing

has become
has

care

that it expects

qualities

For effective leadership,

of these

Safe and high quality

on good leadership.?

and behaviours

I. The

in community
both

is, though

of leaders.

nursing

care.S8 Developing

of morbidity,

policy

nursing

care and a shift from

role of nurses

In response

have

improvement

key to achieving

is

is

in the nature

quality

to community

the leadership

and

of community

emphasising

nursing

policy'

to drive change

functioning

hospital

and

Recent policies'"

across all of health

LBcturer,lJniveIsItyofEdinburgh

Existing NHS policy fails

to clarify adequately

teams,

811, RGN,IISc

in community

leadership

rapid change due to the impact

and

01 Edinburgh

is limited.

by politics

the potential

Reseen:h assocIate.lJniveIsIty

around

nursing

undergoing

UnIvonIIy 01 Edinburgh

PhD, MSo:, RN, DIpH

evidence

influenced

~andhelllll_~,
....

in the UK is directly

committee
boards

and

from April to December

were

recruited

verbatim.

by the research
the

research
of the

data

and
three

were gathered

2009. Participants

by cascading

information

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

about

the study through

the health

via the nurse directors.

within

boards

Data were managed

NVivo 8 software.

The research

Table 1. AfC band of participants

team

board

by health

Health board 1

Health board 2

Health board 3

Sand 2

Band 4

Sand 5

FIndings and discussion

Sand 6

Demographic

Band 7

Band 8

undertook

thematic

views

sought

and

themes

The

analysis 22

of the inter-

agreement

on the key

of the analysis.

profile of participants

39 community

assistants

nurses,

interviewed

leaders

represented
(AfC)

and

a range

of Agenda

for Change

community

roles (see Tables 1 and 2),

The interviewees
experience

had

between

community
indicates

and

over 500 years of

them

nursing

bands

in

of working

(see Table

3), which

an ageing workforce.

More

members

health

of district

visiting

teams

nursing

were

reflecting

the

current

community

nurse workforce

than

interviewed,

profile

Executive level

of

the

in Scotland.

Table

Roles of participants*

2.

Role

Number

District nurse (qualilled)

14

Community staff nurse

12

Health Yls~or (qualilled)

SChool nurse (quallfled)

Nursery nurse

Health care assistant

Increasing the visibility and Ihe Imporlance

Acute care maneger for community sector

of community

Assistant nursing director

Director of nursing

nursing work

Community

nursing

considered

invisible-!

suggests

has previously
and

been

evidence

that this is often still the situation.

However,

strong

address

the

nursing

leadership

invisibility

can
of

help

" Team leaders have been assigned according to their qualification either as a district nurse or
health visitor, while one lead nurse and both nursing directors had acute care backgrounds

to

community

Table 3, Years of experience of working in the community

work, as this lead nurse indicates:

I think it's that bit about trying to explain to

people

that

we have

community,

very sick folk

that you live in a community.

have huge health challenges

we

because there's a

kind of feeling within healrh, 1 think, that

all sick folk are sitting in the hospital and
we're doing all the, you know, cups of rea
and
"there, there" stuff-and
we? I mean,
This
senior

nurse

health
that

continued

board

was sometimes
board

that

management

necessary
many

community

real health

care

1.2).

lead

one

to the

ill in the

are

board

the

level, it

to explain

people

at

member

had

expressed to the lead nurse that they did not

know that a patient could have two long.
term conditions
nursed

autonomy

community
attraction
This

and a wound

be

and still

at home.

The

nurses

enjoyed

by

many

is often

seen

as an

to working

preference

community
following

in the community.

for independence

workforce
district

Years In current
community position
(n-37)
Years qualilled as
a nurse
(n=35)

is pointed

in the
out by the

nurse:

14

25.85

51038

32

15.37

2.51030

26

" Two nursing directors are excluded from this sample

"Two health care assistants and two nursery nurses are excluded from this sample
this sample

lead nurse would - she cascades information

to us if things are changing in rhe [Child
Health Promotion programme}, if there's

culture

gonna be new ways of working

is exactly

like that (District

However,
autonomy,

nursing'

We do manage.

know, our own caseloads,

you

our own staff. It

would only be if there was problems that the

there can be a downside

argued

this context

and

managing

(Team

questioning
in community

to this

to the invis-

work in the community.

that 'there's

It

one team
of

community

1.1),

the effectiveness
nursing.

that

not a culture
in

Leader

question

of how

implicitly

of leadership

Indeed,

there

is the

workforce

the lack of visible

nursing

general

NHS and recently

larly in relation
One district
the distance
frontline
nurse

that

to the demands

makers,

generations'

has

'no
can

leadership

in

has exposed

the

of others such as
managers

in the

social services.

to health

visiting

nurse explained

particuwork.

how she sees

and lack of visibility

community
leaders

that

or management'

It could be argued that it

be led effectively.

policy

a service

of leadership

community

as it can contribute

is also within
leader

or anything

Nurse 3.1).

ibility of nursing

leading

83 Nurrber

11026

t Two health care assistants, two nursery nurses and two nursing directors are excluded from

We tend to be ... we manage ourselves as much

\bIume

8.8

Years of experlenca
In community nurslngt
(n-33)

as possible. you know.

....,. 2010

Number of respondents with

over 10 years' experience

Renge (years)

we're not at all, are

we're doing

(Lead Nurse

Mean (years)

in the

nurses

as being
perspectives

akin
within

COMMUNITY

and

between
senior

to different
a family:

PRAcnnoNER

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

25

~ I've never worked at that leveL 1 have

very little contact. I see these people ... 1 can
only imagine that when you go to the next
level, you're worrying about the level
that's reporting to you, so it's different
problems, you know. It's like having ...
grandchildren, you know. At the moment,
I'm just concerned about children, I don't
have any grandchil- dren level to worry
about. So once J get to that stage, you know,
you will have a bit of input but you don't
have ultimate control, so it's the parents. So I
think it could be just a bit like that, like a
family tree (District Nurse 1.3).
Essentially, the more levels within the
nursing hierarchy, the less likely people are
to really know and understand the experiences and views of the nurses beyond their
immediate level of the hierarchy. This
reinforces the invisibility of both the
leaders' and followers' work. This organisation of leadership is in sharp contrast to
the leadership literature, which frequently
argues the transcendence
of effective
leadership at alllevels.12,13.24.25
Leadership in this study was very much
experienced
within
the hierarchical
structure of the NHS, and either appeared
to be running alongside the managerial
hierarchy or was synonymous
with
management. A top-down approach to
leadership was common, with little interaction between senior leaders and frontline
nurses. While 'being visible' was one of the
leader qualities often mentioned by participants, the organisation of leadership within
a hierarchical NHS structure had implications for the visibility of their leaders. Data
suggest that the leaders who did not have a
'visibility' problem were team leaders - a
relatively new leadership
role in
community nursing. Where there were
tearn leaders, nurses felt that:
I would say (that the team leader is]
definitely more - what's the word! She's ... she's
there and we know she's there and she's
around all the time ... And she, you know,
she is in and out... interact quite a lot.
so, you know, although it', no specifically
maybe been for me to go and do things,
you know, it's probably been more for
Band 6,. But ,he's definitely more around
(Staff Nurse District Nursing 1.4).
While this is a Band 5 staff nurse, she
suggests that their team leader 'is definitely
more around' and thus visible and accessible. This view is substantiated by other
nurses across the sample but also by the
team leaders, who understood the importance of their visibility and made efforts to

be visible to lead the frontline community

nurses delivering the direct patient care. It
can be surmised from the data that clinical
leadership is developing well within
community nursing with the new team
leader roles. Strategic and professional
leadership were not quite so evident.
It is evident from the current nursing
leadership literature that the focus within
nursing remains on developing clinical
aspects of leadership.te There is no doubt
that the nursing profession needs clinical
leaders but, as Antrobus and Kitson's
framework shows,' leadership goes beyond
clinical leadership to encompass political,
clinical executive and academic aspects.
Barriers
Trying to introduce leadership at senior
level into community nursing has been a
slow process, with some people in key
positions blocking or sabotaging the
leadership process. It appears that nursing
still has a culture that tends 'to eat their
young and doesn't celebrate success at all'
(p74)." This nurse director explains the
resistance she has had to overcome in order
to strengthen strategic leadership in the
community nursing workforce:
It's taken me three years really to bring the
senior nurses together and then to develop
this, so it's been a slow developmental
process, but .. I was often frustrated with
the speed ... and would it ever happen, but
it certainly feels like it (Nursing Director

There is a complexity to policy that is

often overlooked. It became evident in
interviews that 'policies' came from
different directions, including national.
local health board and local council
policies, all of which have an influence on
the delivery of community nursing
services. The extent to which different
polices
interrelated,
complimented,
contradicted or even counteracted each
other remained unclear.
What was important was that leadership
was seen to have a pivotal role in translating
the policies into action plans for the
frontline community nurses delivering
direct patient care. As nurses moved into
new leadership positions - the team leader
role, for example - they recognised the
relevance of policy for practice and patient
care, more so than they did when purely
delivering direct patient care. In contrast,
frontline staff seemed to have relatively
little engagement with policy in their dayto-day work. Arguably, not having a good
appreciation of the policy context left many
nurses weakened in the power struggles
with senior nurse leaders around changes in
patient care delivery. Some of the strategic
changes were not welcomed by frontline
community nurses, as they felt the changes
were not in the patients' best interests, but
the community nurses were unable to
engage adequately with the political debate
to advocate for the patients regarding
opposition to some of these changes.

1.1).

Interpretation of the data suggests that

there is a lack of strategic leadership from
within community nursing that, in turn.
functions as a barrier to the development of
the profession. This insight is supported by
other studies that point toward a still
existing leadership crisis and a lack of
suitable nursing leaders.2s27
Policy and leadership Interaction
Policy had a direct impact on setting the
goals, priorities and strategies for people in
senior
leadership.
Leadership
in
community nursing has become very much
focused on policy delivery. This is evident
when a lead nurse explained:
I think there is a lot of policy ... and the
policy is
national that needs to be
translated and then there', the local policy
and then there's the council policy. So
there's lots of different policy directors
(laughs) coming in there and
I think part of it really is kind of synthesising
that, really, in some ways in taking it
forward
(Lead Nurse 1.2).

Leading and following

Leadership was viewed as positive when
leaders listened, consulted before implementing changes, respected and valued the
contributions
staff were making to
community nursing, explained why things
were changing, had an understanding of
different policy agendas and motivated
staff to develop the service with them. The
following contribution was typical across
the sample.
What makes a good leader! Someone who
bas.: is aware of obviously the national
changes that are going on within community
nursing. Someone who has got a vision for
that and actually sees a way of taking that
forward. Someone who consults with their
staff and has consultation but also listens
and takes ... on board our concerns. And also
someone who... 1 think someone who
actually sees it from our perspective as well.
you know. Someone who sees what it's like
for people working in the community. That

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26

COMMUNITY PRACTmONER

July 20SD

\blume

83

Number

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

would

be what

vision

and strong

know (Health

described

being listened
tokenistic,
kept

views

and the nurses

in the dark

Key points

you

negatively

that

they

to. consultations

their

with

qualities,

1.1).

was viewed

nurses

valued,

say. Someone

leadership

Visitor

Leadership
the

I would

Community nursing needs a clear, shared vision from which people can lead and follow

when

were

Leadership is a social process between people, and not leaders doing things to people

not

Community nursing needs conceptual clarity in defining leadership

were seen as

were

not

Community nursing needs more political awareness among the workforce

being

felt they were being

about

changes

and why

how

all of this change would

fulfill a vision.

changes were happening.

When asked if
nurses were consulted
about changes, the

and

following

synonymous

contribu_tions

emerged:

J always feel we're consulted.

if

but you feel as

the end decision's already made before - you

know, it doesn't matter how much you say
and what - there'S been a latta changes lately
and a latta things that have been quite major
changes and so there's been a lotta consultation in that, you know, it's-it/eels
tokenism

(Staff Nurse District

Tokenistic
described

consultations
as having

to several major
Analysis

indicates

that participants

a process,

resulting
that

from

they

a numpty'

Nursing

2.4), but rather

want

that

to

Nursing

the

(Staff

follow'

interplay

not

simply

Nurse

viewed

I would

District
leaders

look

(Staff

is

Some nurses

would

'follow

'somebody

across

that good leadership

leaders and followers.

dear

been

in relation

place

service changes.

indicated

were

1.4).

had

taken

the sample
between

a bit {like]
Nursing

as

up to and

Nurse

District

3.2). It was very much the choice of

the nurse - the follower - to follow a particular

leader.

This

perception

corresponds

with the view of Binney et al,28 who argue

that

leadership

answer,

but

is not about

very much

knowing

the

about

the leader's

ability to tap into the collective

intelligence

and insight
order

challenges.

and organisations

in

and find solutions

to

of groups

to collaborate

This suggests

ship between

leaders

that the relation-

and followers

is a key

aspect of leadership.29,30

Good leaders

are said to 'have a vision',31-33

and whether

there was 'a vision'

board

suggest

that

areas
the

communicated

was

vision

to staff

in all the

unclear.
was

often

Data
not

in such a way that

staff knew either about the vision or where

the way forward
of community
community
Many
leaders

was. The future

nursing

direction

was elusive to many

nurses.

community
explained

nurses
the

and the nurse

vast

amount

of

change taking place in community

nursing.
but few of the participants
were clear about

.JIIty

2010

\bIume

83 NLntter

described

ways

situation

Leadership

by many community

understood

to

to

Community

but

to

happen

you need to lead it

leaders

(Lead Nurse 3.1).

there were a number

of nurses

who

believed

were really of little conse-

For some of them, the importance

of change
almost

seemed

to have passed

them

suggests

leaders

that

the

by

better

registration.
greater

gets excited

with

to undertake
the nursing

differing

perceptions

in the data

in which community
are engaging
with the strategic

suggest different

policy

political

of nurses
leadership

within

agendas.

plans

of senior

nurse

ConclusIons
Leadership

in community

nursing

Community

nursing

needs

rewards

vision

which

people

change

and

and

all

emotions

while a number

old ways of working,

the

change

are sticking

stagnating

number

of competencies.

As Huston+t

suggests,

these would include

the ability to:

A coping

that

result

in

is too fast does not enable real

some of the community

is perhaps

what

nurses were reflect-

ing on when they said that there had been

As a consequence

of too much

change too fast, the vision becomes

followers.

does need change,

too fast can equate

and

environment

This

can lead

in community

will need

of

is to stand still.

to happen.

a clear. shared

clinical

them, with which

change

that

facilitate.

nursing

going on around

drivers

GaD

in a state of

change

policy

leadership
from

needs

is something

Future

of the amount

that

strong

whicb

follow.

as a consequence

change

visibility,

to

apathy

change

ways

action

and

produce

and engage with the

with

leaders

educa-

roles from

profession

challenges,

nursing

to
and

able and willing

engaging

for

nurses

through

greater

no change.

meet

pre- and post-nursing

leaders. Essentially, there is a community

workforce
with a proportion
of nurses

Arguably,

to

leadership

Such efforts should

number

about, but nothing really gets carried through.

1.2).

and apply

practice

for

programmes

you know (Staff Nurse District

Nursing

their

prepared

bandied

everybody

in

all

change
evidence

skills in helping

need

There is a need for community

be

and

in
The

directions.w

kind of pretty static ... there's a few things get

about

leaders

changes

tional

strategy

policy

level, Essentially.

nurses to understand

engagement

can bring,

effective.

and

preparation
processes.

community
strategic

completely:

and

as leadership

to become

nursing

need

actually. In the 10 years I've been here, it's

nurses
vision

and educatIon

to develop,

at grassroots

I don't think there's reany been much change

These

and

needs to create 'space'

and effort

management

in the community

that the changes

quence.

for practice
nursing

leadership

takes time

nurses

the change,

actually move it forward,

However,

leadership,

makers need to allow time for real change to

to manage

working

for

was

mean change:
You need

Implications
Community

or more of the

of working.

to develop

as being

as opposed

which was viewed as contain-

ment of the current

same

change

with leadership

space in which
this takes time.

they have little or no engagement.

Leading and change

health

Several nurses
management,

fit together

unclear

Integrate
mobility

beyond

and

new technology
and portability

interactions
Develop

the

develop

'a

creating

that facilitates
of relationships,

and operational
expert

recognises
Understand
processes

processes

decision

an organisational

Community

with little or no

to focus

Develop a global perspective or mindset

about healthcare and professional issues

but too much

change for some community

nurses. As part
of this change, new leadership
roles need
time to develop and new leaders need the

leaders

making,
culture

that

quality health care

and

Balance authenticity
expectations

intervene
with

Be visionaries and proactive

to rapid cbanges in everyday

in political
performance
in response
health care.

COMHUNITY PRACT1TIONER

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27

must be remembered that leadership is a

social process that happens between people,
reflecting the need to work with people as
opposed to leaders doing things to
people.w In community nursing, there
should be more of a focus on the process of
leadership, rather than the attributes of
leaders. Leadership is a process involving
many more people than the leaders.

~ It

Acknowledgments

The authors thank the participants who

took part in the research for giving freely of
their time and thoughts in relation to the
focus of this research. They also wish to
acknowledge the financial support of the
Queen's Nursing Institute Scotland, which
made this research possible.
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22 Thorne S, Kirkham S, MacDonald-Eames'.

Interpretive description: a noncategorical qualitative
alternative for developing nursing knowl~
Research in NUrsing and HeAlth, 1997; 20: 169-n.
23 Low H, Hesketh [. District nursing: the invisible
workforu. London: Queen's Nursing Institute, 2002.
24 Edmonstone J. What is clinicalleadenhip?
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COMMUNITY

PMCTTTlONEA

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