an overview of the role of nurses and midwives in ... · portugal 21 germany 23 belgium 24 slovenia...

An Overview of the Role of Nursesand Midwives in Leadership and

Management in Europe

Hilary Watkins, UK HOPE National Coordinator

“Leadership is too important to be left to develop by chance asnurses gain experience. Instead, leadership must be part of their

training and the jobs they do from the very beginning.”(Canadian Health Services Research Foundation)

© Copyright NHS Institute for Innovation and Improvement and the European Hospital and Healthcare Federation 2010

An Overview of the Role of Nurses and Midwives in Leadership and Management in Europe is published by the NHSInstitute for Innovation and Improvement, Coventry House, University of Warwick Campus, Coventry, CV4 7AL.Copyright in this publication and every part of it belongs to the NHS Institute for Innovation and Improvement. All rights reserved.

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Contents

3An Overview of the Role of Nurses and Midwives in Leadership and Management in Europe

FOREWORD 4

EXECUTIVE SUMMARY 5Introduction 5Summary of Findings 5

EMERGING THEMES FROM THE STUDY 8

SCOPE 10

BACKGROUND 10

METHODOLOGY 12

FINDINGS FROM QUESTIONNAIRES 13Summary of the European national perspectives 13Key points arising from the national questionnaires 13Key issues arising from Table 4 in relation to provision of training 15Organisational perspective in selected countries 15Key points arising from the local questionnaires 16

FINDINGS FROM EUROPEAN VISITS TO SELECTED ORGANISATIONS 20Sweden 20

Portugal 21

Germany 23

Belgium 24

Slovenia 25

Malta 26

Appendix 1 - Summary of identified education supporting Nurse Leadership in healthcare 29

Appendix 2 - Full analysis of national questionnaire responses 32

Appendix 3 - Organisations visited or contacted 37

Appendix 4 - Bibliography 42

An Overview of the Role of Nurses and Midwives in Leadership and Management in Europe

Foreword

4

All European countries are confronted with everincreasing demands on their health system. The pressures from ageing populations, costs of newtechnologies and increasing expectations within limitedresources places politicians in challenging positions andseeking innovative strategies and solutions.

Leadership is critical to the challenge of improvingthe health of our populations and the ways in whichhealth care is delivered. Over the past decade highprofile reports around poor quality and safety of carehave regularly hit the media. Building greaterleadership capacity and capability within healthsystems, facilities and services is now a matter ofurgency. Yet as very large employers we are morefortunate than many as we have considerablenumbers of staff whose aptitude for, and interest in,leadership and management can be identified andnurtured internally.

There is a movement across many Europeancountries to enhance clinical leadership andengagement. In the UK, the NHS Institute forInnovation and Improvement (NHS Institute), inconjunction with the Academy of Medical RoyalColleges has developed a Medical LeadershipCompetency Framework (MLCF). This applies to alldoctors at all stages of their training and careers andwill mean that in future all doctors will have attaineda core set of leadership and managementcompetences. This should mean that doctors willseek to be more engaged in planning, organisationand transformation of services and potentially moremight seek to move into formal positional leadershiproles.

Other clinical professions in the UK also recognisethe importance of including similar leadership andmanagement competences in curricula and trainingprogrammes and a study is currently being led by theNHS Institute to ensure that all clinical professionsincorporate an agreed set of leadership andmanagement competences similar to that introducedfor doctors.

We need to find ways of identifying and developingthose staff from any discipline or profession whodemonstrate leadership potential. Delivery of healthcare is a team activity; leadership similarly has to be

shared and distributed across a health system andwithin organisations.

This report seeks to share the learning from a studyundertaken by Hilary Watkins on behalf of theEuropean Hospital and Healthcare Federation andNHS Institute of the role of nurses and midwives inleadership and management across a number ofEuropean countries. Nurses and midwives accountfor more than 30% of the healthcare workforce andit is important therefore to ensure their contributionto leadership at all levels is maximised. It is veryevident that there are many different models ofeducation and roles. The position and status ofnurses and midwives differs according to the historyand cultures of each European country. As the reportstates quite clearly there is no ‘one size fits all’ butwhat is clear is that all countries recognise the needfor effective leadership to drive improvements inaccess, quality, outcomes and productivity.

We hope that all who read the report will find some‘pearls of wisdom’ from the examples described.

This has been a good example of partnershipworking between the two organisations and we aregrateful to Hilary for carrying out this study.Inevitably with such a quick and relatively smallsurvey we may have misrepresented some of theinformation but hopefully the general content of thereport should be of wide interest and help informany new strategies aimed at enhancing theengagement of clinical professionals, particularlynurses and midwives in leadership.

John ClarkNHS Institute of Innovation and Improvement

Pascal GarelEuropean Hospital and Healthcare FederationMay 2010

Executive summary


IntroductionHealthcare organisations are complex and theirmany professional networks are key to influencingchange. The need for change arises from increasedpatient expectation, changing demographics,improved technology and newly availabletreatments amongst others. The requirement forstrong leadership has never been more important toensure organisations can respond to thesechallenges. Nurses and midwives account for morethan 30% of the European healthcare workforceand hence have a vital part to play in leadershipand management.

The European Hospital and Healthcare Federation(HOPE), in conjunction with the NHS Institute ofInnovation and Improvement (herein after ‘the NHSInstitute’), is exploring different ways in whichnurses and midwives are engaged in leadership andmanagement and how they are prepared for suchroles. This builds on a project undertaken by theNHS Institute to enhance medical engagementwhich included the development of a MedicalLeadership Competency Framework (MLCF). TheMLCF applies to all doctors at every stage of theirtraining and career.

This report provides a comparative study ofEuropean countries to establish:

• The variations in organisational arrangementswith a particular focus on the role of nurses andmidwives in leadership and management

• The extent to which nurses and midwives areengaged in leadership, management andtransformation of healthcare

• Learning that may be transferable to the NHSand other European healthcare systems.

The 27 EU member states were invited toparticipate through completion of a nationalquestionnaire. 17 of the questionnaires werereturned (63%). In addition, six countries wereselected for more detailed review – Sweden,Portugal, Germany, Belgium, Slovenia and Malta.Midwives warrant separate mention as, in countries

which offer direct entry training, they do not haveto train as nurses prior to specialisation.

Organisations visited included small and largehospitals (both acute and psychiatric), universities,other educational institutions and nursing andmidwifery associations. During the period of thestudy over 100 interviews were undertaken with awide range of senior and middle managers from avariety of professions.

Summary of FindingsNo country selected for more detailed review canbe said to be representative of the part of Europe inwhich it is situated, nor of any other Europeancountry. However, by reviewing countries fromNorthern, Southern, Central and Eastern Europeand the Nordic region, it is possible to gain someinsight into the variety of healthcare managementmodels. In addition the national governance policiesdirecting such models, and specifically the issue ofcurrent nursing and midwifery leadership in healthcare, give an indication of the potential for thefuture.

Despite the publication of Directive 2005/36/EC1 in2005 it is clear that there are still significantdifferences in the education of midwives acrossEurope. However, the scope for midwives to havean equal claim with nurses on wider leadershiproles was not disputed although the acceptance ofmidwives in such roles by other professionals was aconcern for some.

The Role of Nurses and MidwivesThe role of the midwife varies considerably acrossEurope. For example, Swedish midwives supportwomens' health from pregnancy through to theentire reproductive years. However in Slovenia andMalta, where planned home births are rare, themidwives role is predominantly to support theobstetrician during the mothers hospital stay for thebirth of her child. This is relevant to the study ofleadership as it is apparent that both the educationlevels and the level of autonomy in the role affect

1 Directive 2005/36/EC of the European Parliament and the Council 7 Sept 2005 on the recognition of professional qualifications ‘guarantees persons havingacquired their professional qualifications in a Member State to have access to the same profession and pursue it in another Member State’

An Overview of the Role of Nurses and Midwives in Leadership and Management in Europe6

the self-esteem and the confidence of the midwifeto develop as a potential leader.

The role of the registered nurse does not varysignificantly across Europe although this cannot besaid to be true in the development of specialistnurse roles. However, despite an increasingemphasis on multi-disciplinary working, there is stilla perceived superiority of the medical profession inmost hospitals. This is seen to arise due to thehigher educational achievements and the legalresponsibility for clinical care resting with them.This perception is shared by doctors and nursesalike although it was more evident in universityhospitals. Within these hospitals there was a clearpreference for management to share a similarstandard of education as the academic staff and assuch many of the Directors were professors. Thedevelopment and uptake of PhD qualifications fornurses may change this in time although someinterviewees felt that greater emphasis on teamworking was a possible solution. However therewas general recognition of the vital part played bynurses working with the medical profession todeliver the dual roles of ‘cure and care’.

EducationEducation of nurses also varies across the countriesvisited with most countries having registered nursessupported by assistant nurses or technicians. This isnot the case however in Germany where theassistants fulfil a non-clinical support role orPortugal where there is no such role. The level ofnurse training available varies from 2-4 years forDiploma or Bachelor of Science (BSc). Specialistnurses, usually supported by Masters education,were found in most countries visited. Variationswere found in Slovenia where nurse education isstill under development. A lack of accessibleresearch funding for nurses impacts on PhDeducation and there is currently no PhD programmeavailable in Slovenia or Malta.

Leadership and ManagementNurses and/or midwives were identified as beinginvolved in leadership and management roles across

Europe. Of the 17 countries responding to thenational questionnaire nearly all identified them asleaders of clinics or units. Most countries identifiednurses and midwives with specific responsibilitiesand, although there was variation in these, mostincluded patient safety, infection control andquality. In some organisations, however, these areaswere more usually led by doctors and supported bynurses. Other roles of interest included hospitalplanning, logistics and technical investments,serious untoward incident reviews, the developmentof patient records, and the development ofeducation.

Executive RoleNurse membership of executive management teamsvaried from country to country and in some casesby hospital. Most countries included a nurse leaderon the hospital executive management boardalthough this was not often the case in Sweden.Here the highest level nursing post is usually thechief nurse of a ward. Other specialist nurse roles inSweden supporting areas such as quality wereobserved working to a Medical Director on theexecutive management board. These roles did notgenerally have line management responsibility fornursing in the organisation, which gave rise tosome concern amongst middle-level nurses. InSlovenia, the role of the Chief Nursing Officer hasrecently been renamed ‘Assistant Medical Director –Nursing and Care’, but they continue to sit on theExecutive Team. In Germany, the Nursing Directorwas not always a member of the ExecutiveManagement Team. In Malta the only Director ofNursing was found in the acute hospital. ExecutiveManagement teams in Malta are still underdevelopment with most hospitals directlyaccountable to the Director General (Healthcare). In Belgium the Nursing Director post is required bylaw.

In no country visited was there any formal limitationor statute preventing the appointment of a nurse tothe top leadership role. However, such posts areusually appointed from medical or non-clinicalprofessions. A few nurses were identified in the topleadership role usually in smaller hospitals but one


such nurse was identified leading a universityhospital in Germany. In most cases these post-holders held a non-clinical higher degree ordoctorate in addition to their nursing qualification.

Incentives and DisincentivesIncentives and disincentives to become a nurseleader were similar in all countries visited. Theability to make a difference to patient care was themain reason given for wishing to become a leader.Increased salary was mentioned but it was alsogenerally recognised that this did not usuallycompensate for the increased responsibility. Theneed for further qualifications was a disincentive forsome to aspire to higher roles, as was the potentialloss of income previously attributed to unsocialhours.

Leadership and Management TrainingGood examples of leadership and managementtraining and continuing professional developmentwere seen in all countries visited although only oneexample was found of a leadership competencyframework for nurses and midwives and this was ata local level in Belgium. Further details of theseexamples can be found in Appendix 1.


Throughout this report reference is made to areas ofgood practice relating to leadership andmanagement for healthcare professionals and inparticular for nurses and midwives. However, eachcase is to be judged according to the culture withinwhich it abides and cannot naturally be assumed tobe applicable to any other healthcare system.

Fundamental differences occur between healthcareenvironments of the six countries visited and theseare summarised in Table 1 (page 11).

The following emerging themes and key learningpoints have been identified during this review, not allof which relate exclusively to nursing and midwiferynor to any one country:

• In most countries nurses account for at least 30%of the workforce and there is usually aprofessional hierarchy within the overallmanagement structure. Where this is not the casethere was apparent frustration among nurses bothin terms of career path and management’sperceived understanding of nursing issues.

• In several hospitals visited there was mention ofthe need for nurses and midwives to be able toevidence their role (in the dual roles of ‘cure andcare’ “cure” is measurable while “care” is not soeasily evidenced by outcomes). This was seen asimportant in raising the profile and understandingof the profession amongst colleagues from otherprofessions and also providing a strongerargument for attracting research funding.

• Many hospitals are involving nurses and midwivesin a broad range of leadership roles. The mostcommon outside of the normal clinical roles(patient safety, quality and infection control)concerned the planning of new hospitals, use ofexisting space and clinical pathways as well as thedevelopment of patient records. Nurses have a keyrole to play in influencing these areas of work andcan offer a valuable contribution.

• There seemed to be little incentive to become aleader outside of the opportunity to make adifference, and money was not a key motivator.Involving nurses and midwives in change projectsat an early stage in their career to make themaware of their own ability to make a difference

may increase the interest in future leadershiproles.

• Where available, leadership training was generallywelcomed, particularly where this was multi-professional. Discussion of case studies seen fromdifferent professional perspectives gaveparticipants an insight not previously recognised.The benefit of meeting colleagues face to facewas also identified, highlighting the need formulti-professional working rather than reliance onelectronic communication systems.

• In the hospital where a leadership competencyframework for nursing had been developed, ahigh level of support was offered to both linemanagers and new leaders to ensure theyachieved the competences identified. This hasbenefits for the organisation and is worthy ofexploration by those organisations who have notyet considered such an approach.

• It seems unlikely that the nursing profession willever be seen as equal to that of medicalcolleagues. This is due to the educationaldifferences and to the legal responsibility held bydoctors for the care of patients. Some interestingtripartite models of management were seenparticularly in hospitals in Germany and Belgium(doctor, nurse and either business manager oreconomist) but the doctor usually remainedaccountable overall.

• Continued professional leadership developmentwas evident in Malta and in individualorganisations elsewhere. Those participating in on-going training found it be very supportive andrecommended its continuance.

• Empowerment of staff in leadership roles,including front-line clinical staff yet to move intoleadership, was seen in many countries. Wherethis appeared to be most successful was when linemanagers showed a real belief in their abilities andoffered active encouragement in facing newchallenges. This in turn increased levels ofconfidence and self-belief building a potentialpool of higher level leaders for the future.

• A strong legal framework was apparent inBelgium and in some landers (or counties) within

Emerging Themes from the Study


Germany. This was generally seen as supportivebut the work undertaken in various hospitalsvisited showed that it was not essential toleadership development. In a university hospital inBelgium a new management model had beendeveloped working within the legal frameworkbut pushing the boundaries to facilitate jointmedical and nursing management. Also inBelgium centralised training was available,generally in the cities, to meet part of the legalrequirement. However, some large hospitals orgroups of hospitals had developed an in-houseprogramme which had been accredited as analternative for their area avoiding unnecessarystaff travelling. In Slovenia, laws regarding thepercentage of overseas tutors at university andpreventing lecturers working at multipleuniversities were seen as adversely affecting thedevelopment of healthcare managementeducation.

• Whilst a national pay structure was seen to exist inSlovenia, Malta and Portugal, in Belgium thenational agreement stated a minimum level foreach grade. In Germany and Sweden pay wassubject to local negotiation. Whatever system wasin place, work-rounds had been developed locally.For example in Malta a separate Foundation had

been set up allowing local determination of payfor top posts, in Slovenia additional paymentswere made in respect of travel to work toencourage retention of those who could notafford to live locally and in Belgium competitionwas clear between different hospitals in a singletown, with the larger university hospital havinggreater financial stability to be able to pay moreand hence attract staff. No single system stoodout above the rest although a national system didseem to offer some clarity around staffexpectations.

The following pages provide further detail in relationto the project, firstly outlining the scope andbackground to the study and describing themethodology. The findings from each of thecountries responding to the questionnaires are thenshown with further detail in respect of theorganisations’ response from the six selectedcountries. The report continues with detailed reportsfollowing discussions at the organisations visited inthose six countries.

A summary of the identified educationalopportunities supporting Nurse Leadership is shownin Appendix 1 with further detail supporting the textshown in Appendices 2 and 3.


Scope

10

This project provides a comparative study of European countries to establish:

• the variations in organisational arrangements witha particular focus on the role of nurses andmidwives in leadership and management

• the extent to which nurses and midwives areengaged in leadership, management andtransformation of hospital services, and

• learning that may be transferable to the NHS andother European healthcare systems.

Background

Healthcare organisations are complex with manyprofessional networks which are key to influencingimprovement. The need for change arises fromincreased patient expectation, changingdemographics, improved technology and newlyavailable treatments amongst others. Therequirement for strong leadership has never beenmore important to ensure organisations can respondto these challenges. Nurses and midwives accountfor more than 30% of the European healthcareworkforce and hence have a vital part to play inleadership and management.

The European Hospital and Healthcare Federation(HOPE), in conjunction with the NHS Institute, isexploring different ways in which nurses andmidwives are engaged in leadership andmanagement and how they are prepared for suchroles. This builds on a project undertaken by the NHSInstitute to enhance medical engagement which

included the development of a Medical LeadershipCompetency Framework (MLCF). The MLCF appliesto all doctors at every stage of their training andcareer.

To this end and in order to gain a more detailedperspective six countries were selected for moredetailed organisation-level review drawing on front-line experience. These included:

• Sweden in the Nordic countries

• Portugal in Southern Europe

• Germany in Northern Europe

• Belgium as the home country for the project

• Slovenia in Central and Eastern Europe

• Malta as an island community.

Table 1 Fundamental Differences Affecting Nursing and MidwiferyLeadership and Management in Countries Visited


Swed

enPo

rtu

gal

Ger

man

yB

elg

ium

Slo

ven

iaM

alta

Dec

entr

alis

ed c

ontr

olSt

ron

g le

gal

fra

mew

ork

Yes

Som

e at

Lan

der

orC

ount

y le

vel

Very

exp

licit

Yes

- ce

ntra

lised

Yes

- ce

ntra

lised

Yes

Nu

rses

leg

ally

ab

le t

o b

e C

EO o

f h

osp

ital

Yes

Yes

Yes

Yes

but

need

PhD

and

5 ye

ars

man

agem

ent

ofdo

ctor

s so

unl

ikel

y

Yes

A f

ew n

urse

s id

entif

ied

Nu

rses

or

Mid

wiv

es

as C

hie

f Ex

ecu

tive

so

f H

osp

ital

sN

one

One

iden

tifie

d as

CEO

of U

nive

rsity

Hos

pita

l –m

aybe

mor

e

One

nur

se id

entif

ied

1 nu

rse

out

of 2

6ho

spita

lsN

o bu

t on

e C

hair

ofH

ospi

tal M

anag

emen

tBo

ard

and

one

Dire

ctor

of

HR

No

Dir

ecto

rs o

f N

urs

ing

lead

ing

nu

rses

Yes

– le

gally

set

car

eer

path

way

Yes

Yes,

by

law

Yes

Stro

ng n

ursi

ng a

ndm

idw

ifery

car

eer

path

but

only

DoN

in a

cute

hosp

ital

Yes

but

rare

Evid

ence

of

Nu

rses

man

agin

g d

oct

ors

Yes

but

rare

No

Not

lega

lN

oN

o

Mos

t fe

mal

eN

urs

es u

sual

ly f

emal

e –

[vis

its

sho

wed

that

Ph

D r

esea

rch

fu

nd

ing

an

dac

cep

tan

ce b

y d

oct

ors

can

be

affe

cted

by

gen

der

]

20%

mal

e st

uden

ts b

uthi

gher

% m

ale

lead

ers

15%

mal

e

Sour

ce: W

HO

Eur

opea

nO

bser

vato

ry ‘H

ealth

care

Wor

kfor

ce in

Eur

ope’

Fede

ral O

ffic

e St

atist

ics

2003

Man

y m

ale

nurs

esin

clud

ing

Dire

ctor

s of

nurs

ing

Mos

t fe

mal

e bu

t 1/

3st

uden

ts a

re m

ale

50%

mal

e

Mor

e m

ale

nurs

ele

ader

s th

an f

emal

e

Yes

Nu

rses

Bas

ic T

rain

ing

via

Bac

hel

or

Deg

ree

Yes

New

- m

ainl

y D

iplo

ma

Yes

Dip

lom

a on

lyYe

s

Yes

Mas

ters

deg

ree

avai

lab

leYe

sN

ewYe

s, a

nd r

equi

red

by la

wat

inte

rmed

iate

leve

ls o

fnu

rsin

g

1st

stud

ents

for

Nur

sing

Mas

ters

200

7

Mas

ters

- H

ealth

care

Man

agem

ent

unde

rde

velo

pmen

t fo

r 20

10

Yes,

in N

ursin

g an

dH

ealth

care

Man

agem

ent

Mid

wiv

es a

nd n

urse

sco

mbi

ne f

or M

aste

rs

Yes,

but

res

earc

h fu

ndin

glim

ited

and

usua

llyaw

arde

d to

doc

tors

PhD

ava

ilab

leYe

sYe

sYe

s, b

ut r

esea

rch

fund

ing

limite

dN

ot y

et in

nur

sing,

onl

yin

non

-hea

lth e

.g.

orga

nisa

tiona

l sci

ence

No

30%

- 5

0%A

vera

ge

% o

f n

urs

es in

ho

spit

alw

ork

forc

e –

take

n f

rom

loca

l res

po

nse

s26

% -

38%

23%

- 6

1% p

sych

iatr

ic33

% -

45%

23%

- 5

4%33

% in

acu

te c

are

No-

nego

tiate

d lo

cally

Nat

ion

al p

ay s

tru

ctu

reYe

sA

t La

nder

or

Cou

nty

leve

lN

atio

nal m

inim

umYe

sYe

s bu

t so

me

wor

karo

unds

iden

tifie

d

Yes

Evid

ence

of

Succ

essi

on

Pla

nn

ing

No

In s

ome

hosp

itals

In s

ome

hosp

itals

No

No

Onl

y as

the

lead

ersh

ipel

emen

t of

bas

ic n

urse

trai

ning

Evid

ence

of

nat

ion

al c

om

pet

ency

fram

ewo

rk f

or

nu

rsin

g/m

idw

ifer

ym

anag

emen

t o

r le

ader

ship

No

No

No

Onl

y fo

r cl

inic

al a

reas

,no

t le

ader

ship

yet

Not

yet

Not

pol

icy

but

aim

to

supp

ort

all e

mpl

oyee

sw

ith t

he r

ight

ski

lls a

ndpe

rson

al q

ualit

ies

to g

row

into

a le

ader

ship

rol

e

Exp

licit

aim

of

nat

ion

al h

ealt

h p

olic

y to

incr

ease

nu

rse

lead

ersh

ipN

oN

oYe

sN

oN

o


Methodology

12

Questionnaires were developed to gather the initialinformation.

The first, aimed at National level, was sent to all 27EU member states and explored the following areas:

• ways in which nurses and midwives are involved inleadership or management roles

• if it is an explicit aim of national health policy toincrease the involvement of nurses and midwivesin leadership or management

• available training at undergraduate, postgraduateand post-registration levels

• the existence or otherwise of a nationalcompetency framework for nurse leadership ormanagement

• any existing relevant research.

The second, aimed at organisation level, was sent tothe hospitals within the six selected countries whichhad participated in the HOPE European ExchangeProgramme 2009. This was not the case in Slovenia,which was new to the programme and thus here thequestionnaire was sent to all 26 hospitals. In total therewere 87 hospitals invited to take part in this way andthese are shown by country in Table 2 below.

Table 2 Organisational questionnairessent out*

*Please note that questionnaires were not sent out in Malta, as the smallnumber of organisations meant face-to-face discussions were undertakeninstead.

The organisation-level questionnaire explored thefollowing areas:

• the nursing and midwifery staff complement

• ways in which nurses and midwives are involved inleadership or management roles

• if it is an explicit aim of the organisation toincrease the involvement of nurses and midwivesin leadership or management

• available training for nurses and midwives inleadership or management

• awareness of the existence or otherwise of anational competency framework for nurseleadership or management.

Following receipt of the initial national and localresults selected organisations were contacted, settingout the points of specific interest and requestingfurther information and/or a visit.

Sweden Portugal Germany Belgium Slovenia Total

12 19 20 10 26 87

Findings from Questionnaires


Summary of the European nationalperspectiveOf the questionnaires issued to all 27 EU memberstates, 16 were returned. The countries which

submitted responses to the national questionnaireare shown in Table 3 below. A full analysis of theresponses received is shown in Appendix 2.

Key points arising from the nationalquestionnairesSeveral countries have indicated that Chief Executivesusually come from a variety of professional backgroundsincluding nursing (Austria, Sweden, Denmark, Estonia,Hungary, Spain and Cyprus). Belgium indicated thatthey could come from medical, nursing or legalprofessions but explicitly stated that they would notusually come from a nursing background.

All countries except Bulgaria stated that Directors ofNursing or Midwifery are members of the top executiveteam. (This was not apparent however at the hospitalsvisited in Sweden).

All countries stated that nurses and/or midwives wereleaders of units, clinics or divisions.

Most also stated that nurses and/or midwives hadspecific responsibilities within the hospitals (excludingAustria and Hungary)

In a number of countries it is the explicit aim of healthpolicy to increase the involvement of nurses and/ormidwives in leadership or management roles. Belgium,France, Sweden2, Denmark, Spain, the Czech Republic,Cyprus, Lithuania and Hungary all stated this to be thecase. However, only Belgium and Denmark providedsupporting evidence.

In Belgium this was via ‘a multi-annual plan to makenursing more attractive’ published in November 2008by the Belgian Minister for Health and Social Affairs.This plan states that the nursing executive function is tobe developed by extending the bonus payment formanagerial activities and then by granting a pay levelcompatible with relevant training requirements as setdown in Belgian law. The plan also mentions astructured involvement of nurses in decision makingprocesses and increased provision of higher-leveleducation.

Table 3 Summary of National Questionnaire responses received

Nordic countries Central andEastern Europe

Southern Europe Northern Europe

Finland (Fi)

Sweden (Se)

Denmark (Dk)

Estonia (Ee)

Hungary (Hu)

Bulgaria (Bu)

Slovenia (Si)

Czech Republic (Cz)

Lithuania (Lt)

Portugal (Pt)

Spain (Es)

Malta (Mt)

Cyprus (Cy)

France (Fr)

Germany (De)

Austria (Au)

Belgium (Be)Countries replied

Latvia (Lv)

Slovakia (Sk)

Poland (Po)

Romania (Ro)

Italy (It)

Greece (Gr)

Netherlands (Ne)

Ireland (Ir)

United Kingdom (UK)

Luxembourg (Lu)

Countries notresponding

3 of 3 6 of 10 4 of 6 4 of 8Number returned

100% 60% 66% 50%ResponsePercentage

2 Sweden added that ‘it is our ambition to support all employees with the right skills and appropriate personal qualities to grow into a leadership roleregardless they are doctors or nurses. An opportunity for development and responsibility for all employees is an important goal, and that also includes anopportunity to reach a leadership role’.


A national competency framework fornursing/midwifery leadership and management waspositively indicated in Austria, Finland3, Sweden andPortugal. In Sweden, the national competencesrecommended by the National Board of Health andWelfare for the training of entry level nurses andmidwives includes leadership as one of three categories.The other two are ‘care theory and practice’ and‘research development and education’. Further detail onthe leadership component is given in the chapter onSweden. However, of the Swedish organisationsresponding to the local questionnaire, only one smallhospital was aware of its existence.

There was little awareness of any significant researchbeing undertaken into nursing and midwifery leadershipor management. However some projects were identifiedat universities and the Association of Nursing Directorsin Hungary, some faculties and schools of health inPortugal (through Masters, Doctorate or post-doctorateprogrammes), some Lithuanian postgraduate researchstudies, one Belgian study and some Danish projects.

The answers in relation to training are more complexand it should be recognised that some countries did notrelate to the concepts of undergraduate, postgraduateand post-registration. The results are summarised inTable 4 below:

3 Finland provided further information clarifying no such framework is in place at national level although local arrangements exist in some areas

Table 4 Positive national responses in respect of provision of training

Question Undergraduate Postgraduate Post-Registration

Specific nurse andmidwifery training inleadership andmanagement?

Se; Es(N); Es(M); Mt; Pt; Cz;Hu; Bu; Lt; Cy

Se; Fi; Es(N); Mt; Pt; Ee; Cz;Hu; Au; Be; Bu; Lt; Cy

Se; Dk; Fi; Es(N); Mt; Pt; Ee;Sl; Cz; Hu; De; Fr; Be; Bu;Lt; Cy

Level agreed?

National

Regional

Hospital

Es(M); Mt; Pt; Cz; Bu; Lt; Cy

Se; Es(N); Es(M); Pt

Se; Fi; Mt; Pt; Ee; Cz; Hu;Au; Be; Bu; Lt; Cy

Se; Es(N); Pt; Be

Fi; Mt; Pt; Ee

Fr; Bu; Lt; Cy

Se; Dk; Es(N); Pt; Hu; De

Se; Dk; Es(N); Mt; Pt; Ee;Hu; De; Be

Provided by?

Hospital

University

Commercial

Other

Se; Es(N); Hu

Se; Es(M); Mt; Pt; Hu; Bu; Lt;Cy

Es(M)

Cz; Cy

Fi; Es(N); Mt; Pt; Ee

Se; Mt; Pt; Ee; Hu; Au; Be;Bu; Lt; Cy

Au

Cz; Lt; Be

Se; Fi; Mt; Pt; Ee; Hu; De; Be

Se; Dk; Fi; Es(N); Pt; Be; Ee;Sl; Bu; Lt; Cy

Dk; Ee; Sl; Hu; De; Be

Mt; Cz; De; Fr; Be; Lt; Cy

How assessed?

By exam

By interview

By regular assessment

Other

Se; Mt; Pt; Cz; Hu; Bu; Lt; Cy

Se; Cy

Se; Es(N); Mt; Hu

Lt

Se; Fi; Mt; Pt; Cz; Hu; Au;Be; Bu; Lt; Cy

Se; Be

Se; Fi; Es(N); Pt; Cy

Lt

Se; Dk; Fi; Pt; Cz; Hu; Bu; Lt;Cy

Se; Dk; Hu; Fr; Cy

Se; Dk; Fi; Es(N); Pt; Fr

Fr; Lt

Competence is assessed? Se; Es(N); Mt; Pt; Cz; Hu; Bu;Lt; Cy

Se; Fi; Es(N); Be; Mt; Pt; Cz;Hu; Au; Bu; Lt; Cy

Se; Dk; Fi; Es(N); Pt; Cz; Hu;Fr; Bu; Lt; Cy


Key issues arising from Table 4 inrelation to provision of training• Two separate responses were received from Spain

regarding nursing (Es-N) and midwifery (Es-M) andthese have been reflected individually in Table 4.

• Nine countries provide undergraduate trainingagreed at either national or regional level. Most training is undertaken at university and iscompetence assessed, mainly by exam. Sweden,Spain (nurses), Malta and Hungary also identifyregular assessment. No assessment was identifiedfor Spanish midwives. Countries which did notidentify provision of undergraduate training wereFinland, Denmark, Estonia, Slovenia, France,Germany and Austria.

• Thirteen countries provide postgraduate trainingagreed mainly at national level. Most training isundertaken at university and is competenceassessed, mainly by exam. Sweden, Finland, Spain(nurses), Portugal and Cyprus also identify regular

assessment. Countries which did not identifyprovision of post-graduate training were Denmark,Slovenia, France and Germany.

• Sixteen countries provide post-registration trainingagreed at national, regional or hospital level.Training is undertaken at a variety of organisationsand in 11 countries is competence assessed. The means of assessment varies between exam,interview and regular assessment. Malta, Estonia,Slovenia, Belgium and Germany did not identifyany form of assessment and Austria did notindicate provision of any post-registration trainingat all.

Organisational perspective in selectedcountriesOf the 87 questionnaires sent to individualorganisations in the selected countries 36 werereturned (41%). An analysis by country is shown inTable 5 below:

Table 5 Summary of Organisational-level Questionnaire Responses*

Sweden Portugal Germany Belgium Slovenia Total

12Number oforganisations

19 20 10 26 87

6Numberreturned

11 3 4 12 36

50%ResponsePercentage

57% 15% 40% 46% 41%

*Questionnaires were not sent out in Malta, as the small number of organisations meant face-to-face discussions were undertaken instead.


Key points arising from the localquestionnaires:

SwedenSix questionnaires were completed in respect ofhospitals in Sweden, two from university hospitalsand four from county hospitals or county councilsresponsible for health care. The following key pointswere identified:

• The percentage of hospital staff in nursing rangedfrom 30% to 38% in the university hospitals andfrom 33% to 50% elsewhere.

• Only one (county council) stated that there is achief nurse or midwife who sits on the top levelexecutive team.

• In only two cases is the Chief Executive involved inthe appointment of senior nurse leaders (oneuniversity hospital and one county council).

• Nurses provide leadership for units, clinics ordivisions as well as leading in specific roles. Theseroles include quality, patient safety and infectioncontrol (this latter point in all but one countycouncil). Other specific responsibilities variedbetween hospitals but included improvementprojects, education and development.

• Only one county hospital stated it was an explicitaim of the organisation to increase theinvolvement of nurses and/or midwives inleadership through a systematic approach toidentify and train nurses who have a talent forleadership.

• Leadership and/or management training wasprovided in four hospitals, with one of the countycouncil areas and one university hospital statingthis was not the case. This was usually agreed atregional or hospital level and was generallyprovided in-house or at the university.Competence was assessed but the methodologywas unclear from the responses given. Thistraining was only mandatory for appointments ata certain level in one county hospital.

• Two of the six hospitals were aware of a nationalcompetency framework for nurse leadership ormanagement.

PortugalEleven questionnaires were completed in respect ofhospitals in Portugal, two from oncology hospitalsand the rest from central general hospitals. The following key points were identified:

• The percentage of hospital staff in nursing rangedfrom 26% to 38%.

• All stated that there is a chief nurse or midwifewho sits on the top level executive team.

• All stated that the Chief Executive is involved inthe appointment of senior nurse leaders.

• Nurses provide leadership for units, clinics ordivisions as well as leading in specific roles. Theseroles usually include quality, patient safety andinfection control. Other specific responsibilitiesvaried between hospitals but included training,bed management, discharge planning, ethicscommittee, disasters committee, clinicalgovernance, sterile services, information systemsand research and development.

• 5 of the respondents stated it was an explicit aimof the organisation to increase the involvement ofnurses and/or midwives in leadership.

• Leadership and/or management training wasprovided at 10 of the 11 hospitals. This wasusually agreed at national or hospital level andgenerally provided at the university. Sevenhospitals identified the assessment of competence,usually by regular assessment. This training wasmandatory for appointments at a certain level ineight hospitals.

• Nine of the 11 hospitals were aware of a nationalcompetency framework for nurse leadership ormanagement.

GermanyThree questionnaires were completed in respect ofhospitals in Germany, two from psychiatric hospitalsand one from a university hospital. The following keypoints were identified:

• The percentage of hospital staff in nursing was40% in the university hospital. Figures forpsychiatric hospitals appeared higher but weredifficult to interpret.

• All three hospitals stated that there is a Nursing


Director who sits on the management committee.

• In all cases the Chief Executive is involved in theappointment of senior nurse leaders.

• Nurses provide leadership for units, clinics ordivisions as well as leading in specific roles. These roles include quality, patient safety andinfection control. Other specific responsibilitiesvaried between hospitals but included control ofthe patient pathway, outpatients and the nursetraining school.

• Only one hospital (psychiatric) stated it was anexplicit aim of the organisation to increase theinvolvement of nurses and/or midwives in leadership.The university hospital stated the opposite.

• Leadership and/or management training wasprovided in all three hospitals. This could beagreed at national, regional level or in-house andwas usually provided in-house or at the university.Competence was assessed in all cases by exam,interview and at two of the three, by regularassessment. In two hospitals (including theuniversity hospital) this training was mandatory forappointments at a certain level.

• Two of the three hospitals were aware of anational competency framework for nurseleadership or management.

BelgiumFour questionnaires were completed in respect ofpublic hospitals in Belgium, one from a psychiatrichospital and the others from university hospitals. Thefollowing key points were identified:

• The percentage of hospital staff in nursing rangedfrom 33% to 40% in the university hospitals but wasslightly higher at 45% in the psychiatric hospital.

• As per Belgian health care law, nurses are alwaysmanaged by a Nursing Director who sits on themanagement committee.

• In all cases the Chief Executive is involved in theappointment of senior nurse leaders.

• Nurses provide leadership for units, clinics ordivisions as well as leading in specific roles. These roles include quality and usually patientsafety and infection control. Other specificresponsibilities varied between hospitals but

included space planning, in-house education,informatics and the electronic patient record.

• In two of the three university hospitals it was anexplicit aim of the organisation to increase theinvolvement of nurses and/or midwives in leadership.

• Leadership and/or management training wasprovided in all four hospitals. This could be agreedand provided at national, regional level or in-house. In two of the university hospitalscompetence was assessed by exam and interviewand in one by regular assessment. In these twohospitals this training was mandatory forappointments at a certain level.

• None of the four hospitals was aware of anational competency framework for nurseleadership or management.

SloveniaTwelve questionnaires were completed in respect ofhospitals in Slovenia, three from university hospitalsand the rest from general or specialist hospitals. The following key points were identified:

• The percentage of hospital staff in nursing rangedfrom 23% to 50%. In the university hospitals thisranged from 38% to 47%.

• All stated that there is a chief nurse or midwifewho sits on the top level executive team.

• All but one stated that the Chief Executive is involvedin the appointment of senior nurse leaders.

• Nurses provide leadership for units, clinics ordivisions as well as leading in specific roles. These roles usually include quality, patient safetyand infection control. Other specific responsibilitiesvaried between hospitals but included educationand research, patient counselling, woundmanagement, hospital hygiene, palliative care,clinical nutrition, information systems, patientrights and ethics.

• Seven of the respondents stated it was an explicitaim of the organisation to increase the involvementof nurses and/or midwives in leadership.

• Leadership and/or management training wasprovided at eleven of the twelve hospitals. This was usually agreed at hospital level andgenerally provided in the hospital or at the


university. Some commercial involvement was alsoindicated by six hospitals. Ten hospitals identifiedthe assessment of competence, usually by exam orinterview. This training was mandatory forappointments at a certain level in eight hospitals.

• Ten of the 12 hospitals were aware of a nationalcompetency framework for nurse leadership ormanagement.

MaltaNo questionnaires were issued to Malta as with feworganisations and only one acute hospital face toface discussions were undertaken.

A comparison was made between the national andlocal questionnaires for each country. Whilst thequestions asked were not the same at each levelsome cross comparison is possible in six areas, theresults of which are shown in Table 6 (page 19).

Table 6 Comparison of National and Organisational QuestionnaireResponses


Dir

ecto

r o

fN

urs

ing

/Mid

wif

ery

on

Exec

uti

ve T

eam

?C

ou

ntr

y

Lead

ersh

ip o

f U

nit

s,C

linic

s o

r D

ivis

ion

s?Sp

ecif

ic R

ole

s?Ex

plic

it a

im t

o in

crea

senu

rse/

mid

wif

ery

lead

ersh

ip?

Post

reg

istr

atio

ntr

aini

ng in

man

agem

ent

and

lead

ersh

ip?

Co

mp

eten

cyfr

amew

ork

?

Whi

lst

the

natio

nal r

espo

nse

was

posi

tive

only

one

of

five

orga

nisa

tions

res

pond

ed

posi

tivel

y to

thi

s qu

estio

n.

Of

hosp

itals

vis

ited

no s

uch

post

was

iden

tifie

d

Swed

enTh

is w

as r

ecog

nise

d pr

actic

eTh

is w

as r

ecog

nise

d pr

actic

eal

thou

gh t

he r

oles

var

ied

–m

ost

how

ever

iden

tifie

d pa

tient

safe

ty,

qual

ity a

nd in

fect

ion

cont

rol

Alth

ough

sta

ted

as n

atio

nal

polic

y on

ly o

ne o

f fiv

eor

gani

satio

ns s

tate

d th

is a

san

org

anis

atio

nal a

im

This

was

rec

ogni

sed

bym

ost

orga

nisa

tions

alth

ough

the

ass

essm

ent

ofco

mpe

tenc

e w

as n

otal

way

s un

dert

aken

by

the

orga

nisa

tions

res

pond

ing

This

exi

sts

with

in t

he b

asic

trai

ning

of

nurs

es b

ut w

as o

nly

reco

gnis

ed b

y on

e re

spon

ding

orga

nisa

tion

Yes

this

is u

sual

pra

ctic

ePo

rtu

gal

This

was

rec

ogni

sed

prac

tice

This

was

rec

ogni

sed

prac

tice

alth

ough

the

rol

es v

arie

d –

abou

t 80

% id

entif

ied

patie

ntsa

fety

, qu

ality

and

infe

ctio

nco

ntro

l. T

rain

ing

and

CPD

was

also

com

mon

Not

nat

iona

l pol

icy

but

five

of e

leve

n or

gani

satio

nsid

entif

ied

this

as

an a

im

This

was

rec

ogni

sed

bym

ost

orga

nisa

tions

alth

ough

the

ass

essm

ent

ofco

mpe

tenc

e w

as n

otal

way

s un

dert

aken

by

40%

of t

he o

rgan

isat

ions

resp

ondi

ng

This

was

rec

ogni

sed

natio

nally

but

not

evid

ence

d –

how

ever

mos

t or

gani

satio

ns r

espo

ndin

gw

ere

also

aw

are

of t

his

Yes

this

is u

sual

pra

ctic

eG

erm

any

This

was

rec

ogni

sed

prac

tice

This

was

rec

ogni

sed

prac

tice

alth

ough

the

rol

es v

arie

d –

all

iden

tifie

d pa

tient

saf

ety,

qua

lity

and

infe

ctio

n co

ntro

l

Not

nat

iona

l pol

icy

and

only

one

orga

nisa

tion

iden

tifie

dth

is a

s an

exp

licit

aim

This

was

rec

ogni

sed

by a

llre

spon

ding

org

anis

atio

ns.

The

asse

ssm

ent

ofco

mpe

tenc

e w

asun

dert

aken

by

the

orga

nisa

tions

res

pond

ing

Not

rec

ogni

sed

natio

nally

–bu

t re

cogn

ised

by

two

of t

here

spon

ding

org

anis

atio

ns

Belg

ian

law

dic

tate

s th

is t

o be

the

case

Bel

giu

mTh

is w

as r

ecog

nise

d pr

actic

eTh

is w

as r

ecog

nise

d pr

actic

e –

all i

dent

ified

pat

ient

saf

ety,

qual

ity a

nd in

fect

ion

cont

rol

and

info

rmat

ics

was

als

oco

mm

on

Nat

iona

l pol

icy

indi

cate

s th

isto

be

so a

nd t

wo

of t

heth

ree

univ

ersi

ty h

ospi

tals

als

ost

ated

thi

s to

be

the

case

This

was

rec

ogni

sed

by a

llre

spon

dent

s al

thou

gh n

otal

way

s as

sess

ed f

orco

mpe

tenc

e

This

doe

s no

t ex

ist

at n

atio

nal

leve

l

Yes

this

is u

sual

pra

ctic

eSl

ove

nia

This

was

rec

ogni

sed

prac

tice

This

was

rec

ogni

sed

prac

tice

alth

ough

the

rol

es v

arie

d –

mos

t ho

wev

er id

entif

ied

patie

ntsa

fety

, qu

ality

and

infe

ctio

nco

ntro

l

Not

nat

iona

l pol

icy

but

reco

gnis

ed b

y se

ven

oftw

elve

res

pond

ing

orga

nisa

tions

– e

duca

tion

unde

r de

velo

pmen

t in

thi

sar

ea

This

was

rec

ogni

sed

bym

ost

orga

nisa

tions

alth

ough

the

ass

essm

ent

ofco

mpe

tenc

e w

as n

otal

way

s un

dert

aken

by

the

orga

nisa

tions

res

pond

ing

Not

rec

ogni

sed

natio

nally

–ha

s be

en r

ecen

tly d

evel

oped

for

clin

ical

com

pete

ncie

s bu

tno

t ye

t in

clud

ing

lead

ersh

ip


Findings from European Visitsto Selected Organisations

20

Following analysis of the organisation levelquestionnaires in the selected countries, a variety oforganisations were visited to enable a more detaileddiscussion drawing on front-line experience.

At each visit interviews were held with a variety ofnursing and non-nursing professionals drawn from the:

• Chief Executive Officer or equivalent

• Chief Medical Officer

• Director or Head of Nursing

• Director or Head of Midwifery

• Dean or Head of Nurse Education (universities)

• Nurse and Midwifery leaders of the future

• Professional Associations.

The following pages summarise the findings in eachcountry visited. Specific examples of identifiededucation supporting nursing leadership inhealthcare are shown in Appendix 1 and theorganisations informing this work in Appendix 3.

In most countries there was a commonunderstanding that whilst management is more todo with processes and systems to plan and controlthe work, leadership is more to do with people -inspiring and motivating followers to deliver a goal.In some hospitals however there was a greater focuson management with less apparent emphasis onleadership although it was unclear whether this wasonly due to translation.

Sweden

The Governance and Management of hospitalsThe structure of University Hospital Management variesconsiderably from a county hospital. Universityhospitals have a Board of Governors with politicalmembership to whom the Hospital Director (CEOequivalent) is accountable. In the County Hospital ofVaxjo on the other hand the Hospital Director isaccountable to the Director of the County Council whoin turn is accountable to the County Board. There is noHospital Board of Governors. This layer ofaccountability was removed to allow the politicians todirect what the residents require and the health careprofessionals to deliver it in the best way possible.

Sweden has a recognised medically-led system wheredoctors are perceived by all to be the seniorprofession. In the institutions visited there was noDirector of Nursing at Board level and it appears thatit is not usual to have such a post within the hospitalstructure. Where such a post was identifiedaccountability was to the Chief Medical Officer whoholds the Board position.

Status of Nursing and Midwifery ProfessionsMidwives in Sweden – unlike other countries – havea role in women’s health that supports them throughpregnancy through to the end of cervical screeningat the age of 60. Both staff and the generalpopulation respect midwives as a competent safepair of hands with a special role in the big events ofpatients’ lives.

Nurses on the other hand often perceived themselvesas subservient to doctors. There is not generally anurse working at Board level and the most seniornurse in each organisation is usually working atmiddle management level.

System for educating nurses and midwivesHealth care in Sweden is governed by the NationalBoard of Health and Welfare which sets outs therequired competences for registered nurses andmidwives basic training. This includes three elements- theoretical and practical knowledge of nursing,research and education and leadership.

The leadership competences are based on patients’needs and include:

• systematically lead, prioritise, allocate andcoordinate the work of the team based onemployees differing skills

• evaluate the teams efforts based on knowledge ofgroup dynamics

• develop the group to strengthen capacity

• conflict management and problem solving

• motivate the team and provide positive feedback

• conduct patient care in a quality and costconscious way

• facilitate research and development

• lead and develop the nursing process


• plan, consult, inform and interact with otherplayers in the patient pathway to achievecontinuity, efficiency and quality.

A registered nurse in Sweden holds an academicBachelor of Science degree and a Diploma in Nursing.

Midwifery training is not direct-entry and to becomea midwife you must first train and practice as a nursethen return to university for one and a half years tospecialise as a midwife by gaining a GraduateDiploma in Specialist Nursing.

The Swedish PhD programme takes four years fulltime with limited places and limited funding availableto pay nurse salaries whilst in full time training.When the PhD is completed there is a requirementfor continued research to maintain academiccredibility but funding for this is not easily availableto nurses.

Incentives to become a Nurse LeaderIncentives include the possibility to make a differenceto patient care and influence decisions, avoidance ofworking unsocial hours where these conflict withpersonal commitments, the attraction of a highersalary, and the possibility to move to a higher levelwithout the Masters degree required for becoming aspecialist nurse.

Barriers to becoming a Nurse LeaderBarriers include nurses’ perception of and confidencein their own abilities, fear of responsibility and lackof financial recognition related to that responsibility,and the need to give up clinical care at a certain levelof leadership.

How are Swedish Healthcare Leaders educated?However difficult and obscure the career path mayappear there are no formal limitations in Sweden toprevent nurses, midwives and other professionalsfrom becoming Hospital Director.

Some good examples of support for leadershipeducation and succession planning were seen inStockholm and at regional level.

Portugal

The Governance and Management of hospitalsPortugal is divided into five healthcare regions eachhaving a Directive Council. Members of the Boardare political appointments usually drawn frommedical or administrative functions althoughunusually in the Lisbon region there is a nurse on theCouncil. These are full time appointments for threeyears after which they may be re-appointed or returnto their previous post.

Within each hospital there is a Board chaired by thePresident (Chief Executive equivalent) who is appointedby the Minister of Health. Legally it is possible for thisappointment to be a nurse with suitable qualificationsin healthcare and management although this is notcurrently the case in Portugal. The Presidentrecommends to the Regional Council the members ofhis hospital Board. Mandatory posts on the Board arethe Nurse Director and Clinical Director, with the otherthree posts usually being drawn from non-clinicalareas. Once ratified by the Regional Council theMinister of Health gives final approval.

By law only doctors can manage clinical services(groups of departments). However those medicaldirectors work alongside a supervisor nurse and anadministrator (a recognised profession in Portugalqualified in Public Health Administration) in equalroles. For non clinical services, such as quality, it islegally possible for a nurse to manage doctors.

Status of Nursing and Midwifery ProfessionsNurses in Portugal currently have a lifelong licence topractice although this is expected to change over thenext few years. Midwives in Portugal are specialistnurses and no direct entry training is available –hence future references will only refer to ‘nurses’ asthis encompasses all.

There are currently too many nurses in Portugalfollowing an increase in student numbers to addressa perceived shortage. This has led to high levels ofunemployed nurses with many taking upappointments overseas. There is also a shortage ofdoctors particularly in primary care and rural areas.Both professions have very strong unions protectingtraditional boundaries and there are currently noplans to transfer some doctors’ roles to the nursing


profession. This could change if the national fundingsystem recognises nurse-led consultations in the future.

The career path for nurses is clearly set as nurse,specialist nurse, head nurse in charge of a ward,supervisor nurse in charge of a department andnurse director. This is currently under revision and itis proposed to simplify to three levels (nurse,principal nurse, nursing director). For posts of headnurse and above, no clinical work is undertaken andthese are purely management roles. There is nonurse assistant or nurse technician role in Portugal.

Nurses are held in high esteem in Portugal both byother professions and patients. Their profile hasimproved in recent years as they have developedtheir knowledge and educational achievements andthey are well-recognised as a vital part of thehealthcare process. As in other European countriesthe medical profession is seen as the superiorprofession in healthcare due in part to the highereducational attainment, but mainly due to the legalresponsibility carried by the profession.

System for educating nurses and midwivesThe first degree which gives licence to practice as anurse is a four year degree and this includes someelements of basic management theory. After afurther two years study nurses may qualify asspecialist nurses with a Masters degree. This coursegives an increased management focus.

A nurse with a Masters degree is able to beappointed as a Head Nurse of a ward. This is a non-clinical management role. No further formal trainingis required to be appointed to be the higher gradesof supervisor or Director.

A PhD is available in nursing although nursesworking in clinical practice who wish to undertakeone may have difficulty in getting release from theirhospital duties. In addition, research funding isdifficult to obtain for nursing research as theevidence base is low, and most subjects arequalitative rather than quantitative and thereforecompete unfavourably against research proposed byother professions.

Further continuing professional training is availablefor leadership and management subjects at university

and these courses can contribute up to 10 credits toa Masters degree or up to 18 credits for a PhD.

Incentives to become a Nurse LeaderIncentives include wanting a challenge and a realinterest in management as well as gainingrecognition for achievements which is thought to beeasier in a leadership role.

Barriers to becoming a Nurse LeaderBarriers include the desire to continue in a clinical carerole and the concern over significant reduction ofincome due to the loss of allowances for unsocial hours.

How are Portuguese Healthcare Leaderseducated?Ordem dos Enfermeiros is the professionalassociation for nurses in Portugal and also regulatesthe profession. It does not have any trade unionresponsibilities. The Ordem has 60,000 members. In 2003 the Ordem Board of Directors identified aneed for nurses to have:

• good perception of the context and objectives ofthe health reform

• vision to develop health and nursing at all levels

• ability to think critically, plan change strategicallyand manage it

• the strength and confidence to be proactive andable to respond in a changing and demandingenvironment.

Leadership for Change™, developed by theInternational Council for Nurses (ICN), is theprogramme chosen by the Ordem Board of Directorsto satisfy their requirements. Over 70 nurses have sofar been trained in this way with ICN trainers.However, training has now been given to Portuguesenurses who applied to become approved trainers andso, with the translation of all course materials intoPortuguese completed, it is now possible to providethis training both within the Portuguese healthregions and within organisations.

An intensive healthcare management course wasalso identified in Lisbon and Porto.


Germany

The Governance and Management of hospitalsGerman healthcare is largely the responsibility of the16 ‘landers’ (or counties) and therefore althoughthere are similarities in governance there are alsosome differences. The three hospitals visited wereeach in a different lander.

There is an Executive Management Board in eachhospital. In Hamburg University Hospital (withinHamburg City Lander) this consists of the MedicalDirector, the Finance Director, the Nursing Directorand the Dean of Education and Research. All areequal but the Medical Director is the Chair of theBoard and represents the organisation externally. (Foreach department in a University hospital there is alsoa Board with a similar structure as above althoughonly the nurse is trained in management).

In Leipzig (within Saxony Lander) the ExecutiveManagement Board is just two Directors – theMedical Director and the Business Director – andthey are equally accountable for both business andmedical issues. However, there are regular meetingswith a broader leadership team including theDirector of Nursing.

In Charité Hospital Berlin (within Berlin Lander) theManagement Team consists of the Chairman (amedical professor), the Dean of the faculty (also adoctor) and the Business Director. The businessdirector is also Chair of the Leadership Team whichsits below the Management Team and includes theDirector of Nursing and the Medical Director.

In all cases there is a political Board to which theManagement Board is accountable withrepresentatives from both Federal Government andthe relevant hospital. For example in Leipzig thisincludes, in addition to the governmentrepresentatives, two medical professors from anotheruniversity hospital, three economists from the area ofLeipzig, a member of the faculty and a representativeof the staff (elected by the staff followingapplications). This Board meets formally twice a yearin confidential session, with staff being informed ofdecisions by the Business and Medical Directors viathe management hierarchy.

Status of Nursing and Midwifery ProfessionsMidwives in hospitals have, by law, to lead in thedelivery ward and although a midwife must alwaysbe present at the birth this is not so for the doctor.Midwives are therefore quite autonomous, increasingtheir self-esteem. About 95% of births take place inhospital but have a length of stay of just a few hoursafter which the midwife supports the mother athome for 4-5 weeks. As in other countries visited,the midwife’s role is popular and hence there is littleinterest in progressing to management especiallygiven the additional education required.

As in other European countries visited, the doctor isseen as the superior profession due to the higherlevel of education and the legal responsibility held.However there is a perceived management intentionin Germany to treat all professions equally.

It is legally possible for nurses to become leaders ofhospitals with the relevant managementqualifications but it is rare. However one such post-holder was identified running a ‘university’ hospital -the only example of its kind found in any of thecountries visited.

In some hospitals both nurses and midwives are onlyallowed to become leaders in their field of expertise.This was not the case everywhere however and inother areas, subject to holding the relevantmanagement qualifications, nurses and midwivescompete equally for leadership posts. Midwives dohowever appear to have better opportunities thannurses for private practice.

Nurses are generally not held in very high esteem by thedoctors and their own pride in their profession isregarded below that perceived in other countries visited.This may well be due to the lack of a universityeducation and recognition of nursing as a profession.

The staffing at Leipzig (and potentially Berlin) wasinfluenced by its location and history. Former EastGerman citizens are keen to work full-time or nearlyfulltime whereas former West German citizens prefer towork less than half-time hours. Similarly former EastGerman citizens are reportedly less likely to challengewhat they are asked to do. Male nurses are morecommon in the former West German population.


The pay structure for Germany is agreed by thelanders (boundary or area) in respect of all UniversityHospitals within the lander and sets out either theminimum or the actual pay. The pay for ward leadersis seen as low relative to the level of responsibility,making them hard to recruit. Many nurses work inother German-speaking countries, where both thepay and respect for the profession are higher.

System for educating nurses and midwivesNurses currently study for three years at a nursingschool – not university – and gain a Diplomaallowing them the status of Registered Nurse. Afterthis they may study for a further two years atUniversity to gain a Bachelor degree (newlyavailable), which in turn allows them to continue tostudy for a Masters degree (also new). At the presenttime few registered nurses study for a Bachelordegree and fewer still go on to Masters levelalthough the numbers are increasing. It is probablethat the diploma will be replaced by the Bachelordegree in the coming years. The PhD qualification isavailable for nursing in Germany although it variesfrom lander to lander.

In some hospitals no financial support is available forUniversity education but in others financialencouragement is offered where the managementbelieves this is a sound investment. In these hospitalsthis support may be subject to the employeeagreeing to stay in the hospital a further three yearsafter finishing the course.

There are nurse assistants in Germany trained for one totwo years but they deal mostly with administrativematters and not usually clinical support.

Midwives in Germany have for many years beentrained as direct-entry students and not as a sub-specialism of nursing.

Incentives to become a Nurse LeaderA few nurses wish to become leaders to avoidunsocial hours and increase their salary although thisis largely offset by the loss of unsocial hourspayments. Most choose to become leaders in orderto influence change.

Funding for education will also incentivise nurses andmidwives. This was evident at UKE Hamburg where

scholarships available for the three most successfulnursing school students allow them to take thecourse part time over four years.

Barriers to becoming a Nurse LeaderThere are fairly strict regulations regarding theeducation levels to be attained to become a leaderand this will act as a barrier to many, especiallywhere no funding is available to support thestudents. Having attained a Bachelor degree there isno automatic pay increase unless further study isundertaken and appointment to a leadership post isconfirmed. As in other countries the salary increase isnot seen as relative to the increased responsibility.

How are German Healthcare Leaders educated?There are management courses in place in Germanyto support ward leaders in their role varying from in-house to a legal requirement (in three landers) toundertake 750 hours vocational managementtraining. This latter requirement makes it increasinglydifficult to appoint suitably qualified ward leadersand so, as a means of improving successionplanning, deputy ward leaders may be educated tothis level in some hospitals thereby creating a pool ofpotential ward leaders.

To become a Department Head in public hospitals inGermany it is necessary to gain a Diploma in NurseManagement from University. This course lasts forfour years if studied part-time.

Belgium

The Governance and Management of hospitalsPublic hospitals have an executive team including theDirector of Nursing. Although the Chief ExecutiveOfficer of University Hospitals is always a (medical)Professor of the University, some smaller hospitals inBelgium have a Chief Executive from a nursingbackground.

Status of Nursing and Midwifery ProfessionsBelgian law is very explicit with regard to thestructures, responsibilities and qualifications ofprofessional healthcare staff. By Royal Decree it isonly possible for nurses to be managed by a nurseand doctors to be managed by a doctor. The nursing


and medical structure is also specified in detail in thelaw along with the responsibilities of each level. Thecompetences however are not specified.

Midwives in Belgium work as assistants toobstetricians and their role is only to support themother through the delivery in hospital. They do nothave any role once the mother is discharged home.

System for educating nurses and midwivesRegistered nurses hold a Bachelor of Science degreeand under Belgian law any nurse or midwife wishingto attain a Nurse Manager position (running adepartment or group of wards) or higher must holda Master of Science degree. There is a diplomaeducation in place for nurses not wishing toundertake the full registered nurse training.

Direct entry midwifery training has been in place inBelgium for approximately six years. There was noindication that this would disadvantage them incompeting for leadership positions within the hospitals.

Incentives to become a Nurse LeaderIncentives include a desire for increased responsibilityand management and the opportunity to makechange. Disincentives identified included therequirement for management posts to be full time,disadvantaging staff that prefer or need to work parttime hours.

How are Belgian Healthcare Leaders educated?In Belgian law there is a requirement for continuingprofessional development for all leaders above acertain level. This is usually run centrally but can beprovided by individual hospitals.

Good examples of leadership and managementtraining were identified in Ghent and Leuven withthe latter also having developed a competencyframework for nurse leadership.

Slovenia

The Governance and Management of hospitalsThe Council of each hospital is the supreme bodythat supervises and directs the activities of thathospital. The structure and number of members ofthe Council is defined by the institution in their

"establishment act" and statute, and is dependenton the importance, size and foundation of theorganisation. In the organisations visited this variedbetween seven and 11 members including:

• the founder i.e. the Ministry of Health (four-sixmembers)

• employees of the institution (one-three members)

• representative of Health Insurance Institute ofSlovenia (one member)

• representative of the local community (onemember) – only for secondary care hospitals.

In some cases the hospital management team directsthe professions from which the employee membersshould be drawn whilst in others there is a free election.

The profession of the General Director (CEO-equivalent) varies with clinical and non-clinicalprofessionals fulfilling this role – there is also anursing professional as General Director.

All hospitals have a Chief Nursing Officer (althoughrecently this job title has been changed to AssistantMedical Director for Nursing and Care). This post is partof a tripartite management team including the GeneralDirector (Chief Executive equivalent) and the MedicalDirector. Each Medical Director and Chief NursingOfficer also have an internal Medical or Nursing Councilrespectively made up of the head doctors and nursesfrom the various units. This model is also used by thehead nurses for all their subordinates.

Status of Nursing and Midwifery ProfessionsThere is the potential for a good career path for nursesand midwives in Slovenia. As stated above all hospitalshave a Chief Nursing Officer (Assistant Medical Director– Nursing and Care) and some of these have nursemanagement teams including quality, infection controland nurse education posts. Below this level are ChiefNurses of units or departments and below this, HeadNurses of wards.

Slovenia specialist nurse roles through education arejust being developed although there may be manysuch ‘specialists’ based on experience. The nursingestablishment consists of Registered Nurses andNurse Technicians (or assistants).


For the last five years there has been a direct-entrysystem for midwifery training (there are no plannedhome births in Slovenia and the midwives role is towork in the hospital during the period of labour).

The nurses’ acceptance of responsibility for their ownwork reflects a culture when they were assistants todoctors and although this is no longer the case it isgoing to take some time to instill a sense of selfcritical appraisal throughout the profession.Education will improve this. The views of the patientsand the pride in their own achievements were seenas secondary to the doctors’ approval of their work.

System for educating nurses and midwivesIn order to understand the education system fornurses it is first necessary to summarise the generaleducation system in Slovenia. Children attend‘primary’ education until the age of 15 at which timesome elect to attend general upper secondaryeducation for a further four years of generaleducation. Others will elect instead to join atechnical upper secondary education such as a‘nursing school’ for their next four years. In this casethey will receive a general education until the age of17 and then commence practical attachments inhospitals to leave the school as a nurse technician.Many nurses undertake no further formal training.

There are now eight nursing schools in Slovenia.Three are part of the universities and two areindependent higher educational institutions. All ofthese are funded by the state for regular students. Inaddition there are three private schools established in2009 which have no access to government fundingfor regular students. The Nurses Chamber(Association of Nurses and Midwives) believes this tobe too many student places overcompensating forthe current shortage of registered nurses. Only onesuch college – Jesinice - has a nurse as its Dean withall others led by the medical profession.

Registered nurses undertake a three year course givingthem a Diploma and since 2007 it has been possible tofollow this with a Masters degree in nursing.

The Nurses Chamber (Association of Nurses andMidwives) have developed a nationally approved setof competences for nurses which indicates thepotential processes and procedures that nurses at

various levels can undertake. This does not yetinclude leadership competences but may be revisedto do so. A revision currently underway will reviewthe procedures currently undertaken by doctorswhich could be done by nurses in the future.

Continuing professional development is important asall registered nurses must gain 70 credits every sevenyears and all nurse technicians 35 credits as nursinglicences are only valid for seven years.

Incentives to become a Nurse LeaderIncentives include wanting the challenge of adifferent role with more responsibility andresponding to the belief shown by the line manager.

Barriers to becoming a Nurse LeaderBarriers include the lack of formal leadership trainingavailable, compromising personal time available forfamily, the fact that the increase in pay for a UnitLeader is not relative to increased responsibility andthe lack of ambition for change preferring tocontinue with what they have always done.

How are Slovenian Healthcare leaders educatedIn recent years the lack of availability of relevanteducational opportunities has led to a shortage ofsuitably qualified personnel. Some hospitals havedeveloped internal management trainingprogrammes to support new leaders and one suchexample was seen in Maribor.

All nursing schools offer different formal educationcourses but all are likely to include a mix ofobligatory and optional modules on various aspectsof leadership and management.

Most post graduate leadership training however isundertaken through short courses with no formalqualification.

Malta

The Governance and Management of hospitalsMalta is the size of a city and has six public hospitals,a network of health centres and three privatehospitals. As such the system is relatively centralisedfrom the Government offices. The Unions are alsostrong in Malta and have a significant influence onthe development of services.


Although currently most Chief Executive Officers aredirectly responsible to the Director General (HealthCare Services), Malta is currently piloting a model ofgovernance in two hospitals where the ChiefExecutive reports to a Management committee.Members and Chairs of these committees arehandpicked by the Minister and neither interviewednor trained for their role. They are appointed initiallyfor six months to one year and this is then extendedas appropriate. The time commitment is one day perweek. With full implementation of this model overtime the Director General (Health Care Services) willbecome responsible for commissioning andregulation of health care and not provision.

There is a narrow national pay scale with strictregulations on how it is to be applied such as alwaysstarting on the bottom of the scale relevant to thejob regardless of experience. In order tocircumnavigate these rules, two workaround systemshave been created. The first one is to appoint seniorstaff through an agency called the Foundation forMedical Services: this allows staff to specify thesalary they would expect for the post for which theyare applying. The second is ‘bridging’ – this allowsstaff to leave for a short while and return on thesame salary. This system was set up to encourageretention of staff in Malta but to some extent hasbackfired in that staff are now encouraged to takeshort breaks!

Status of Nursing and Midwifery ProfessionsThe nursing and midwifery structures are strong inMalta with a good hierarchy in place. Registered Nursescan become nursing officers (manager of ward),Department Nurse Manager (usually specialty level e.g.surgical), Manager Nursing or Midwifery Services. AtMater Dei hospital, the only public acute hospital on theisland, there is also a Director of Nursing4. Both nursesand midwives have been asked to lead particularprojects such as the project planning and developmentof new hospitals for rehabilitation (led by a nurse) andoncology (led by a midwife).

Legally there is no reason why a nurse or midwifecannot be appointed as Chief Executive of a hospitalalthough there are currently no such post holders.

As in other countries doctors are seen as the superiorprofession but although this is changing with morenow willing to work in a multi-disciplinaryenvironment, most doctors in acute care still need tointegrate more into the organisation. Nurseshowever do not generally feel equal with doctorsand are less assertive. There is a very strong privatepractice available to doctors in Malta and those onthe appropriate contract can spend little time in thepublic hospitals. This gives rise to some frustrationamongst the nursing and midwifery professions.

Nurses’ pride in their profession is generally regardedas quite high although there is variation acrosspatient groups. At the University level, where placesare restricted and are therefore given to the brightestand keenest of students, the level of pride is higher.There are only 15 midwifery places each year andhence the selected students are particularly strong.

There is a serious shortage of nurses on the island,constraining the ability to address long waiting times.Further student places have been made available at theUniversity this year but it will be three years beforethese students qualify and the benefits can be realised.

Recruitment is managed centrally in Malta meaningthat leaders in hospitals may not be involved inappointments and that specific skill requirements ofa vacant post may not be met making leadershipever more challenging.

The role of midwifery supports childbirth in hospitaland has extended outside of the hospital settingsupporting new mothers for up to 30 days.

There are a high proportion of male nurses in Malta andas female nurses leave – albeit temporarily to havechildren – it tends to be the male nurses who attainleadership roles as they have continuous service.

System for educating nurses and midwivesThe Maltese Nurse Education has undergonesignificant reform in the last few years following adetailed study of other education systems andbuilding on the best as they apply to the Malteseculture. There is only one University in Malta where aBachelor of Science in Nursing and a Master of

4 Mater Dei is the only acute hospital in Malta however there are five other public hospitals including an elderly care, psychiatric, general and two rehabilitationhospitals.


Science in Nursing are offered. It is also possible nowto study for a Masters in Health Care Management.Students also choose to undertake overseas Mastersdegrees and are supported financially to do this withtheir job protected while they are away. It is notpossible to study for a PhD in Malta and there are asa consequence only four to five nurses on the islandswith a PhD which has been obtained overseas.

The state registered nurse (SRN) is the normalqualification with the last state enrolled nurse (SEN)intake in 2001. All state enrolled nurses were offereda conversion course and most of the youngerstudents took this opportunity. As the older nursesretire the proportion of remaining state enrollednurses is falling.

A specialist psychiatric qualification is available and thereare currently about 40 such qualified staff in Malta.

Midwifery education is direct entry at Bachelor ofScience level but they study Masters courses withnurses.

Incentives to become a Nurse LeaderIncentives include the opportunity afforded to try tochange the system and gaining recognition forachievements which is thought to be easier in aleadership role.

Barriers to becoming a Nurse LeaderBarriers include a significant loss of income due tothe inflexibility of the national pay structure, the wishto remain in a clinical care role, and the wish toremain working in the area of expertise –management jobs on Malta are appointed centrallyand hence do not allow staff to apply formanagement positions in their field of expertise.

How are Healthcare Leaders educated?The Central Government in Malta is very aware ofthe lack of leadership skills in the country. Until 1964Malta had always been ‘managed’ by other countriesand it was felt that this has contributed to a cultureof ‘good soldiers’ but ‘poor leaders’. In addition tothis until 1970 the nursing profession was dominatedby nuns where obedience was a fundamental rule ofeveryday life. This is now part of the Maltese cultureand may take several generations to change. Thiscould also explain why there is a perception by themost senior healthcare managers that male nursesare more confident in their abilities.

With the high educational achievements and strongEnglish language Maltese healthcare professionalscan compete favourably for posts overseas. Maltahas now recognised the need for training anddevelopment of managers at all levels and acrossprofessions in order to retain staff, enhance itsleadership skills and strengthen the potential foreffective and efficient health care delivery.

A comprehensive award-winning Leadership andManagement Skills and Values programme has beenrunning for the last three years for each of theidentified three tiers of management. Although notuniquely for nurses and midwives due to the staffnumbers they are by far the largest component atlevel 1 (first line management) and level 2 (middlemanagement). The programme is supported by aminimum number of hours of continuingprofessional development for each level and somecross-level conferences are also being undertaken.

This work on training and development reflects ahistorical situation where people were promoted intopositions of leadership and management primarilybecause of their technical expertise and seniority andnot because they had the necessary skills and valuesfor leadership and management.

Appendix 1 - Summary ofidentified education supportingNurse Leadership in healthcare


SWEDENSkane Region and Vastro-Gotland Regioncommissioned a ‘Leadership for Future Directors’Programme for identified potential Directors of thefuture. This is not specific to nursing.

Although there is no formal requirement atKarolinska University Hospital for staff to take aleadership qualification to progress to more seniorposts, many nurses take a post registration course in‘Leadership, Organisation and Development’ lastingone and a half years and contributing creditstowards a masters degree. When advertising forsenior nursing posts this will always be mentioned inthe person specification.

The policy at Karolinska University Hospital is to‘take care of all sorts of talents in leadershipregardless of profession’. To support this policy theHospital Director has a talent pool that people of anyprofession may apply for or they may be approachedto join. There is also a mentor programme in place.

PORTUGALLeadership for Change™ (LFC) was developed bythe International Council for Nurses and this was theprogramme chosen by the Ordem Board of Directorsto satisfy their requirements. The training was madeavailable to nurses who achieved certain criteria suchas minimum length of professional practice andminimum of 10 years to retirement among others.

The programme is composed of five interrelatedcomponents, workshops (usually four which run over18-24 months), team projects, personal mentoring,individual development planning and learningactivities. The programme addresses the usualleadership areas - political skills, external awareness,influence and negotiation, vision and creative andstrategic thinking. It includes significant role play(and other learning activities) to increase nurses’confidence in speaking to a wider audience. External speakers are also invited to help inspire theparticipants in their future leadership roles. The programme encourages both individualdevelopment plans and appointment of individual

mentors as well as training participants to becomementors of the future. In addition to this theparticipants benefit from the planning andimplementation of group projects. These must besustainable, have a measurable outcome and provideparticipants with project management skills andexperience. Groups are given a small grant as start-up but are encouraged to source their own funds (ifrequired) for the project.

Over 70 nurses have so far been trained in this waywith ICN trainers. However training has now beengiven to Portuguese nurses who applied to becomeLFC certified trainers. With the translation of allcourse materials into Portuguese completed, it isnow possible to provide this LFC training under alicensing agreement with the ICN both within thePortuguese health regions and across organisations.In this way both participants and the organisationmay benefit from the programme in the future.

The Ordem has yet to follow up the nurses from theonly completed course to evaluate its long termsuccess but it has the potential now to be rolled outacross all nurse leaders in Portugal. The ICN LFCprogramme is currently active in 35 countriesworldwide and all LFC participants are eligible to jointhe electronic LFC Network thus providinginternational perspectives.

The Centro Hospital Porto support and fund anMBA in Health Care Administration for future leadersof services (Lead Doctor – Director of Service,Supervisor Nurse or Administrator)

In addition a three month healthcare managementcourse (Programme of High Direction for Health– PADIS) is available to healthcare professionals inPortugal and run by a private Business School. This isa case study based course utilising the varyingprofessional perspectives of the attendees. It is wellregarded but expensive, hence restricting the numberof places organisations may be prepared to fund.

Although not relevant to Portugal, discussions withICN regarding Leadership for Change identifiedfurther information on the Global NursingLeadership Institute which may be of interest to


readers of this report. The International Council ofNurses facilitated the first annual Global NursingLeadership Institute in September 2009 for 30 seniorand executive level nurse leaders from 23 differentcountries across all world regions. Participants camefrom a variety of backgrounds and positions; ChiefNursing Officers, Presidents and Officers fromNational Nursing Organisations, Directors of Nursing,Deans and Associate Professors, executive officersfrom regulatory bodies and practitioners fromspeciality service areas. The ‘Institute’ employed anaction-learning approach where participantsobserved and analysed strategic global leadership inaction from a variety of global leaders, internationalagencies and non-governmental organisationsincluding the World Health Organisation, the WorldTrade Organisation and the Red Cross and RedCrescent Societies. The participants actively engagedin smaller learning and development groups. Groupmembers from different countries and backgroundsprovided a rich learning environment to discuss anddebate current and future health and nursingchallenges. The ‘2009 Institute’ included a focus onthe global economic challenges to health care, theimpact of global demographic changes and providedan opportunity for senior nurse leaders to enhancetheir strategic planning skills.

GERMANYIt is well recognised in German public hospitals thatmanagement training is important for ward leaders.There are a variety of management training courses inplace varying from in-house training to 750 hoursvocational management training. This latter example isa legal requirement (in three landers). As a means ofimproving succession planning deputy ward leadersmay be educated to this level in some hospitals therebycreating a pool of potential ward leaders.

To become a Department Head in German publichospitals it is necessary to gain a Diploma in NurseManagement from University. This course lasts forfour years if studied part-time.

BELGIUM Masters degree required for intermediate nursemanagers and above (requirement laid down inBelgian law).

At Leuven University Hospital a nurse heads theLearning and Development Department. A Competency Framework for Leadership has beendeveloped within the hospital reflecting the differentcompetences required at each level of leadership andmanagement. Behind the competences are details ofpotential behaviours for each so that managerswhen looking for a new leader can select the 10most relevant competences and the level ofattainment expected by that post.

The competency framework is used in interview ascandidates are assessed against this frameworkbuilding a profile for their strengths and weaknesses.On appointment their profile against the frameworkis shared with the manager to facilitate their supportfor their new leader. It is also shared with thesuccessful applicant to facilitate their on-goingpersonal development plan. In addition the newappointee is provided with a starter kit with someareas to focus on during the first four weeks andthey are supported in finding a mentor either fromwithin or outside of the hospital.

Three times a year all starters since the last event areinvited to a two day workshop to hear some basicconcepts of leadership and to discuss their profileand how they can use it for their personaldevelopment.

In addition to this every year a compulsory two yearprogramme is launched (14 days in total) for all newleaders clinical and non-clinical. This meets theBelgian legal requirement for CPD and is multi-disciplinary.

A Management Development Programme atUniversity Hospital Ghent which requires a doctorand a nurse from the department to attend together.If they still fail to work together ‘core teams’ will bedeveloped for a doctor and a nurse from thedepartment to work together on a given project. This model is led from the top with the ChiefMedical Officer and Director of Nursing workingtogether on a day to day basis.


SLOVENIAThere is a Management Development Programme forChief Nurses at University Hospital Mariborproviding leadership and management training fornurses who have not had the opportunity for sucheducation in Slovenia. This includes modules onpersonality testing (Myers Briggs), strategy, HRmanagement, team work and how to leadindifferent situations – motivation, conflict resolution,delegation, etc. - doctors are invited for somemodules such as team working.

The Nursing College at Jesinice is developing thefirst Masters Degree in Healthcare Management tobe available from September 2010, but the lack oftraining in this area in recent years is creating ashortage of lecturers for this course with anincreasing reliance on visiting lecturers from overseas.

MALTA A comprehensive award-winning Leadership andManagement Skills and Values programme hasbeen running for the last three years for each of theidentified three tiers of management: level 1 – firstline management, level 2 – middle management,level 3 - senior management. Although not uniquelyfor nurses and midwives due to the staff numbersthey are by far the largest component. Theprogramme is supported by a minimum number ofhours of continuing professional development foreach level. Some cross-level conferences are alsobeing undertaken.

The programme was designed to constructivelyaddress the following issues proactively:

• appreciate that the business and management worldis in a constant state of flux and that managerswithin the healthcare sector need to equipthemselves with new management tools andleadership skills and values to overcome thesechallenges

• acknowledge that effective management ismeasured on what is achieved over a specific andreasonable time frame

• accept the responsibility of assessing situationsand deriving feasible solutions

• communicate assertively and proactively atdifferent levels of the organisation

• develop a true client–patient–citizen centredorganisation and not one that simply addressesstaff needs

• break away from the exhausting and highlystressful micro and crisis management trap anddevelop real leadership and management valuesand skills

• generate a solid sense of identity and belongingbetween management to directly address the silomentality which is based on the most powerfulprofessional groups (which also triggers rivalry andfragmentation) rather than teamwork andinterdependence.

The main management structure was divided intothree levels:

Level 1 first line managers including principals,nursing officers, midwifery officers and theirrespective assistants and deputies

Level 2 all middle management within the healthsector including assistant directors, seniorprincipals and service managers

Level 3 administrative directors, Chief ExecutiveOfficers, Directors General and thePermanent Secretary

First line managers were required to attend 60 hours oftraining delivered as two sessions per week over a sixweek period. Structured and consistent CPD trainingand development sessions have been organisedthroughout the last three years for each level.

In 2009 a complementary project was undertaken forall level 2 managers to clarify their job content andassess individual personal competences. The resultsof this work are being used to identify the generaland specific training and development gap to informon-going programmes.


Appendix 2 - Full analysis of national questionnaire responses

Appendix 2 - Full analysis of national questionnaire responses


Appendix 2 continued

Appendix 3 - Organisationsvisited or contacted


SWEDEN

Red indicates questionnaire only

Organisation Location No of beds Total staff wte % Nurses

SALAR Stockholm

Karolinska Institute Stockholm

Karolinska University

Hospital

Stockholm 1600 15000 40%

Institute for Health andCare Sciences –Sahlgrenska Academyat University ofGothenburg

Gothenburg

Sahlgrenska UniversityHospital

Gothenburg 2300 16000 38%

Vaxjo University Vaxjo

Central Hospital ofVaxjo

Vaxjo 415 2750 50%

University Hospital Malmo 750 6000 30%

Norbottens CC Lulea 774 7000 33%

Lindesberg Hospital Orebro 100 620 35%

Sodra AlvsborgsHospital

Boras 560 3586 43%

Varforbundet (NursesAssociation)

Stockholm

National Board ofHealth and Welfare

Stockholm


PORTUGAL


Instituto Português deOncologia de CoimbraFrancisco Gentil

Coimbra 200 914 26%

Centro Hospitalar deSetúbal

Setubal 456 2115 31%

Instituto Português deOncologia do PortoFrancisco Gentil,

Porto 319 1800 34%

Centro Hospitalar dePorto

Porto 610 4200 35%

Catholic University ofPortugal - Institute ofHealth Sciences

Porto

Ordem de Enfermeiros Porto

International Councilof Nursing

Geneva - Switzerland

Centro Hospitalar doTamega e Sousa

Guilhufe - Penafiel 452 520 33%

Hospital de S. JoaoEPE

Porto 1104 5347 38%

Centro Hospitalar doMedio Ave EPE

Santo Tirso 297 382 31%

Centro HospitalarEntre o Douro eVouga EPE

Santa Maria da Feira 312 n/a n/a

Hospitalar Prof doutorFernando FonsecaEPE

Amadora 800 800 30%

Centro Hospitalar deCoimbra EPE

Coimbra 532 2602 33%

Unidade Local desaude do Alto MinhoEPE

Viana do Castelo 476 849 n/a


GERMANY


University MedicalCenter

Hamburg 1400 6500 23%

University NursingSchool

Hamburg

University Hospital Leipzig 1355 3200 40%

Charite UniversityHospital

Berlin 3000 9000 Sending

Pfalzklinikum fürPsychiatrie undNeurologie

Klingenmünster 150 150 61%

Landeskrankenhaus furForensische Psychiatrie

Bernburg 179 150 100%

BELGIUM


University Hospital Ghent 1000 5025 33%

University HospitalSaint-Lucl

Brussels 1000 3600 40%

University Hospital Leuven 1955 5771 35%

Psychiatric hospitalBethanienhuis

Zoersel 621 214 45%


SLOVENIA


University ClinicalCentre

Ljubljana 2274 914 45%

University ClinicalCentre

Maribor 1281 2808 47%

Psychiatric Hospital Idrija 200 200 42%

University Clinic ofRespiratory and AllergicDiseases

Golnik 200 458 38%

Nursing College Jesenice

Institute of Oncology Ljubljana 320 840 33%

Slovenian Associationof Nurses andMidwives

Ljubljana

Psychiatric Hospital Ormoz 140 143 n/a

Sposna Bolnisnica DrFranca Derganca

Nova Gorica 457 909 23%

Hospital forGynaecology andObstetrics

Kranj 62 124 50%

Sposna Bolnisnica Brezice 137 291 45%

Bolnisnica Sezana Sezana n/a 125 46%

Sposna Bolnisnica DrJozeta Portca

Ptuj 254 448 54%

Hospital Topolsica Topolsica 123 101 44%


MALTA


Office of thePermanent Secretary(Health, Elderly ,Community Care)

Malta

Zammit Clapp/ KarinGrech Hospitals

Malta 215 n/a n/a

St Vincent de PaulResidence for Elderly

Malta 1064 n/a n/a

Mater Dei hospital Malta 810 n/a 33%

Primary Health CareDepartment

Malta

Gozo General Hospital Malta 279 n/a n/a

Mount Carmel Hospital Malta 609 609 609

Maltese GovernmentOffice

Malta


Appendix 4 - Bibliography

42

Canadian Health Services Research Foundation Stories for Safety – Nursing Leadership and Patient Safety – 10Steady Steps, [Online], Available: http://www.chsrf.ca/research_themes/nlop_stories_safety_e.php /http://www.chsrf.ca/research_themes/pdf/11115_ss_Nurs_Lead_e_Final.pdf [06 April 2010]

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