Nurse Directors' jobs – a European perspective

J. FILKINS M A S o c S c , R N , F E T C , M H S M

Professor, Dean of Faculty of Health and Social Care, St Martin’s College, Cumbria, UK

In 1993, at a meeting in Geneva, a small group of Nurse

Directors from across Europe formulated the wish to

establish a forum for Nurse Directors. By 1995, a

congress for Nurse Directors had been organized which

was held in Finland. The forum became a standing

committee and by 1996 this forum agreed, at a meeting

in London, to establish the European Nurse Directors

Association (ENDA). Since then, the Association has

developed and has formulated three key aims which

underpin its activities. They are:

Correspondence

J. Filkins

Dean of Faculty of Health and

Social Care

St Martin’s College

Fusehill Street

Carlisle

CA1 2HH

UK

E-mail: j.filkins@ucsm.ac.uk

F I L K I N S J . (2003) Journal of Nursing Management 11, 44–47

Nurse Directors' jobs – a European perspective

Background of study The European Nurse Directors Association (ENDA) was

founded in 1996. Members agree on an annual action plan based on the three main

aims of the Association to strengthen the nursing contribution to policy makingwithin Europe, further nursing leadership and to establish a communication net-

work of experts Nurse Directors across Europe. This study supports the above aims

by examining issues relating to the job of Nurse Directors across Europe.Aim The aim of the study was to identify shared aspects of the job from which

further work could emerge to support the three aims of the Association and, in

particular, to further nursing leadership across Europe.

Method An action centred research method (strengths, weaknessess, opportunities

and threats [SWOT] analysis) was chosen which gave the opportunity for re-

spondents to expand on key points. The texts were submitted in French, German

and English with opportunities built in to individually discuss statements in order to

minimize inaccuracies which could have emerged during translation.

Results Nurse Directors of today give a clear indication of �can-do� mentality

and the strengths and weaknesses which are demonstrated indicate that there are

areas which need to be further explored and supported. The findings were presented

at the 5th Congress of ENDA in Rotterdam in 2001 and were well received.

Funding has been obtained from the National Nursing Leadership Centre to expand

the research.

Limitations This study is a snapshot only of those working at the leading edge

in nursing. The responses also reflect feedback from nurses working in mainly

acute hospitals and further work needs to be undertaken to include additional

European countries.

Conclusion It has been demonstrated how Nurse Directors in Europe are taking

and making opportunities to lead influence nursing and healthcare. Areas of further

work that need to be addressed have emerged.

Keywords: Directors, Europe, leadership, nursing, opportunities

Accepted for publication: 4 July 2002

Journal of Nursing Management, 2003, 11, 44–47

44 ª 2003 Blackwell Publishing Ltd

• to strengthen the nursing contribution to policy

making in the context of health care management in

Europe;

• to further development of the art and science of

nursing leadership and management in Europe;

• to establish formal links between Nurse Directors

across Europe to support a communication network

of experts.

In order to influence at strategic level, there is a

need to network. The Steering Group of the Associ-

ation is formed of members who should, where

possible, have strong links with his/her national nur-

sing organization. This allows for reciprocal flow of

information amongst organizations and supports net-

working. In order to obtain information that could

contribute to addressing the aims of ENDA, it was

decided to undertake some action research relating to

Nurse Directors’ jobs. Over the years it had become

apparent that many commonalities existed between

the job holders in different European countries. A

SWOT analysis was developed and the results were

presented formally at the ENDA Congress in Rotter-

dam in October 2001.

In order to set the scene and focus on the role of

Nurse Director within the UK, an excerpt of an adver-

tisement for such a post was presented. It reads:

�This is a senior management appointment with

many responsibilities. The person appointed will

have a major influence on the continuing devel-

opment of the Hospital as a Centre of Excel-

lence.�To be considered for this position, candidates will

need to have exceptional vision and leadership

qualities in addition to superior professional

and personal credibility. Relevant management

experience in a significant and comparable health

care environment will be essential together with

a successful track record in substantial and

sustained achievement in an acute health care

facility.’

This is a powerful wish list that looks for personal,

professional, leadership and management skill to be

present in abundance. Such adverts are not new and

have been analysed in the past (Filkins 1997). It is not

surprising that Nurse Directors across Europe, where

similar contents are to be seen in advertisements, iden-

tified the need to share experiences and learn from each

other. Increasingly, the words �influencing� and �leader-

ship� come in to play. From a personal perspective, this

is seen as a maturing of roles for people who are no

longer afraid of change.

Methodology

The method and the results of the SWOT analysis were

as follows:

The outline of the SWOT analysis was discussed and

the framework set up and sent out to members in

French, English and German. Each Nurse Director was

asked to state the overall aspects of their job as it is seen

in their country in relation to its overall strengths,

particular weaknesses, internal and external opportun-

ities and threats.

Fourteen representatives from a possible 11 countries

were sent a SWOT framework. Eight responses (57%

response rate) from the following seven countries

were received: Germany, Finland, Belgium, Slovenia,

Croatia, the Netherlands and UK. An additional verbal

response was received from France that largely corro-

borated the outcomes that we will be discussing.

All responses were coded in order to maintain confi-

dentiality and the emerging themes were grouped

together for review at a meeting with representatives.

Where uncertainties emerged in the text (mainly because

of language), individual consultations have taken place

to clarify meaning and accuracy of translation.

The SWOT analysis was meant as a snapshot view of

how Nurse Directors in Europe perceive their jobs. It is

not a comprehensive survey. Nevertheless, it does give a

good feel of emerging commonalities.

Results of SWOT analysis

The summary of the strengths, weaknesses, opportun-

ities and threats are as follows:

Strengths

Two powerful main grouped answers emerged.

1. The most striking phenomenon is the almost unan-

imous reflection on the cross-department, cross-

professional sphere of responsibility (six references)

and having responsibility for such cross-depart-

mental working.

2. Specific reference to leadership (five references) has

been made almost as frequently as the reference to

cross-departmental responsibilities. From the infor-

mation provided, all participants inferred leadership

as synonymous with the job of Director of Nursing.

The above reflection on cross-departmental respon-

sibilities could be a reflection of the fact that because

Nurse Directors have leadership skills, they are

asked to lead in other areas (quality, etc.).

Nurse Directors' jobs

ª 2003 Blackwell Publishing Ltd, Journal of Nursing Management, 11, 44–47 45

The sound educational background and knowledge

base of Nurse Directors was referred four times as was

the ability to motivate staff.

The positive aspect of having a budget to manage was

referred three times.

The wealth of experience, ability to influence strategy

and quality were highlighted equally frequently (three

times each).

Some respondents reported that they saw the need to

have perseverance and be adaptable and entrepreneur-

ial.

Weaknesses

Two main groups of weaknesses were identified.

1. The first one refers to difficulties with medical staff

and ranges from lack of communication between the

Nursing Director and doctors, to pressures on the

Nurse Director from the medical staff, to lack of

ability in influencing medical/administrative decision

making (five references).

2. The second weakness is identified as having to work

with unsuitable legislation and unsuitable nursing

education (four times). The isolation felt by Nurse

Directors was recorded four times and the impact on

family life was recorded twice.

Lack of recognition by hospital and society of the role

of the Nurse Director was referred to three times as

were the difficulties relating to multiplicity of tasks

inherent to a Nurse Director’s role.

A multiplicity of other weaknesses were referred to

singly.

• Insufficient development opportunities to meet new

demands.

• Need to make choices between quality of care and

hospital costs.

• Having to take on responsibilities which are not

linked to the function of the post.

• Lack of autonomous structure.

• Difficulty of being up to date in relation to the tech-

nical and administration changes.

• Insufficient requirement of entrepreneurial and

managerial know-how.

• Always having to justify what nurses do.

• One respondent stated that in (economic) hard times,

Nursing Directors are not needed and that �they� do

not know what Nurse Directors do and only want to

see (recognize) the work of doctors. �They� do not see

who is the main co-ordinator. Discrimination against

women, lack of progression, high turnover of Nurse

Directors were referred to individually as was the

impact of mergers and governmental bureaucracy.

• The lack of qualified staff was mentioned as a

weakness once and the lack of staff with specialist

education (once).

• Interestingly, one respondent referred to the fact that

Nursing Directors are not always willing to learn

from their mistakes.

• One respondent stated that doctors feel threatened by

Nursing and another that there is resistance by staff

to innovations led by the Nursing Director.

Opportunities

Two clear foci of opportunities are identified.

1. One relates to the opportunity to collaborate with

other institutions for research and evidence-based

nursing (five references).

2. The other identifies opportunities to influence both

government and hospital-wide policies (five times).

The opportunity to influence nursing education is

mentioned three times as is the opportunity to network.

Two responses make specific reference to the oppor-

tunity to increase standing/recognition of Nursing.

Two respondents see an opportunity to review

existing systems in order to improve quality.

Two respondents refer to changes in health care and

the blurring of professional margins as an opportunity.

One respondent notes the opportunities offered to

influence as a result of large staff numbers and the

opportunity to influence cost reductions.

Opportunities to identify resource needs and develop

new specialist services have been specified by two

respondents.

Threats

Two main areas are perceived as threats.

1. One refers to the lack of funding and the subsequent

reduction of staff (referred to by five respondents).

2. The second main area of threat is identified as �pol-

itics� seeing only short-term objectives instead of

long-term objectives and the lack of evaluation (five

respondents).

The other major area of concern relates to Health

Reforms having a negative effect on quality and quan-

tity of health services (four respondents).

Three respondents have spoken about the difficulty of

always having to do more with less.

J. Filkins

46 ª 2003 Blackwell Publishing Ltd, Journal of Nursing Management, 11, 44–47

The lack of interest in the nursing profession, which is

leading to recruitment difficulties, has been mentioned

twice and the fact that nurse education and continuing

professional development do not prepare nursing

adequately for the future.

Other threats mentioned individually (once only

each) are: having an autocratic health government,

doctor dominance, siege mentality of the profession, the

structure of professional associations does not facilitate

the influencing of politics.

Furthermore it is felt that the strengthening of nursing

is on a collision course with other power bases, esp-

ecially doctors. The difficulty of working with

unqualified staff and inadequate leadership pro-

grammes also received a mention.

Lastly, a division of purpose between directors was

seen as a threat; innovation saturation leading to lack of

stamina and energy contributing to the change agenda

and the increasing instability of the world and the

European economy were referred to.

Tentative conclusions

It is most encouraging to note the almost unanimous

description of the ability to cross professional bound-

aries and departmental workings, the leadership ethos

and the willingness to lead multiprofessional teams.

There are two main stumbling blocks identified: again,

almost unanimously, the working relationship with doc-

tors has been mentioned and the issues relating to nursing

education being unsuitable for present-day nursing.

We should not overlook the fact that clarity emerges

when looking at opportunities for nurse leaders which

can be summed up in the opportunity to collaborate

with other institutions, and also the ability to influence

both at governmental and hospital level.

Nurse Directors of today give a clear indication of

�can-do� mentality but it is yet to be fully explored and

supported. This snapshot of working at the leading edge

in nursing identifies areas which should be further

researched. These areas relate to the gap between the

two powerful professions: medicine and nursing, and

issues relating to education and preparation for the role.

The above piece of work has highlighted a number of

common, significant themes which need to be shared

and require further investigation. The significance lies in

the fact that there are commonalities that have emerged

despite the very differing health care background of the

countries involved. There are some clear developments

that appear to take place across Europe which point at a

strengthening of the role of the Nurse Director in gen-

eral, and to Nursing Leadership in particular. This

review of the role has highlighted that Nurse Directors,

wherever they may be working, have the ability of

�thinking outside the box� and to meeting requirements

as stated in the advertisement.

The next steps

With the encouragement and support of the Director of

the National Nursing Leadership Project, it has been

possible to identify some funding which will allow more

detailed work to take place. Higher education institu-

tions have been identified which will work collaborat-

ively on this and it is anticipated that the outcome will

raise the awareness at European level of the significance

of these posts and the need to invest in their development.

Discussions have begun to identify the possibility of

establishing learning sets which will contribute further

to addressing the three main aims of ENDA and in

particular to strengthen the Nurse Director’s network.

Battram (1998) has summarized Lipnack and Stamp’s

work on the processes most often required to formalize

informal networks:

• clarify the purpose (why are we doing this?);

• identify the members (who is involved?);

• establish the links (how are we connected?);

• multiply the leaders (who is responsible for what?);

• integrate the levels (how are we connected to the

hierarchy and �lower� archy?).

If we apply those five key points to ENDA and its

members and to the wider European community we will

not fail to make an impact.

Summary

The summary of the SWOT analysis has indicated the

almost unanimous description by participants of the

ability to cross professional and departmental bound-

aries. It also demonstrates an increasing maturity and

broadening of responsibilities for the Directors of

Nursing.

Areas where further work is needed have emerged but

above all, it has been demonstrated how Nurse Direc-

tors in Europe are taking and making opportunities to

lead and influence nursing and health care.

References

Battram A. (1998) Navigating complexity, industrial society in

Edwards N (2001) On the right track. Health Management

Journal 9, 20–21.

Filkins J. (1997) Director of Nursing and Quality: a gilt-edged

bond for Trusts? Journal of Nursing Management 5, 301–309.

Nurse Directors' jobs

ª 2003 Blackwell Publishing Ltd, Journal of Nursing Management, 11, 44–47 47