nurse directors' jobs – a european perspective
TRANSCRIPT
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: [email protected]
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