Management roles in nursing: current issues, perspectives and responses


Researchers in their respective clinical expertise and leadership discourses and particularly in the case of research concerning development of new and specialist posts have paid scant attention to the adoption and internalization of the management element of existing and emerging roles. Nurses are often ill prepared for the role of leader or manager of a service and many take up this role without clear planning or preparation (Foster 2000). Yet, early experience of leadership and support play an important part in the development from novice to expert in internalizing and adapting to the role of nurse manager (Shirey 2007) and recent research has revealed that ‘engaging’ leadership increases employees’ motivation, job satisfaction and commitment, and is directly related to improved performance (Alimo-Metcalfe et al. 2007). The authors of the papers in this themed issue present discourses on issues and responses concerning preparation of front-line managers, perspectives on the development of new and advanced roles, and the nurse managers’ contribution to the development and support of the nursing workforce.

The first three papers address preparation of nurses for the role of front-line management. Lee and Cummings present a systematic review of the research literature addressing determinants of front-line nurse managers’ job satisfaction. The authors identify evidence of a positive relationship between support for managers, participative organizations, empowerment and job satisfaction. They conclude that reducing managerial span of control and workload and developing strategies to increase support and empowerment of front-line managers are pivotal for positively influencing patient health-related outcomes. The authors suggest that such approaches will enhance the job satisfaction of front-line managers.

The papers by Skytt et al. and Foster and Fairbairn-Platt report on approaches adopted to support the development of staff in first-line management posts. Skytt et al. present a Leadership and Management Inventory, which they suggest can be used to measure first-line managers’ leadership and management skills and as a tool to provide feedback from superiors to more junior staff. Foster and Fairbairn-Platt report on a bespoke charge nurse development programme which was introduced in a large teaching hospital in London. They argue that many nurses are promoted to ward manager/charge nurse roles which carry substantial responsibility but with little or ‘no formal management preparation’. In these roles they characteristically show ‘an inherent under-confidence and in some cases a tangible reluctance to manage’. The authors’ description of the experiences of programme participants provides valuable information for senior managers considering this type of programme. A key finding is the importance of the development of relationships and communication channels between participants.

The expansion of nursing roles, alongside the proliferation of new and advanced roles is a global phenomenon. The next three papers by McKenna et al., Onishi et al. and Halcomb et al. provide a commentary at a national level on senior nurse managers’ perspectives on new and advanced nursing roles and their impact on patient outcomes and care. McKenna et al. use a qualitative approach to explore new nursing and midwifery roles from the healthcare providers’ perspective across all 18 Health and Social Services Trusts and four Health and Social Boards in Northern Ireland. They conclude that there is wide support for the development of advanced and specialist posts which are perceived as having a positive effect on patient care. However, further research is required into their efficacy, and, effective implementation is dependent on securing sustainable funding.

Similarly, Onishi et al., in reporting a study from Japan where nurse specialist roles were first introduced 10 years ago, seek to clarify how Japanese nurse administrators consider the current state and future prospects of nurse specialists to develop a future Japanese HR management model. They conclude that ‘offering opportunities for career development, establishing an environment of life-term continuous learning, providing well-balanced support for the needs of organizations and individual nurses,’ are pre-requisites for the effective development of nurse specialists.

Halcomb et al. discuss the recent evolution and current state of Australian practice nursing. The authors provide insight into the challenges facing Australian practice nurses and consider how the culture and environment can evolve to develop innovation to promote nursing management and leadership in general practice. They argue that practice nurses themselves need to demonstrate their potential to evidence the impact that their practice has on health outcomes. The paper suggests health systems need to accommodate the development of the practice nurse role and provide appropriate recognition, remuneration and policy frameworks to meet the needs of an ageing population and an increased emphasis on community-based care.

The next group of papers present perspectives on the development of new and advanced roles. Endacott et al. address the three future goals of leadership roles in critical care nursing namely: the immediate goal – the imperative to improve quality and safety of patient management; the continuity goal – improved transitions in care through improving communication between professionals, and the sustainability goal – sustaining improvements through empowering junior nurses and doctors. They conclude that evidence is emerging of the return on investment for patients and service outcomes from investment in strategic leadership roles for critical care nursing but that the achievement of these goals depends on action taken by policy makers, healthcare organizations and critical care nurse leaders. The challenge for nurse managers will be to further develop a firm evidence base, and to identify and educate the next generation of critical care nurse leaders.

Gould et al. in considering the re-introduction of the matron role in acute National Health Service (NHS) Trusts in the UK, provide an in-depth evaluation at a local level. The authors present useful insight into the scope of the role and the frustrations experienced by post holders where lack of autonomy prevents them from performing effectively. In addition, they identify the importance of senior staff maintaining their continuous professional development (CPD) to be able to perform effectively in their role. In this study, post holders placed their own development needs second to running the service. Key development needs identified include: business planning, equal opportunities, administration and providing cover for senior colleagues.

In presenting the collaborative development of a Master’s level Advanced Practice Programme in the UK, Livesley et al. discuss how employers, commissioners and educationalists can work together to prepare health care practitioners for sustainable advanced roles. They conclude that organizational readiness is a fundamental requirement to enable the advancement of practice.

Lockwood and Fealy present a review of the recent introduction of nurse prescribing into the Irish health service. In examining the introduction of this expanded role, the paper explores the attitude of Clinical Nurse Specialists (CNS) in Ireland to nurse prescribing and the perceived barriers to engagement of this aspect of role expansion. Of importance is the finding that the fear of litigation was identified as the most significant barrier to nurse prescribing. The paper provides useful lessons for nurse managers concerning the introduction of expanded roles and the potential to enhance capability through addressing the legal and educational requirement of such activity.

The final two papers consider nurse managers’ contribution to the development and support of the nursing workforce. The paper by Ikeda et al. analyses the effects of personal and professional variables on career advancement intentions of Licensed Practical Nurses (LPNs) in Japan. Using discriminant analysis, the authors show that the’ image’ of Registered Nurses, and ‘role acceptance’ emerged as important factors in explaining the varying intentions of LPNs to advance to RN status. Sankelo and Akerblad in exploring nurse entrepreneurs’ attitudes to management argue that nurses who are planning to start up in business should have earlier leadership experience and should attend some form of managerial training. The authors report that difficulties experienced with the adoption and internalization of the manager’s role were indicated by the fact that most respondents portrayed themselves as healthcare professionals rather than as managers. They conclude that, without management training, nurse entrepreneurs generally display a lack of assertiveness and do not fully appreciate the contribution of management to ‘business efficiency, staff well-being, customer perceptions of service quality and business profitability’.

The health care environment is changing, new and advanced roles are emerging, the public have increasing expectations of the care that they receive and new technologies are changing the way that we work (DOH 2008). Opportunity exists as never before for clinical nurse leaders to positively influence the patient’s experience of healthcare provision. Is nurse leadership and nurse leadership preparation ready to face this challenge? The papers presented in this issue provide encouraging examples of the contribution that emerging advanced and leadership roles are contributing to improvement in patient outcomes. However, evidence of continuing ill preparedness is also evident. Why are we still discussing the need to introduce leadership and management themes into pre-registration nursing curricula? Should these skills not already be firmly embedded? Why do we have first-line nurse managers coming to these posts by accident, not by choice?

This themed issue recommends a number of important areas for the future development and preparation of nurses for management and leadership roles. The challenge now is how to bring about a cultural change where talent management is embedded and where future leaders and managers are identified and nurtured? Are we as nurses prepared to grasp the opportunity to truly influence and lead future strategic developments for the provision of high-quality healthcare? Evidence from many of the papers presented in this issue suggests that there is much work still to be done.