With disproportionately few nurses being appointed chief executives, Jean Faugier and Helen Woolnough ask whether they face prejudice or are simply illequipped for the role

Published: 06/12/2001, Volume III, No. 5784 Page 24 26 27

Chief executives with nursing backgrounds are few and far between. Since nurses constitute the largest workforce in the NHS, they are arguably under-represented at this strategic level. So why is it that nurses are not reaching the 'top job'?

We conducted a study to investigate the myriad issues facing nurse directors in achieving chief executive positions.

More than 300 nurse directors were contacted, and about two-thirds of them responded, discussing their views in semi-structured telephone interviews.

To gain a representative insight into nurse directors across England, participants were selected from each NHS region and from different types of trust - for example, acute, mental health, community and primary care trusts.

All 200 participants were initially asked if they had applied for a chief executive position. Seventy-eight per cent said no, largely because they had no inclination to become a chief executive.

The main deterrents were the added pressure, increased stress and poor job security of the chief executive position, and a reluctance to 'give up' the professional aspect of their current role.

Twenty-two per cent said they had applied for a chief executive position. Most (58 per cent) cited career progression as their main incentive. Other reasons included being encouraged by others, a desire to take on more responsibility and fitting in with respondents' personal development plans.

Respondents were also asked to indicate whether or not they had been shortlisted. Only 53 per cent of those who had applied for a chief executive role had been asked to attend a selection process.

Nurse directors invited to take part were asked why they felt they had been unsuccessful. On reflection, a few respondents recognised the limitations of their skills and experience and, consequently, felt there were candidates capable of performing the chief executive role more effectively.

Most respondents, however, highlighted specific barriers, including an emphasis on financial skills and a devaluing of clinical knowledge. Respondents commonly reported that their clinical background was a 'disadvantage' and felt 'obliged to apologise for being a nurse'. Rather disturbingly, a number of respondents reported that selectors knew who they wanted for the post before the interview, and the selection procedure was merely a formality.

According to one respondent, 'I went to see the chair after my interview. He said that he knew who he wanted, and it wasn't me. '

To find what skills nurse directors thought chief executives needed to perform their role effectively, all 200 respondents were asked whether, in their opinion, certain competencies were vital, desirable or unimportant.

All 200 respondents said strong leadership skills were essential. Championing and embracing change, political astuteness and board effectiveness were also regarded as vital by the vast majority of respondents (98 per cent, 96 per cent and 95 per cent respectively). Clinical knowledge was regarded as desirable but not essential by most respondents (77 per cent).

All respondents were asked to identify any extra qualities that nurse directors could bring to the chief executive role. Certain common extra qualities were deduced from the rich qualitative data this question generated. The most commonly identified extra qualities were:

nclinical knowledge;

npatient focus;

nholistic knowledge of the service;

nability to work across agencies;

nemotional intelligence.

Respondents commented that clinical knowledge gave them professional credibility, particularly among fellow nurses.

The consensus was that changes are more likely to be accepted by those charged with their implementation if they are advocated by chief executives with a clear understanding of clinical issues - and of the impact their decisions are likely to have on frontline staff and patients.

Chief executives, previously accountable for financial matters, now also carry ultimate responsibility for assuring the quality of services provided by their trust.

1Ensuring internal clinical governance is now effectively a statutory requirement, and chief executives are responsible for continuously improving the services they provide, providing reports on their actions and progress, and fostering an environment which encourages and supports the pursuit of clinical excellence.

2Nurse directors are ideally placed to relate their wealth of clinical knowledge to the management of an organisation that has patient care at its core. The succession of clinically intelligent managers to chief t executive positions is therefore likely to impact heavily on the ability of trusts to deliver this agenda.

The survey also attempted to investigate perceived barriers facing nurse directors who want to become chief executives.

Most respondents (88 per cent) identified barriers, and most identified multiple barriers.

Again, this question generated a large qualitative data set and the most commonly identified barriers were extracted from the information given.

Most (70 per cent) said that nurse directors are kept from the chief executive role because, as nurses, they are stigmatised.

They stressed that the common perception of nursing as a subordinate, submissive profession continues to pervade the NHS, and also exists at board level. This is often reflected in differences in salary between nurse directors and colleagues on the board.

3As one respondent commented: 'The director of nursing is often seen as a subordinate post on the board, someone who works for the director of operations or finance, for example. We are not considered equals. '

Many respondents expressed frustration at the inability of other executives and factions of the NHS to look beyond the 'nurse' title. As such, respondents felt that executives and those selecting future chief executives fail to recognise the additional capabilities and potential of nurse directors.

Gender was identified as a barrier by 43 per cent of respondents and was invariably cited alongside the stigma of the label 'nurse' as a 'double whammy'.

While the vast majority of nurse directors are female, most chief executives are male. According to respondents, this has several implications.

First, respondents commented that female nurse directors applying for chief executive positions are immediately disadvantaged because of their gender - in terms of the traditional family roles associated with women and their preferred leadership style.

Alhough female leadership strengths, such as interpersonal communication, nurturing and mutual respect, are beginning to gain more respect in the NHS, they are yet to be regarded as definitive.

'Nurse directors have transformational skills, which are often regarded as female characteristics. There is a perception that people with these attributes are too soft to manage an organisation. '

Second, the fact that few women reach chief executive level acts as a deterrent to other women.

Some respondents said that an absence of positive role models due to the preference for homophily (gender similarity) in appointments prevents them from applying.

4Other barriers identified were resistance from the medical profession, and age (9 per cent and 5 per cent respectively).

Some respondents said nurses are afforded less status than medics and consequently occupy a lower power base. Respondents felt that, as a result, appointment panels may have reservations about the willingness of consultant medical staff to respond to nurses. Anecdotal evidence from the medical community working with chief executives with nursing backgrounds does not reflect this concern.

Furthermore, 23 per cent of respondents claimed that they would be nearing retirement in the next few years. Age was therefore identified as a barrier to obtaining chief executive positions. Nurse directors nearing retirement generally said that they achieved nurse director status relatively late in their careers and felt that their age would count against them if they pursued a chief executive role.

Only a small proportion (12 per cent) of respondents did not identify any barriers. They had generally not applied for a chief executive position and did not intend to do so in the near future. This suggests that they had never experienced any of the barriers facing those who had applied for a chief executive role or expressed interest in applying.

In light of the barriers identified, respondents were asked whether or not they felt more opportunities need to be created to enable nurse directors to become chief executives.

Respondents stressed that in order to identify developmental needs and create the nurse executives and chief executives of the future, more attention needs to be paid to succession planning throughout the nursing workforce.

Succession planning needs to be implemented early in a practitioner's career so they can steadily acquire relevant skills and experience. Respondents identified a number of strategies that could be incorporated into the succession planning process, including mentoring, shadowing and secondments. Leadership development and management experience were highlighted as essential parts of the learning process.

Many respondents stressed that developmental initiatives are likely to fail if NHS culture as a whole is not addressed and the perception of nursing as a subordinate profession is left unchallenged. As one respondent commented: 'The culture of the NHS needs to change to dispel the myth that nurse directors are not capable of being chief executives. '

To investigate the potential future interest of nurse directors in the chief executive role, all respondents were asked what their next career move was likely to be.

Thirteen per cent categorically stated that they would be seeking chief executive status, and 9 per cent said they might pursue a chief executive role.

Most respondents (30 per cent) were unsure. This reflected a perceived lack of career opportunities.

Many had not been recommended as chief executive material and felt unsure about what direction to take next.

Almost a quarter (23 per cent) of respondents said retirement was likely to be their next move. Others (11 per cent) felt that their next move would probably be a director of nursing role in a larger trust and some (6 per cent) intended to pursue another director of nursing role in a similar trust.

Four per cent said they would be looking for another management role in the NHS.

A small proportion (4 per cent) intended to leave the NHS altogether.

The study indicates that there are issues that need to be addressed to ensure that aspiring nurse directors are given an equal chance of acquiring chief executive roles, and the potential success of aspiring clinicians in strategic roles is recognised and developed. The National Nursing Leadership Project is considering the implications of this study for the future development of nurse directors.

Future work will address the barriers identified by respondents, namely the stigma of the nursing title, and gender, and the implications of findings for leadership development.

We need to develop a cadre of clinically intelligent leaders to take forward the modernisation agenda.

The question we need to ask is: is modernisation of the NHS going to be delivered by reshuffling the same clinically unintelligent leaders?

National Nursing Leadership Project. www. nursingleadership. co. uk


1Department of Health. The New NHS, Modern, Dependable. HMSO, 1997.

2Department of Health. A First Class Service: quality in the NHS. HMSO, 2001.

3 Healy P. Bottom of the board. Nursing Standard 1997; 11 (16): 12.

4Northouse PG. Leadership Theory and Practice. Second edition. Sage Publications, 2001.

Professor Jean Faugier is director, National Nursing Leadership Project and Helen Woolnough is research assistant, National Nursing Leadership Project.