Unwelcome arrivals on some trust boards initially, nurse executives are proving their worth. But keeping a balance between corporate management and professional leadership can be a headache. Ann Dix reports

Have you heard the one about the nurse executive who takes her sleeping bag into the office? Lisa Rodrigues has, and it is not a practice she espouses - although as nurse executive of a large community and mental health trust she understands the pressures.

To keep the workload under control you need to be extremely focused, she says. Her work at South Downs Health trust falls into three areas: external working with other agencies, internal work advising the trust board, and working alongside staff developing clinical practice.

'Anything outside those areas, I don't do.'

Over the past three years, as layers of middle management have been removed, giving staff more autonomy and responsibility, her job has changed to more of a 'leadership and influencing role'. She also has more clinical governance responsibilities, such as research and development, clinical audit and quality.

Honorary president of the European network of nurse directors Professor Jacqui Filkins believes the emphasis on clinical governance in The New NHS white paper will further strengthen the nurse executive role, but that more work is needed on leadership and succession planning.

She recently left her post as nursing and quality director at Carlisle Hospitals trust to become dean of the faculty of health at University College of St Martin, Carlisle. She remembers it as 'immensely rewarding', particularly seeing 'changes which we battled for and had the vision to develop' become accepted and owned by staff. But it is also 'a tough job', requiring 'immense stamina', she says.

Talib Yaseen, honorary secretary of the Royal College of Nursing network group Nurses in Executive Roles, says initially trusts appointed nurse directors because they had to, but he believes few chief executives would now be without them.

As a board-level position, the post is unique, he says, except perhaps for the medical director, in that it demands professional leadership and accountability for nursing, without line-management control. 'To some extent you are a hostage to fortune, ' he says.

One difficulty is getting the right balance between corporate management and professional leadership.

'Nurses often see you as a nursing representative. But your first priority is patient care, and in that respect nursing is only a means to an end.

You are not a shop steward for nursing.'

The breakdown of traditional career structures can make promotion to nurse executive a big career leap. Jean Bailey, RCN adviser in management, wants to see more support for new and would-be nurse directors. A recent RCN survey on the motivation and satisfaction of nurse executives has shown that 'some of the newer and younger executive directors are floundering', she says.

The survey of nearly 250 nurse executives by the University of the West of England showed that 52 per cent of nurse directors wished to stay in their current jobs, but that another 27 per cent wanted to leave, especially in the first two years in post.

Nurse executives placed low value on their own personal development.

And, notwithstanding wide variations in job descriptions and salaries (£27,000 to£75,000), the biggest influence on whether to remain in post was the quality of their relationship with the chief executive - their 'perception of the nurse executive role, their expectations and their overt and covert support'.

Survey researcher June Girvin spent three years as a nurse executive before changing career, for reasons mirrored in the survey. 'The people who were dissatisfied were not always unhappy in their jobs; they were unhappy in their organisations, ' she says.

She advises aspiring nurse executives to find out as much as possible about the prevailing culture of the organisation, the chief executive's management style, and the value placed on nursing and the nurse executive post. Had she taken this approach, instead of accepting her first board-level post at face value, she believes she would still be a nurse executive today.

It is an experience she would not wish on anyone. But she survived, thanks to an employment history of 'achievement and recognition', good contacts and networks, and independent and expert coaching, which 'enabled me to analyse my own abilities and refocus my career into a more rewarding and more influential direction'.

She is now a senior research fellow at the University of the West of England. She believes the reason nurse executives don't set more store by their own personal development may be 'a feeling that requesting help of any kind is seen as a failure', or that 'having achieved these dizzy heights one shouldn't need any more development'.

But she says it is extremely difficult to get the sort of experience that prepares nurses for this role. She advises new nurse executives to get professional, constructive advice and assistance as part of a continuing development plan. 'Paying attention to personal growth and development is a sign of strength, not weakness.'

Ask Mary Monnington about the rewards of being a nurse executive and she will joke, 'love, respect and lots of red carpet'. But she is serious when she says she has won the 'respect and acceptance' not only of the senior directors, but also of clinicians.

'My biggest success has been to get nursing back on the map at the trust board and recognised as important in its own right, ' she says.

Leading on nursing without having line-management control can be frustrating, she admits. 'You occasionally discover things after the event it would have been nice to know earlier. It can be very difficult to negotiate progress and change when you have no right of passage, and it always takes a lot longer than you would like.

'You have to be articulate, persuasive, pushy, stubborn, determined, a completer/finisher and, at times, a diplomat.

You must not be coerced and you need to take a broad-brush view. A sense of humour is vital, and you need to make sure that working for the NHS is only part of your life.

'When you score a success and get things changed you may even improve things for patients.'

Her broad professional background helped her make the career leap, but she stresses the need for good support.

'When I arrived I told my boss I was arranging for an external mentor - a retired nurse executive. Until you get to know your chief executive well, you don't always feel safe to talk about your weaknesses. . . You need someone you can go to in safety - someone who will listen, advise and challenge.'

She describes her relationship with her chief executive as 'generally pretty healthy', although 'we don't agree on everything'. This has been key, she says.

But she is in no doubt that 'without my excellent deputy, I couldn't have sustained this job'.

career profile

Name: Mary Monnington

Age: 45

Job: executive nurse director, Salisbury Health Care trust (integrated acute/community/mental health trust).

Main responsibilities: professional head of nursing, trust education lead, associate director for clinical effectiveness directorate.

Salary:£45,000 +

Budgets:£300,000 + board-level responsibility for trust budget of£80m.

Staff directly managed: 8

Average hours worked: 55-60 per week.

Background

1994-95: head of service review and development, Dorset health commission.

1992: regional project manager, care in the community, Wessex RHA.

1991: regional waiting time co-ordinator, Wessex RHA.

1987: service/general manager, surgical and paediatric services, Princess Margaret Hospital, Swindon. Employer: Swindon HA.

1982: infection control nursing officer, followed by four years as senior clinical nurse, general surgery, and one year as professional nurse development tutor, Southampton HA.

1972-79: A progression of jobs in nursing and nurse education at St Thomas' and Lambeth hospitals, London, followed by one year as a charge sister/teacher in Melbourne, Australia.

Qualifications: MSc nursing and research method (1987), BSc economics (1982); registered clinical nurse teacher (1976), diploma in nursing (1976), obstetric nurse certificate (1972), state registered nurse (1972).

Management training: making general management work, Nuffield Institute, Leeds (1988-89); middle management training, Southampton and South West Hampshire HA (1985-86).