So how difficult is it for nurses to break through the glass ceiling into top management? Ann Dix finds out

Published: 06/12/2001, Volume III, No. 5784 Page 25 26 27 29

Dickon Weir-Hughes, chief nurse/deputy chief executive, Royal Marsden trust I became chief nurse three years ago, and the deputy chief executive part of my role was added on in April this year. Do I want to go on to be a chief executive? I do not know. Until six months ago, it would never have crossed my mind.

But my chief executive, who is a brilliant role model, though she's not a nurse, has changed my perception of the way in which a chief executive can really make a clinical difference to the patient.

It might also reflect changes in the NHS. Now chief executives are more focused on clinical governance, a lot of nurse executives are taking on deputy chief executive roles. Even five years ago, the role would have been more likely to go to a finance director.

My appointment has been welcomed not only by the nurses but by the medics - though at the Royal Marsden, nurses and medics work extremely well together.

It would be a shame if the chief nurse post was merely regarded as a stepping stone to becoming chief executive, because it is important that these posts are well regarded in their own right. But nurse executives have particular skills they can bring to the chief executive's role. They are good at juggling things and they have an understanding of how the whole hospital runs - from the kitchens, to night duty to x-ray. They also have the ability to keep their eye on hundreds of issues and then to focus on what is really important.

I do not know what the barriers are. There seems to be a view that nurse directors are not financially aware enough, but anyone who needs to make finance a prime responsibility will do so. Bluntly, there might be an issue about presence, though I think this country is lucky to have some strong nurse directors, and not all chief executives are great.

If there is a perception that we want more nurse directors to take up chief executive roles, I think chief executives need to help in that.

If more nurse directors had the opportunity to work with chief executives who were outstanding and allowed them to experience a lot, to experience the right things and to shine, it would help.

I can't really comment on the gender issue as a man, but I think there is a diversity issue. Most chief executives of acute trusts are white men. We need a greater variety of race, sexuality and gender.

I do not know if there are any gay 'out' chief executives, but if I became a chief executive I would be one of them. I guess that would be an issue for some boards, though I wish it wasn't.

'Helen Moffatt, chief executive, Queen Mary's Sidcup trust I've been in my current post since July last year.

Before that, I was acting chief executive of Hillingdon Hospital trust on a year's secondment. I started at Hillingdon as a staff nurse, before moving into operational management. Ten years after joining the NHS I had secured my first big management job as divisional manager for medicine.

After four years, I started to look outside the organisation - then the opportunity of becoming director of operations and chief nurse came up.

It was a wonderful combination of professional leadership and operational management.

After a further two years, I thought: 'I really have been here for some time. ' I started to look around again, but the chief executive secondment came up.

I applied for it and got it. At the end of the year, I had to decide whether to apply for the same job on a permanent basis or work for a different organisation. I chose the latter.

I had good encouragement at Hillingdon to progress, to operate outside my role and to become more visible in the organisation.

I felt well supported, developed and nurtured. Plus, the opportunities were there and I am a bit of an opportunist.

I had not envisaged myself as a chief executive even when I was in junior management, but from early on I enjoyed changing and improving services.

Experience of managing groups of services and services for the elderly, which involved working with outside organisations, gave me a taste of what I could do. Doing an MBA made me hungry to run a whole organisation.

I do not think a nursing background is, or should be, a problem. Nurses are good organisers, good leaders and good motivators of teams. Having been on the wards, I have a good understanding of what it is like to deliver care. It means you never lose touch with what the patient wants and I think you can communicate better and connect more quickly with the clinical staff. But if I had come purely through the professional route, I may not have been as confident about operating as a chief executive.

I had a very good welcome at Queen Mary's.

I think people were interested in the fact that I had already had a year as a chief executive and experience of operational management in a similar organisation. But obviously, any change can make people a bit wary, and they have to get used to a different style and approach.

There are more female chief executives than ever before, but I would like to see more women at the head of big acute trusts.

It is important for nursing professionals who want to take this route to broaden their experience and to try to operate in different spheres - to work outside their box. It gives you an opportunity to learn more and you become more visible in your organisation.

Professional networks and the support of my family and friends have been crucial, and as a new chief executive I found the coaching sessions at the NHS leadership centre extremely helpful.

'Helen Walley, chief executive, South West London Community trust My case is unusual in that for the first six months, I was joint chief executive and an executive director of the trust. In 1999, I became director of nursing and primary care when the trust was formed from three organisations. In August 2000, the chief executive announced that she was leaving. As the trust will cease to exist in April 2002, we felt it was important to ensure some continuity.

The director of Queen Mary's Hospital and I put a plan together to job share the chief executive role while maintaining our executive director roles.

We were interviewed both together and individually by a panel that included [NHS chief executive] Nigel Crisp, while he was still a regional director, and we worked together successfully for eight months, until Paul, my job share, got another job. Then I took on the full chief executive function.

I already had aspirations to become a chief executive. And I had no grand illusions about the job. Managing the wholesale dissolution of an organisation is not easy, but in fact it has been positive in this case because people have felt able to influence the agenda.

I think being a nurse definitely gives you an advantage. Having clinical knowledge and experience means you can relate to clinical colleagues more quickly than someone who doesn't have that background.

A key part of my experience was having a mentor - one of my tutors from a King's Fund course on effective services for older people.

The relationship lasted 11 years. It built my confidence and helped me to challenge the status quo, both personally and in my career.

My other key experience was going on the top management programme at the King's Fund. That gave me the confidence to become a director. In fact, I got my first director's post on my last two days of the programme.

I think more nurse executives are becoming chief executives now. I had no good role models when I made the transition. One of the people I knew had had a very difficult time.

The more positive role models we have, the more we will see the transition, and I think we need to work with nurse directors who do want to be chief executives as a group.

'Lezli Boswell, chief executive, Ashworth Hospital Authority I started out as a generic nurse and worked in general nursing, mental health and as a health visitor. My first general management job, as an area director in Brighton, was followed by a number of dual roles, combining clinical leadership with general management.

I found mixing and matching in this way very helpful. You can make things happen.

My previous job was clinical executive, mental health services, at Salford trust. I was asked to take up my current role as a secondment by North West regional office. They felt I had the credibility and background to help the situation, because I had experience of general management and clinical leadership at Broadmoor.

I didn't think I wanted to be a chief executive, but now I am doing it I love it. I do not think I appreciated the total role of chief executive before, and the way the different parts of the role can connect to make the clinical agenda work.

I feel I can do a better job of really changing the nature of clinical care than when I was a clinical director.

My background and my grasp of the business from a clinical and management perspective, plus the fact that I was known to them, helped the clinical staff embrace me. It is about having street credibility and understanding how professionals work and encouraging them to work in different ways. Because they trust you, you can drive forward the change agenda.

It is true that having clinical experience can be perceived as a disadvantage when you are going for a chief executive's job. People label you 'nurse' and view you as not having the total skills to do the job. But once you are in the job, it becomes an advantage. I think a lot of nurse executives do not choose to become chief executives because their interest is being professional clinical leaders. They feel That is what they do best.

I do not think It is due to a lack of opportunities.

The support and mentorship is there at national level. I think nurses need to exploit those networks more. It is about getting to the right people so that they view you in a better way.

Is gender an issue? I would like to say no, but I guess it is. I've never experienced discrimination as a woman working in mental health, which is very male-dominated, but I am sure there are examples of it, perhaps in the acute sector, which is seen as very macho.

And the NHS is still not good at creating opportunities for flexible working. Unless you put in all the hours God sends, people see you as not doing your job properly. But I think It is an issue for men as well as women.

I was in very senior jobs when my two children were very young, but I never expected any difference in workload as a result. I worked as an equal.

'Mark Morgan, chief executive, Rushcliffe primary care trust, Nottingham I took up this post as we became a second-wave primary care trust on 1 April. I had been director of nursing at a mixed mental health and learning disability trust, and before that a clinical director (general manager) for learning disability services.

Becoming a chief executive was part of a career plan, but I had not really considered a PCT until I became part of the project board to establish PCTs locally. When the posts were advertised I applied.

My chief executive, Martin Barkley, was always positive about career progression and was willing to build in new challenges to equip me with the competencies to become a chief executive myself. Whenever I sought to stretch myself, he was willing to offer new opportunities. I like to think the organisation gained because of the work I did, but I definitely gained professionally.

I have always had a mentor, focusing on particular areas of work. The latest is Chris Butler, a deputy chief executive in London and a former assistant chief nursing officer. With a King's Fund programme on nursing leadership, he focused my development around organisational politics.

All chief executives bring a large part of themselves and their experience to the role. As a psychiatric nurse, I believe in trying to understand how the patients see services, working effectively with a range of professionals - but especially doctors - and recognising that a range of agencies and external factors contribute to health.

I try to make sure another senior manager takes on the role of nursing leadership. While I continue to have a keen interest in nursing policy, professions need to feel I have an equal interest in their contribution - and value them all.

Many people with patient care backgrounds successfully make the transition to chief executive if they feel the role is attractive. My colleague PCT chief executives come from a range of backgrounds.

It may be that PCTs will be more attractive to nurse directors. They may have been concerned that running a large secondary care trust is too remote from why they joined the NHS.

But there are development needs. In mentoring up-and coming leaders, I find some nurses, more than other managers, lack self-belief. My advice is to find an organisation you believe in enough to give it 110 per cent, and a chair that you can 'fit'with.