International Journal of Trend in Scientific Research and Development (IJTSRD)

Volume 4 Issue 6, September-October 2020 Available Online: www.ijtsrd.com e-ISSN: 2456 – 6470

Challenges in Everyday Leadership Capabilities -

Conversations with Senior Clinical Nurses
Grace M Lindsay1, Sahar Mohammed Aly2, Pushpamala Ramaiah3
1Professor, 2Assistant Professor, 3Associate Professor,
1,3Faculty of Nursing, Umm Al Qura University, Mecca, Saudi Arabia
2Faculty of Nursing, Port Said University, Egypt

ABSTRACT How to cite this paper: Grace M Lindsay |

Abstract: Senior Charge Nurses (SCNs) are faced with an increasingly wide Sahar Mohammed Aly | Pushpamala
range of responsibilities as part of their workload and consequently devote Ramaiah "Challenges in Everyday
less time to patient care. It is noted that Leadership and organizational Leadership Capabilities - Conversations
management are also important, although adequate training, education, with Senior Clinical
resources, and support to realize these ambitions lag needs. Design: A mixed- Nurses" Published in
method focus group informed by a well-established leadership framework was International Journal
used to explore senior clinical nurses' perceptions of their Leadership. of Trend in Scientific
Methods: Purposive sampling of SCNs working in Scotland was employed. Research and
Data sources included a small focus group and one to one face to face Development (ijtsrd),
interview. 142 SCNs participated in this interview from 2000 to 2013. ISSN: 2456-6470, IJTSRD33442
Results: Twelve main themes were identified: 'Patient-focused leadership and Volume-4 | Issue-6,
Organization focused leadership" These two themes were further described October 2020, pp.1817-1822, URL:
through domains of Leadership and capabilities that articulate confidence, www.ijtsrd.com/papers/ijtsrd33442.pdf
quality improvement, and team performance.
Copyright © 2020 by author(s) and
KEYWORDS: Quality improvement, Leadership domain, Nurses perception International Journal of Trend in Scientific
Research and Development Journal. This
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INTRODUCTION
Over the last decade, management in nursing has become "Releasing Time to Care" (5) comprise part of a more
increasingly demanding with the role of the Senior Charge comprehensive cross-professional approach to improving
Nurse (SCN) having undergone significant change with Health Care Quality (1). SCNs have been identified as critical
increased administrative and managerial responsibilities, staff in the delivery of this strategy. They act as Clinical
broader responsibilities for direct patient care, and a more Leaders and Guardians of safety and quality in their wards,
prominent leadership role in the management of staff within explicitly working to meet the strategic objectives at an
the organization. When these factors are considered organizational and national level. This contribution is
alongside increased patient acuity, nursing shortages, and supported by successful teamwork and the achievement of
organizational pressures, questions arise about the scope key clinical outcomes, patient satisfaction, and a safe
and preparation for the SCN role (1), notably as it has been environment. The SCNs role is summarised in five key points
argued that these expanded roles and responsibilities have (3), namely Improved Leadership Ability, Greater Efficiency,
been taken on without adequate training, education, Enhancing Moral, Team Working, and the Development of a
resources or support (2). It is against this backdrop that caring environment that is safe and secure.
policy leaders within the NHS have developed documents
such as "Leading Better Care" (3) and "Better Together" (4). The significant quality indicators that have been the first to
The central recommendation from these documents was for be used are (a) food, fluid and nutrition, (b) number of falls
"professional development" for SCNs, and has led NHS and problems with pressure area care, and (c) data collection
education for Scotland to produce the developmental at ward level to allow the SCN to monitor these levels of care.
framework "Education and Development Framework for In addition to these 3 factors that may affect the achievement
Senior Charge Nurses." The highlighted dynamic functions of of optimal targets, other factors such as staffing level,
the NHS framework (2) have well designed support to sickness & absence, and patient profile are also taken into
develop individuals in their position and careers. account. "Leading Better Care" has articulated a new role
framework for the SCN with a supportive education".
This framework provides a single consistent, comprehensive, Releasing Time to Care" is essentially a quality improvement
and explicit environment within which to base the review initiative that works in combination with "Leading Better
and development of all staff. "Leading Better Care" (3) and Care" and is complementary and specific to Scotland.

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 International Journal of Trend in Scientific Research and Development (IJTSRD) @ www.ijtsrd.com eISSN: 2456-6470
SCN is recognized as having a key leadership role in nursing. framework was mainly used for structuring the analysis of
Following several reviews of the role, two related functions the themes within the narrative provided by the participants.
were given attention. First, attention was directed towards
enhancing the SCN role in their clinical leadership function, Focus group interviews (10) have been shown to be a highly
and second, to provide nurses more generally with a quality efficient way to collect qualitative data with the range of data
tool to enable them to ensure continuous improvement in key is increased by simultaneously collecting several participants'
areas of practice (6). The hope was that this developing role points of view. Interviews include a natural quality control
would provide the direct link with the broader governance of process as the data is collected, since checks and balances on
clinical care and a patient safety agenda enabling individual views, mainly where extremes exist, tend to be rationalized.
SCNs to understand the impact that their role has in Group dynamics help to focus on the most crucial topic,
supporting the delivery of national policy and strategic although a topic guide was used to structure the content of
organizational objectives. A previous review of the SCN role the interviews. Participants can make comments in their own
carried out by it was shown that people found the job title words while being stimulated by thoughts and comments of
confusing and that levels of responsibility within the role others and topic guides. Advice on group size varies with
were ill-defined, lacking clear performance criteria and some authors (10) recommending 8-12, while other
expectations (Stirling University, Cathy Stoddart). This researchers have used groups of 4-6. Participants are
emanated from patients, the public, and other nurses as well reassured that their comments will be anonymous and that
as doctors. all data will be securely stored following the Data Protection
Act, and hence confidentiality will be ensured. Interviews will
There were misconceptions about the role in general and the be tape-recorded and transcribed for analysis.A total of 142
skills that were necessary to carry out the role effectively. named applicants across 16 hospital sites were contacted as
The review emphasized that maximum benefits would be possible participants in the study. Of these, 47 (33.1%)
gained when SCNs exercised their clinical role with all responded positively, six responded (4.2%) but declined to
patients rather than providing direct patient care via participate while the remaining 89 (62.7%) failed to respond.
handling a caseload of patients. The review's concerns over Of the 47 optimistic respondents, 26 attended an interview, 2
this issue were confirmed by the SCN activity analysis, which of whom were judged to be ineligibly leaving 24 participants
showed that much of their time was spent providing direct in the study.
clinical care that was caseload driven. The need to carry out
general administrative duties, with a minority also providing Key themes
hospital or doctorate cover, has led to the situation in which The following issues highlighted the substantial issues:
little time was spent on developing the team and quality
The need for protected learning/educational/training
improvement. The research to follow has been undertaken to
examine SCN views on their role as a follow-up to IT and non-ward issues increasingly detract from the
undertaking further education based on lean methodology time available for the delivery of direct patient care
and transformational management styles as a mixed-method
The need to reduce the volume of repetitive paperwork.
approach.
Changed directives at an organizational level before the
Research Methodology effect of the previous organizational directives have
The study used a mixed-method approach to address the area reached fruition
of inquiry, as advocated by Creswell (7). Small focus groups
Difficulty in managing workload due to staff shortages
or one-to-one interviews, depending on the availability of
and non-ward duties.
staff was adopted in this focus group technique. Although the
primary purpose of a survey is to produce statistics that are Good communication and educational skills are the key
quantitative or numerical descriptions for some aspects of ingredients that ensure the effective planning and
the study population, the questionnaire used in this study coordination of patient care.
also had an open response section for additional
contributions not covered by the closed questions. Counterproductive nature of a top-down style of
management
The conducted interview used a topic guide covering similar Longer-term initiatives for maintaining staff morale and
areas to the questionnaire introduced in the light of a low the spirit of inclusiveness.
response rate for completing the questionnaire. Focus Groups
(9) and one-to-one interviews were conducted (10). The need to contribute to the workload of the ward team
Participants were assured of the interviewer's independence during peaks in workload
from the initiative and that any comments made would be The onslaught of unfocussed information and filtering it
confidential and anonymous. The participants were informed efficiently for local relevance
about the main topics within the interviews, and focus groups
gathered their views and insights concerning the impact that The need to be alert to future changes in organizational
the training had on their practice. Besides, Challenges to direction
implementing new practices were explored on how this also The need to provide quality patient care at all times
impacted on other staff and care in general. The concept of
visibility to patients and relatives was explored, and also Maintenance of ward skills and fostering the
what participants thought could be done differently. Other development of staff skills.
issues around the job role of relevance could be raised (Topic The benefits of gaining information by networking
Guide - Appendix 2). The questions took into account the within the organization
domains outlined in the role framework (3), although the

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 International Journal of Trend in Scientific Research and Development (IJTSRD) @ www.ijtsrd.com eISSN: 2456-6470
Twelve themes were nitrified from the thematic analysis of the one-to-one guided interviews.

These are presented in figure 1.

Figure 1 The multi-factorial role of a Senior Charge Nurse from analysis of one-to-one interviews.

Some examples of the comments made by the participants in the one-to-one interviews concerning the key themes of the SCN
roles are illustrated in Figure 1.

Leadership - The participants considered the SCN role to be Training - The SCN course was considered better and
pivotal and the 'glue' within the organization/ward area. more appropriate for newly qualified staff, but it could have
They would, however, value further training in managing been more inspiring. Interviewees thought that the course
budgets, health & safety, and human resources, particularly would have been better designed had it been informed from
for newly qualified nurse managers. Diversity, responsibility, the participants and SCNs rather than imposed in a top-down
and succession planning was raised as an essential issue. manner.
Contingency planning is essential to ensure that wards run
effectively when the SCN is absent, e.g., having a deputy, and Audit – Interviewees thought that some of the data collected
would require training to be provided for staff at band 6 level. at audit were without a broader context. At the health board
level, it might mean very little in terms of descriptive details.
Duplication An overload of information and objectives, often They felt that audit feedback did not function as it could in
duplicated by different development groups, but all of which terms of having the facility to change practice. Some were
need time to be read over. However, often they do not relate concerned that the process of being driven by audit and
to your local environment or are organizational objectives target indicators meant that it reduced the possibility for
remote from the "coal face." independent thought and time with patients. Time spent on
the audit was considered to be a trade-off with the amount of
Team-working – The role was recognized as part of a team time that could be spent on direct patient care.
effort and multi-factorial dealing with estates and audits,
pharmacy, entering data, and performing an extensive range Top-down management – Interviewees thought that at an
of administration tasks before necessarily being involved in organizational level, there was no explicit consideration of
direct patient care. Most tasks were supernumerary to the how recommendations could be implemented in practice.
workload of the day –to –day delivery of direct patient care, Often initiatives are put in place so quickly that their
but on frequent occasions when there were staff absences, outcomes and processes have not been thoroughly thought
e.g., sickness or study leave or on courses or an extra heavy through. The issue that priorities change frequently and that
workload, then the SCN became part of the direct care clinical quality indicators drove these as an excellent way to
provision team. ensure that clinical quality was monitored. However, the
prevailing view of interviewees was that there was little
Efficiency – The interviewees thought that 12hr shifts were feedback in audit regarding practice to address the shortfalls
unhelpful in terms of overseeing the management of the ward in terms of the indicator target levels. Some interviewees
area. They preferred the 7.5hr shifts as these gave them a thought that the educational provision given to support
better insight into what was happening at the ward level. Leadership in the SCN role promoted the concept that SCNs
Whether they were running specialized units such as Renal or should be managed from on high rather than that they
Neonatal, in terms of the overall managing of the workload, should function as independent ward managers. Often the
the SCNs felt that they were overloaded with secretarial work imbalance between education directives, and what happened
and domestic chores and that consideration should be given in practice and what was learned from practice, tended to
to potential efficiencies that may be achieved by introducing a treat practitioners as "a rookie."In the perspectives of
post of ward assistant. It was thought that a one-size-fits-all Identifying political and strategic drivers, most staffthe
educational program might not be an efficient way to deliver mechanisms are both local and regional, with consultations
an educational initiative. taking place with Lead Nurses, Regional/Government

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 International Journal of Trend in Scientific Research and Development (IJTSRD) @ www.ijtsrd.com eISSN: 2456-6470
Services, and nursing colleagues external to the local they appreciated the consolidation and reinforcement of
organization. messages and outcomes. Many participants suggested that
the training should be provided at the band six-level, and that
Staff morale– The interviewees thought that a staff having a succession planning process and deputizing facility
satisfaction initiative would be helpful, and many reported in existence would help the role of the SCN. The issue that
that they valued and saw the benefits of reorganizing and priorities changed frequently, and that clinical quality
streamlining the ward practices using the lean methodology. indicators drove these, was seen as an excellent way to
External speakers occasionally attended monthly ward ensure that clinical quality was monitored. However, they felt
meetings, and for them to use a discussion mode of teaching that there was little advice in the audit cycle concerning
with a training element to develop a variety of topics. practice to address any shortfalls in achieving indicator target
levels.
Discussion
Participants considered the course useful, particularly the Some initiatives like the balanced scorecard for infection
networking opportunities with other SCNs giving insight into control and the checklist were seen to be beneficial. SCNs
how the role changed in different areas of practice. They would value further training in managing budgets, health &
considered that there was some overlap with the RCN safety, and human resources, particularly for newly qualified
leadership course and the "Scottish Patient Data nurse managers. One overarching theme from the different
Programme," although it was useful to have a reinforcement participants was that the networking opportunity was
of the critical issues. The training was considered to be more incredibly beneficial for understanding and hearing how
relevant to newly appointed SCNs as the more experienced other SCNs from different areas manage similar issues. They
charge nurses felt that they were aware of the issues and, in felt that this was a very positive learning experience.
many cases, currently undertaking a lot of the role domains
from the role framework. "Releasing Time to Care," a In terms of other initiatives that are aligned to the senior
government-led initiative, was considered by the group to charge nurse review, the Scottish patient safety program was
have good intentions, although at an organizational level, it seen to be very important and has led them on to have a daily
had not been considered sufficiently clear how the safety briefing after the report. In terms of their day to day
recommendations could be implemented in practice. The SCN working practices, they complement the staff providing direct
considered their role to be pivotal and the 'glue' within the patient care. However, if any gap contingencies need
organization/ward area. Most were supernumerary to the covering, they are the people that are drawn in. They feel that
workload, but on the frequent occasions of staff absences e.g., the critical message from the course was that they should
sickness, study leave, on courses or an extra heavy workload, think outside the box and also to stress what the specific
they would assist the team in providing direct care. issues were in their areas of practice, because if people did
not know there was a problem, then it could not be sorted.
They considered their role to be at the helm of the ward with They thought that a staff satisfaction initiative would be
an overview of what was happening across all staff and helpful and many reported that they valued and saw the
patients in the ward. Some considered the role to be like that benefit in reorganizing and streamlining ward practices using
of a 'policeman' to ensure that people were adhering to good the lean methodology (11,12). It should be recognized that in
practice. This was particularly evident with hand hygiene and order to implement the policy documents, "Leading Better
their relationship with medical staff. On other occasions, Care" and "Releasing Time to Care Initiative to Support
when 'gaps' arose with work that required to be done the Leadership in the Senior Charge Nurse Role" (3) will require
SCN would 'pick this up'. Often this could be considered low- education providers to be put in place. Two main concepts
level work that could be done by domestics e.g., linen receipt were embodied in the design of the education program: first
and storage. The role was considered very multi-factorial, was an understanding and implementation of Lean
dealing with estates and audit, pharmacy, entering data, and Methodology (11,12), and second, was an understanding of
performing a broad range of administrative tasks to be done transformational and distributed Leadership. The Lean
before necessarily involving themselves in direct patient care. Methodology was first used in the motor car industry. The
They considered their role to be more visible in the ward components that have been drawn from this approach and
following participation in the training program, although the have been used in health care are:
notion of having an exact person in charge at all times would An understanding of processes in order to identify and
be enhanced by having a deputy. This would require training analyze problems,
to be provided for staff at the band six-level to put in place The ability to organize more effective/ efficient
contingency plans that would ensure that wards were run processes,
appropriately when SCNs were not there. 12hr shifts were Improved error detection and the relay of information to
thought to be unhelpful in terms of overseeing the problem solvers in order to prevent errors from causing
management of the ward area. SCNs preferred 7.5hr shifts as harm,
these gave them a greater insight into what was happening at Methods to manage change and solve problems with a
the ward level. scientific approach.

Their view was that initiatives are often put in place The last item in this list involves a team approach to problem-
relatively quickly and that the outcomes and processes have solving rapidly to ensure that patient safety is dealt with in a
not been thoroughly thought through. They thought that the timely and managed way, and that there is in place a system
RCN leadership course overlapped with the Scottish Patient for rapid problem investigation (11). Other concepts within
Safety Agency course. There was a wide range of experience the Lean process are improving specific sub-processes within
among the participants. The more experienced SCNs felt they the more extensive processes that are ongoing, particularly
had little new techniques to learn from the course, although intending to eliminate wasted effort or non-valuable activities

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 International Journal of Trend in Scientific Research and Development (IJTSRD) @ www.ijtsrd.com eISSN: 2456-6470
within the process (12). Examples of the methodology in that a more inclusive approach by the organization when
practice in the operating theatre introduced different proposing changes would help perform the role of senior
specialism to deal with waste in the system, including charge nurse. Often the organization practices a top-down
introducing a financial specialist, information system style of management in which change is introduced at too
specialist, a scheduling specialist, and a nurse for pre- quick a pace, and often before previous changes have had
admission preparation of patients. time to become fully operational. This style of management
presents difficulties for senior charge nurses. They often feel
Wong & Cummings (2007) (13) suggest that transformational pulled in two separate directions by, on the one hand, their
nursing leadership is vital to an organization for improving responsibility to implement organizational objectives and,
patient outcomes and the clinical environment so that clinical on the other hand, by their need to motivate work colleagues
leaders can deliver quality care and ensure all staff is engaged about the benefits of proposed changes, mainly when those
in the process. (14). Therefore the individual contribution colleagues felt that they had no input into these changes.
that members of the team make should be transparent, that
the leader should be identified and that the contribution of Limitation
their role in delivering a successful team should be made The primary limitations in this review relate to the relatively
clear. Traditional leadership models often result in many staff small numbers of respondents and the fact that the
going unrecognized and, therefore, being underutilized and respondents themselves are drawn from a wide range of
undervalued. Buchanan et al. (2007) state that transmission nursing specializations. This diversity was evident from the
of influence through dispersed Leadership is probably the comments received from the workshops. For example, one
most significant development in healthcare modernization respondent did not do CQI while another comments that
(15). It is a bottom-up grass-roots approach that meets the workforce planning is not appropriate for ITU. Despite the
expectations of the SCN framework and offers a model of smallness of the sample, several common themes have
Leadership that can help meet policy challenges. The emerged, most noticeable being the feeling that
approach is nearly concerned with developing and enhancing organizational objectives often seem remote from day-to-day
the skills and knowledge of all those in the organization life.
towards creating a culture that is functional and effective
(16). Transformational Leadership has an essential role in References
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