A case study of frontline nurse leadership informed by complex responsive processes of relating

Abstract

Aims and objectives To understand the social construction of frontline nurse leadership and how power operates at this level. Background It is argued that frontline nurse leaders are central to the negotiation of care. Evidence suggests they feel ill‐equipped to lead and lack confidence in their ability to do so. Disempowerment has been proposed as a barrier to effective ward leadership. There is a lack of studies about daily frontline leadership practice. Design Single instrumental case study with embedded cases. Methods A purposive sample of one acute National Health Service Trust, with a convenience sample of embedded cases, was selected. Multiple methods of data collection were used including semi‐structured interviews, nonparticipant observations, field notes and documentary evidence. Thematic analysis using constant comparison and categorisation of data within, between and across cases was used to generate a theory of ward leadership in its organisational context. COREQ Checklist compliant. Results These findings suggest the frontline nurse leaders' power is a dynamic and situation‐dependent phenomenon that shapes and is shaped by ongoing interactions between stakeholders in the NHS. In these interactions, power ebbs and flows. These leaders, like all actors involved, were paradoxically both powerful and powerless at the same time. Conclusion This study offers a new contribution to the discussion about the power of ward leaders and problematises the theoretical assumptions that perpetuate calls for increased power. Relevance to practice In their efforts to resolve the spontaneous dilemmas that arise in practice, frontline nurse leaders would benefit from regularly participating in communities of reflexive practice.

Impact of leadership on the nursing workforce during the COVID-19 pandemic

“…Balancing the competing demands of the organisational policy with the needs of staff has been reported previously as a difficult but core element of daily nursing leadership. 30 Arguably, the work and the impact of these decisions was greater in this case where the language used illustrated the moral distress experienced when making and communicating these decisions:…”

The impact of leadership on the nursing workforce during the COVID-10 pandemic

“…Nurse leaders reported difficulty in bringing the organisational expectation laid down in policy together with the expectation of nurses and their own values of caring for staff and patients to make decisions. This balancing of the competing demands of the organisational policy with the needs of staff has been reported previously as a difficult but core element of daily nurse leadership (Phillips & Norman 2020). Arguably the work and the impact of these decisions was greater in this case where the language used illustrates the moral distress experienced when making and communicating these decisions: "I felt like a general in the first world war standing back sitting on a horse saying off you go, it'll be okay.…”

“…This is because they demonstrate that leadership decisions by matrons and ward sisters were not a direct translation of organisational policy or tools like a roster system but the result of bringing knowledge about and the expectations of affected individuals into view alongside the need for organisational need for safe staffing. This practical decision-making is the professional judgement of the experienced nurse leader and the complexity and impact of such judgements have the potential to lead to the moral distress that has been reported in previous studies (Phillips & Norman 2020, Ulrich 2014 The findings illustrate the impact of policy decisions on all participants; what was intended as a beneficial change when setting policy was experienced as both positive and negative across the organisation and this was situation dependent. This presents a challenge to existing thinking about command and control approaches to crisis management and may account for why some of the recommended protective measures did not always seem to afford protection to individual staff wellbeing in this case.…”

“…In the initial evaluation the research team were asked to identify what should be taken forward as business as usual; findings demonstrate the need to support nurses in making sense of their situation together. It has been argued that this is best achieved through creating reflexive spaces where they can think and learn together with supporting the development of skills and resilience for working in complexity (Phillips & Norman 2020, Maben 2020.…”

“…They are often required to adapt quickly to these uncertain circumstances to continue to ensure reliable and safe care for both their staff and the patient base as a whole (Aquilia et al, 2020). The tension of balancing these priorities in decision making has been recognised as central to the daily practice of nurse leadership (Phillips & Norman 2020). Arguably this is a pre-existing challenge of nurse leaders working in complex healthcare systems that is exacerbated in a rapidly evolving situation such as COVID-19 where there is a higher degree of ambiguity and uncertainty.…”