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Climbing the leadership ladder


Climbing the leadership ladder: Why female nurses can struggle to reach the top

Climbing the leadership ladder: Why female nurses can struggle to reach the top

Nursing has historically been seen as a ‘feminised’ profession – but how much is this still impacting nurses working in primary care, asks Kathy Oxtoby

Nurses are now widely accepted as autonomous, educated professionals, with some holding roles among the top decision makers in the NHS. But for many years, nurses were often viewed as doctors’ handmaidens – their subordinates. Despite the advances the profession has seen, how much do these old-fashioned views linger and are they still holding primary care nurses – and female nurses, in particular – back?

Nursing in Practice spoke to women from a variety of nursing backgrounds who hold a range of leadership roles but who all have a shared experience – they have had to work hard for their voices to be heard. 

We heard that although women make up the vast majority of the nursing workforce, men in nursing are more powerful than might be expected. And that in primary care, where women account for an even higher proportion of the nursing workforce than in the wider NHS, the route to leadership roles is even less clear cut. So, what can be done to ensure there are no barriers to the progress of female nurses in primary care? 

Nursing by numbers in England

• 96% of nurses working in general practice are women: 15,706 women compared with just 625 men
• Yet 10% of advanced nurse practitioner and specialist nurse posts in general practice are held by men, and the same proportion of nurse partner posts
• 76.7% of 1.3 million NHS staff are women
• 675,699 people on the NMC register identify as female and 82,576 identify as male
• 88.6% of the 342,104 nurses and health visitors are women

Sources: NHS Digital; NHS England; Nursing and Midwifery Council

Female representation at the top
A research team at London South Bank University including Professor Alison Leary, the university’s chair of healthcare and workforce, revealed stark gender pay inequalities across the UK nursing workforce.1 Male specialist and advanced practice nurses reach higher-paid posts more quickly, women are more likely to accept dropping a pay grade to land a job they want, and men in nursing are overrepresented at higher pay grades, but underrepresented at Band 5, the research found. 

In primary care, although men make up only 4% of the nursing workforce in general practice, they occupy 10% of nurse partner roles (five out of 50 posts that record a gender for the postholder).² They also hold 10% of advanced nurse practitioner and nurse specialist posts (395 out of 3,959 posts with a noted gender), according to NHS Digital figures

This pattern extends to GPs too. On the GP register, women outnumber men, with 19,389 female GPs compared with 17,213 males, but data suggest they are also underrepresented in the most influential roles, with only 6,886 female GP partners compared with 9,636 male partners (meaning men make up 58% of partner roles, where gender is noted in the data).²

Clearly the voices of female nurses need to be heard more as decision makers at all levels, such as in their workplaces and at primary care network (PCN) and integrated care system (ICS) levels. Research over the past two years by the King’s Fund think-tank3 has found that ‘most clinical directors in PCNs are GPs, many of whom have taken on PCN leadership roles as extensions of their practice partnership responsibilities, or due to previous roles on clinical commissioning group governing bodies’. 

The research adds that NHS England’s guidance is clear that ‘clinical director roles in PCNs can be held be GPs, general practice nurses, clinical pharmacists or other clinical professionals working in general practice’.

Nurses told Nursing in Practice there are too few primary care and community nurses in senior decision-making roles. ‘There aren’t enough nurse voices on PCNs and often, therefore, they are not included in decision making,’ says Maggi Bradley, a GPN in west Lancashire and clinical nurse lead at Sefton Training Hub. 

 Sara Baldwin is a general practice nurse manager, place lead for digital and health and wellbeing, and general practice education facilitator for Greater Preston, Chorley and South Ribble, and a member of the CNO for England’s Policy Network.  She says there are ‘very few nurses on Integrated Care Boards (ICBs) and not enough on PCNs, but there is limited data available to confirm the numbers’.

Jenny Bostock, an advanced nurse practitioner (ANP), and a clinical director for Ramsgate PCN, says: ‘There is still the old-fashioned hierarchy of the GP being the senior person on a board, and the nurse being in the minority in some areas.’ 

This underrepresentation extends beyond healthcare settings. The Royal College of Nursing, the world’s largest nursing union and professional body, was shaken after an independent internal investigation painted a damning picture of an organisation with a lack of female voices and women in key positions, as well as worrying instances of sexual harassment. 

Published in October, the Carr report found an organisation and council ‘riddled with division, dysfunction and distrust’, where the make-up of the council does not reflect the membership of the college.4 The report noted that, despite recent improvements in the gender balance, the board is still nearly 60% male whereas the membership is almost 90% female.

Following its publication, RCN chief executive Pat Cullen has pledged to ‘overhaul’ the organisation, and launched immediate investigations into the incidents referred to in the report. And president Dr Denise Chaffer says the report must lead to ‘transformational change’ within the college. 

A feminised profession?
The reasons why men in nursing have a disproportionately powerful voice are complex, but are rooted in the profession’s history. Since men were able to join the register, they have gravitated towards problem-solving ‘male gendered’ work, says nurse academic Dr Elaine Maxwell. These roles are seen as more valuable and more visible than ‘female gendered work’, which is regarded as being more about relationship and social support. 

‘What you then see is male nurses moving quickly into advanced practice or into leadership roles early on in their careers,’ says Dr Maxwell, who is clinical adviser at the National Institute for Health Research Dissemination Centre.

Stereotyping as a ‘feminised profession’ has meant nursing has had to fight hard to be taken seriously. ‘Over the years we have raised the profession’s profile and are now trained at degree level. This means we are getting more recognition for our role, but we are still behind some other medical professionals,’ says Ms Bradley. 

Carole Phillips was until recently a nurse clinical director at Brunel Health Group PCN, and is a national professional advisor for the CQC, and a senior lecturer at the University of Portsmouth, developing the physicians associate and advanced clinical practice course. She says practice nurses can still be seen as subordinates to GPs, as nurses or HCAs in general practice today are given tasks such restocking supplies in the practice rooms, changing the paper on examination tables and emptying bins. 

Ms Baldwin says she has seen nurses who have been ‘pushed aside’ in favour of male nurses when applying for senior posts. She says a former female nurse colleague was told a male nurse had been given a job she had applied for because ‘he had a family to provide for’. 

Career development
One of the barriers to taking on higher-level decision-making roles is that in primary care nursing in particular, there is not as much room for career development as there is in hospital-based roles, which are more attractive to men. For example, unlike in secondary care, practice nurses do not have career pathways equivalent to, say,  a director or associate director of nursing. 

Career development opportunities in primary care depend on the employer ‘who should have a workforce strategy for people to develop’, says Dr Maxwell. 

In practice nursing, this strategy will be down to the individual GP practice. But with general practice so stretched, there may be little time or resources to enable GPNs to develop their careers. 

However, Jade Fenton, a practice nurse team leader in Worcester, says that ‘while there is nowhere near enough education or courses available to keep us progressing quickly, we can still learn by example, and through effective teamworking and support’.

Compared with when she started in practice nursing in 2009, she says ‘there is a lot more on offer now, and we have training budgets from local PCNs to use annually’.

While NHS staff have Agenda for Change, GPNs are reliant on the terms and conditions set out by general practices, which can vary widely. Ms Bradley says: ‘Time and again I’ve seen nurses leave general practice because of terms and conditions.’

Terms and conditions for maternity leave are often poor, and could be holding women back from progressing their careers. ‘I know a lot of practice nurses who have only had the Government’s statutory maternity pay. Considering salaried GPs get full NHS benefits, it does seem unfair – and it doesn’t seem to be improving,’ says Mrs Fenton. 

As well as poor employment conditions preventing nurses from achieving their full potential, confidence can also be an issue when it comes to seeking out and securing senior roles. ‘So-called imposter syndrome is a barrier to nurse leadership,’ says Ms Bostock. 

‘And yet there are nurses who may lack confidence, but with training would make excellent leaders.’

Case study: ‘You need to have confidence in your abilities’

Steph Lawrence is executive director of nursing and allied health professionals, Leeds Community Healthcare and Leeds GP Confederation, and national professional advisor for community services within CQC.

‘I trained as a nurse in the 1980s, then worked in A&E, community, became an advanced practitioner, and started taking on more leadership roles. I’ve taken leadership courses to develop my knowledge, and they are also great for networking and meeting inspiring nurse leaders.

‘You need to have confidence in your abilities. You can spend a lot of time experiencing imposter syndrome, thinking you’re not good enough. You also need to be kind, compassionate, and to seize opportunities that come your way.

‘The picture of whether there are enough female nurses making decisions at different levels, such as PCN level, is variable. A lot of leadership within primary care is still very much medical leadership. It’s difficult for primary care nurses to take on leadership roles, as they are usually employed by GP partners, and are too busy getting on with their job to put their head above the parapet.

‘We’ve got work to do to raise the profile of nursing, particularly in primary care. These nurses don’t get the same opportunities as those in secondary care, such as leadership training and development. We urgently need a national directive on terms and conditions for primary care. If the employment model was changed there would be more opportunities for these nurses to take on leadership roles. This would lead to better recruitment and retention.

‘Nurses looking at taking on leadership roles should think about how they can – at every opportunity – influence and raise the profile of community and practice nursing. Don’t be afraid to seize opportunities. And get rid of that “imposter” on your shoulder.’

The path to leadership
In terms of training and leadership opportunities, the NHS Leadership Academy, the RCN and the Queen’s Nursing Institute (QNI) all run leadership programmes offering learning and support, including ways to build confidence (see Resources). And despite barriers to gaining a ‘place at the table’, PCNs still represent a golden opportunity for nurses to step into leadership positions. ‘I see more female GPNs moving into leadership positions since PCNs started to develop,’ says Mrs Fenton.

But much more needs to be done to ensure more nurses achieve their full potential. A good start would be giving GPNs the same pay and conditions as their NHS colleagues, nurses say. ‘Overall, the majority of nurses who work in general practice would like to see Agenda for Change terms and conditions applied to them,’ says QNI chief executive Dr Crystal Oldman.

Better treatment of women in nursing would lead to better retention, recruitment and more opportunities to progress. Julie Belton has been a GPN and ANP, and is now a strategic and operational director at Cuckoo Lane Healthcare, a nurse-led general practice in west London. She is also a PCN network director, and one of the directors on a GP federation board, where she is the only female and only nurse. ‘Nurses need to feel valued,’ she says. ‘It’s not necessarily about money, it’s about feeling part of a team and having a sense of purpose. Nurses want to feel they’re doing a good job – they need training, support and a sense of belonging.’

Nurses need ‘a good career structure, to feel supported and not overwhelmed with work, and have time to do research and attend courses’, Ms Phillips says. ‘And they should not have to beg for that support – it should be part and parcel of their terms and conditions.’ 

To boost female leadership in nursing, and specifically in primary care, Ms Baldwin calls for ‘opportunities early on in nurses’ careers to develop leadership skills, such as being given ownership of different projects.

Dr Oldman says the importance of networking should ‘never be underestimated’. ‘What you do with networking is you listen a lot, and find somebody who shares your values and also challenges you to think differently – somebody who has “walked the walk”, been a leader, and recognises the importance of growing the next generation of leaders.’ 

Having nurse role models and mentors, and shadowing nurses in leadership roles can also inspire and help with career progression. ‘It’s great peer support, helps you to meet other leaders, and you can learn from their knowledge and experience,’ says Ms Bostock.

Such support also helps to boost confidence and address imposter syndrome. ‘You need that voice to help you say, yes I can do this,’ she says.

Case study: ‘We need more role models in nursing’

Ruth Oshikanlu is a nurse entrepreneur based in London, and author of Tune in to Your Baby.

‘I was a nurse, midwife and health visitor in the NHS for about 14 years. I left the NHS in 2008 in order to grow and develop.
‘I completed a coaching programme and several leadership programmes, including some run by the RCN and the QNI, which have been pivotal to my growth and development as a leader, and have helped me to become braver.

‘In 2010, I founded Goal Mind, a coaching consultancy to help individuals improve their performance at work. I’m also a trustee for a charity, guest lecturer for several universities, and write for several professional journals. I believe in authentic leadership – engaging people and including them as part of any change.

‘One of the reasons why women nurses don’t aspire to be leaders is that they are still working in a “know your place” culture. If you hear this long enough, you believe it. Most men have a quicker route to the top than women: they are supported to rise, and that’s what’s happening in nursing.

‘We need more role models in nursing. If you see people like you at the leadership table then you think, I can do this too.
‘Nurses also need coaching and mentoring – they need support to thrive. And nurse leaders need to bring others with them. The more people they bring to the leadership table, the more support they will have.

‘Nurses are not good at asking for support, but it’s so important that they do. They need to ask people to mentor them. Because people do want to help.’

Ms Belton believes that in order to progress their careers, ‘nurses need to take risks, get out of their comfort zone, be assertive, do their homework and make calculated decisions’.

When carving out a career path it’s important to be proactive. Mrs Fenton says: ‘I have always pushed for career development, sold my case as to why I should be invested in, and made sure people can see the benefits.’ 

And Ms Bostock, who put herself forward for her PCN role says: ‘If nurses aren’t at the table, sometimes you have to invite yourself to the table. So be bold and believe that you can do a leadership role. You can always start small, and work your way up.’ 

Ms Bradley says nurses ‘need to speak up, and ask to be included’ in decision making. Being a nurse leader doesn’t mean having to influence people on a massive scale, she says. ‘If one or two people are influenced by you, that’s leadership.  

‘If we all did our bit to raise our own profile then we would see how worthwhile and valuable we are.’

References

  1.  Punshon G et al. Nursing pay by gender distribution in the UK – does the Glass Escalator still exist? International Journal of Nursing Studies 2019;93:21-29. Link
  2.  NHS Digital. General Practice Workforce, 31 October 2022. Link
  3.  Chauhan G and Baird B. How can we develop professionally diverse leadership in primary care? London: King’s Fund, 2022. Link
  4.  Carr B. Independent review into the culture of the Royal College of Nursing. London: RCN, 2022. Link  

Resources

  • NHS Confederation: Health and Care Women Leaders Network. Link
  • NHS Leadership Academy: Link
  • QNI: Leadership programmes for community nurses. Link
  • RCN: Leadership. Link

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