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The leadership labyrinth: why practice nurses struggle to navigate their way to top positions

Primary care nursing has recently seen an influx of innovative programmes in leadership, an area that has traditionally faced neglect. But could these new schemes – run by bodies such as the Queen’s Nursing Institute (QNI) and NHS England – really be enough to see more nurses in senior positions?

The leadership programmes have been introduced against a stark backdrop. In 2016, research from the QNI found that just 1.6% of practice nurses are nurse partners. And since July last year, while the formation of 1,259 primary care networks (PCN) provided a golden opportunity for practice nurses to step into leadership positions, it led to just 19 nurses filling the role of clinical director, which is the named, accountable leader responsible for delivering the strategy of each PCN. 

A golden opportunity  

However, when the clinical director role was first announced, there was confusion over who was eligible to become one. The British Medical Association initially said that clinical directors would be chosen from among the GPs of the network. But in March last year, NHS England director of primary care, Dr Nikita Kanani, said that PCNs can be led by any clinician. 

Nurses still seemed hesitant to apply for the role. Creating leadership positions that practice nurses can apply for – and ensuring they know they can – is just the first step towards tackling a deep-rooted problem. Dr Crystal Oldman, chief executive of the QNI, says she doesn’t think the ‘tiny’ number of nurse clinical directors is ‘deliberate’ or ‘intentional’. Instead, she points to two factors: a lack of nurses already in leadership roles such as locality leads, who can move across to become clinical directors, and a lack of confidence to say, ‘Yes, I can do this.’

Nurse clinical directors are ‘pioneers of sorts’ when it comes to primary care leadership, says Dr Oldman. The lack of nurses in senior posts could be due to the conversation in primary care often getting ‘dominated by GPs’ and the ‘shiny and new’, which is ‘really good’ but ‘can make nurses feel ignored’, she continues. 

There are also fewer obvious steps in the career ladder than other nursing areas. Compared to secondary care, practice nurses have no ‘clarity of pathway equivalent to an associate director of nursing or a director of nursing’. Lead practice nurses are also likely to be managing smaller teams than in secondary care.

The pipeline of primary care nurse leaders has not been developed due to ‘very little funding or focus’ in the past, even though the system is ‘demanding’ more of them, says Karen Storey, national primary care nursing lead at NHS England and NHS Improvement. She continues: ‘Nurses need to be able to help lead within that new system of primary care networks and changing general practice. But nurses often don’t believe they’re able to influence the system.’

Like Dr Oldman, Ms Storey also finds that nurses often struggle with confidence when it comes to leadership. When speaking at conferences, Ms Storey usually asks the audience whether they are comfortable calling themselves a leader. ‘There’ll be one or two hands in a room of 50-plus people,’ she tells Nursing in Practice. ‘What’s that telling us? Is it something that the system has led us to believe? Is it something in our nursing training? Is it women? I don’t know. It makes me curious because I don’t have the answer.’

She continues: ‘All the things [nurses are] doing, whether it’s in the practice or outside the practice, actually make a difference – to nursing, but also to general practice nursing and to the system. Often practice nurses don’t recognise that. The work they do every day is leadership, but often they don’t recognise it as leadership.’

More investment

Dr Oldman says recent extra investment in the primary care nursing workforce, including leadership schemes, wouldn’t have happened without the General Practice Nursing Ten Point Plan from NHS England, released in 2017 – the second action of which is to extend leadership and educator roles, including supporting existing and potential leaders. 

Nurses filling positions such as clinical director will benefit the entirety of primary care, believes Dr Oldman. For example, better leadership opportunities could help attract nurses to the sector and keep them there. She explains: ‘If you see that fellow students you trained with are climbing their career ladder in the community or in the hospital, and you can see that you’ve got the potential of becoming a clinical director in a primary care network, I think you’re more likely to stay than think about options elsewhere.’

The QNI has launched its own schemes to promote leadership and has recently focused on teaching nurses to articulate their own value and hopefully, in turn, make clear that the workforce needs and deserves investment. 

Specifically, it wants to teach nurses to learn not just to say, ‘don’t forget us’ but ‘don’t forget us because of what we can offer’. Dr Oldman explains: ‘Employers will then be able to say, “Oh, I had no idea that nurses actually keep X number of patients at home or manage really complex COPD or diabetes.”’ 

Abandoned plans 

Last year, the QNI launched a programme tailored for nurse clinical directors, but it was shelved. ‘We weren’t successful in recruiting to it,’ says Dr Oldman. ‘I think we were too early. I think the job and what it entailed hasn’t quite worked out.’ Likewise, some nurses struggled to secure the funding needed to take part: ‘I don’t think there was clarity over whether there would be any funding for professional development of each of those clinical directors.’

Dr Oldman points instead to the QNI’s existing Aspiring Leaders programme for community and primary care nurses, launched in 2017. She says it could be helpful for clinical directors: nurses on the programme don’t just come from general practice – they come from social care, prisons and community service too – and clinical directors must work with all of those as part of their role. But schemes specifically for aspiring clinical directors is the ‘way to go’, she says. ‘I would love to be funded to do that.’ 

NHS England and Improvement launched another leadership programme for practice nurses last year, adapted from the existing Rosalind Franklin Programme. Funded by the GPN Ten Point Plan, which Ms Storey is responsible for helping to deliver, the 10-month course for GPNs is currently working with its first cohort, who will graduate in February and has now recruited its second 32-person group. 

Ms Storey tells Nursing in Practice: ‘We recognise that [developing leadership in practice nursing] is something that we need to do because the system is demanding of it, primary care is changing, general practice nursing is changing, and nurses need to be able to help lead within that new system of primary care networks and changing general practice.’ 

The scheme – created in partnership with psychotherapeutic coaching company Shiny Mind – aims to help nurses change their own behaviour, says Ms Storey. She had previously attended a separate Shiny Mind course to address her fear of public speaking. ‘If you think you’re no good at public speaking, then you’re less likely to do it,’ she says. ‘But you can address those beliefs and behaviours, and develop a set of tools and techniques to overcome those fears.’   

The course is also billed to help nurses engage wider health policy. ‘Often, nurses work in isolation, behind closed doors, in small teams,’ points out Ms Storey. ‘They’re very clinically competent but often don’t have the time, or the headspace, or the opportunity to look outside the wider practice, or outside the system, unless they’re interested
in it or have to do it as part of research for their advanced practice or another degree.’

Helen Crowther, a clinical nurse advisor for NHSX, who is in the first cohort on the programme, says the course ‘is empowering GPNs to become outstanding leaders. There is a lot of commitment required, but it’s worth it. The whole group have bonded and have become a network of support, sharing experience, skills and reflections with likeminded professionals.’ 

Meanwhile, Paula Spooner, an advanced nurse practitioner from Wakefield, signed up due to the ‘culture shock’ of becoming a lead nurse for primary care in her CCG. Likewise, it has ‘completely changed’ her from an ‘unsure, out-of-depth clinician’ to a ‘confident leader’. Now, she says she can support her fellow practice nurses who ‘often have the best ideas but do not have a mechanism to have their voices heard at higher levels’.

She continues: ‘I am much calmer in conflict as I try to understand other people’s opinions and motivators before reacting. I am more confident to stand up and speak in the corporate environment; I understand the systems that I am working in and how this affects decisions, influencing and change making.’

Such courses are vital to promoting leadership in general practice nursing, says Ms Spooner. They ‘equip nurses with the skills they need to find a seat at the table, and if there is not a seat available, to bring their own! 

‘Gone are the days where nurses are doctors’ handmaidens. We are now recognised as professionals who can sit at decision-making tables.’

Cultural shift 

Ms Crowther and Ms Spooner say their professional lives have been transformed by the Rosalind Franklin Programme for GPNs – with the former calling the course ‘life-changing’ and the latter currently excited to speak at three conferences this year, something she ‘never would have previously dreamed of’. 

However, there is the risk that programmes such as these – which are limited by funding and resources by nature – will only impact a small number of nurses unless they are part of a wider cultural shift. Andrea Mann, a practice nurse, managing partner at her practice and clinical director for Crossgates PCN in Leeds, tells Nursing in Practice that such a transformation will take a ‘few years’. 

‘I think a lot of the problem stems from this culture that it would be a GP lead, and I think that’s the assumption of a lot of nurses that, “Well, I wouldn’t get the job because I’m not a GP,”’ she says. ‘There are loads of leaders in nursing, but I don’t think there are many nurses who are working at a strategic level in primary care with management leadership experience and qualifications.’ 

To bolster the process of nurses increasingly ‘coming out of practice to take on some clinical leadership roles’, Ms Mann suggests ‘encouraging and supporting’ nurses through a long-term combination of ‘training and developing leadership’, as well as ensuring that they are at the ‘forefront of all the changes that are happening’. 

Marie Therese Massey, the Royal College of Nursing professional lead for general practice nursing, tells Nursing in Practice that job adverts must ensure it is clear that every primary care team member can apply for clinical director roles and similar positions in PCNs. ‘Make it clear that what you’re really looking for is skills and experience, not whether you’ve got letters after your name.’ 

‘There are some really positive things, but it’s not like our job is done here,’ Dr Oldman concludes. ‘It’s about the sustainability of what’s been started.’

What is the Rosalind Franklin Programme for GPNs?
  • Fully funded in NHS England General Practice Nursing 10-Point Plan. 
  • For mid-level to senior nurses in general practice and primary care, with cohorts of up to 32 people. 
  • Nurses commit up to five hours per week, plus 11.5 days out of the office,
  • to masterclasses, workshops and online modules. 
  • Nurses are matched with a mentor who is influencing policy.  
  • It has four elements: self and self as a leader; organisations and systems; change and improvement for safety in healthcare; and management skills.

Applications for 2020 have closed, but keep an eye on the NHS Leadership Academy website for 2021.

 

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