Nursing leaders have traditionally held leading roles in healthcare. For years, nurses have articulated and advocated collaborative and shared visions of care delivery. We have co-created models of care that have emphasized caring and responsiveness to individual and family (customer) needs. We have acted as strategic and operational connectors, individuals who sat at organizational senior tables informing administrative strategic and operational decisions with an understanding of the impact a particular decision might have on an individual's care. Nursing leaders have served as a valued "check and balance," competent professionals schooled in the complex systems of healthcare who could ensure that decisions made by an organization's administrative leadership were at least informed by the reality of the clinical situation. In short, we have been valued organizational leaders.

Recently, however, nurses appear to have become less important as strategic team players. Over the past decade, nursing has experienced much restructuring, downsizing and rightsizing. The result has been a loss of nursing leadership infrastructure. Many nursing leaders have lost the word "nursing" in their titles. Some nurse executives no longer report to the CEO; some do not even sit at the senior table. We have seen a marginalization of our strategic impact, and we have suffered a loss of morale within the profession. Arguably, healthcare planning and delivery have also suffered.

Why has nursing lost this traditional leadership role?

I would suggest that we must start by recognizing the reality of today's healthcare agenda and how our profession is perceived by other healthcare leaders as influencing that agenda.

Today, more than ever before, governments and health authorities are struggling to ensure sustainability. What public care is appropriate; what is healthcare's core business; how can we deliver care more effectively and efficiently; is today's model the only model - or, perhaps more correctly, which models fit which individual situations, and are all models being investigated? Business models and change are today's healthcare reality.

As nursing professionals, we are trained in the science of nursing and the art of caring, and are seen to be dedicated, compassionate and patient advocates. But we are not seen as business people. Unfortunately, we also have been perceived as professionals frequently pushing a self-serving agenda, not prepared to challenge the assumptions that in the past maintained healthcare stability. We are seen as slow to challenge our colleagues who accept that "this is the way we have always done it," slow to question outdated practices that are not evidence-based. In short, we are too often perceived as obstacles to needed healthcare delivery change, rather than its enablers.

What must nursing leadership do to regain its valued position in a future healthcare system? Where will we be five years from now? Will we be once again valued for our strategic input, or will we continue as marginalized participants, valuable only for the direct care we can provide?

I would suggest that nursing leadership can and should regain its former position of influence, but only if it addresses today's new healthcare reality. We must embrace the importance of business principles to tomorrow's healthcare delivery system, and we must meet today's change-management challenges head on as a profession. We need to listen, act and promote a culture that welcomes change.

Leadership is about action, not position, and nursing leadership must be seen to be prepared to act and effect change positively. We must continue to lead interdisciplinary teams of healthcare professionals delivering services where collaboration, trust and respect of one another's services are valued and integrated into the client's care plan. We must increase professional transparency and re-emphasize our communication strategies, relying on both new and old partnerships and strategic alliances with others.

Most importantly, however, we must be seen to embrace strategies for change willingly and openly. We must demonstrate our alignment with our organizational customer service goals, and combine an appreciation of the business and social responsibilities necessary for today's healthcare leadership decisions in an enabling rather than a resisting way.
Nurses must be encouraged to be strategic thinkers. They must take the time to listen, think, speak, question and reflect in their daily practices. Business skills and a facility with evidence-based quality tools and measures need to complement our more traditional skill sets. Career ladders and succession planning must take a higher priority. And nursing leaders must become more engaged in healthcare policy, legislation and regulation.

I am not advocating that we abandon our traditional professional values. Nursing leadership should continue to create and enunciate innovative visions of client-centred care. We should continue to advocate for universal caring that is safe (both for clients and staff), effective, efficient, equitable and timely. And we need to ensure that clients and their families continue to have input into the decision-making related to their healthcare.

What I propose is only that we frame our practices within a more evidence-based business model, one that promotes quality of care, at the same time recognizing the difficult fiscal realities of today's healthcare environment. I propose a more constructive dialogue, a recognition of the need for balance and a true partnering between nursing and other healthcare stakeholders. Nursing must share its best practices, network, commit to change and engage its employers as well as its customers to formulate the solutions to today's healthcare challenges.

Tomorrow's nursing healthcare leaders will need to advocate with innovation as well as passion. Promoting safe practice and consistently high standards of care, leading quality improvement processes with benchmarked outcomes and increasing our facility with the technology that will redefine tomorrow's healthcare will enable nursing leadership's return to prominence.

A highly educated (university-prepared) workforce, skilled in critical thinking and knowledge transfer techniques, is the needed raw material; professional maturity is the required environment.

I believe that nursing leadership has a future much brighter than today, an opportunity to shine and rekindle our spirit. We can use our skills, knowledge and courage to move the profession forward.

We need to embrace change, refine the skills required for new leadership roles, inspire one another to take risks and remain open to the new experiences needed to lead tomorrow's healthcare system.

As leaders, we must demonstrate that we can bring alternative solutions to the table, not just the problems. We must nurture our future and aspiring nursing leaders and ensure that they have the psychological hardiness and tenacity to carry forth the mandate for the next decade.

Nursing leaders can be tomorrow's entrepreneurial agents. If we are, we will know that adaptation to change is innovation's reward. We will espouse competence, creativity and innovation. We will rethink how we work, learn from our failures, celebrate our successes - and we will once again be valued as healthcare leaders.

It is time to create that shared sense of destiny we have always striven for as nurses. Now is the time to be bold and daring, and to take that risk. The future is ours to create. Let's create!

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