Insights October 2013

Where Has the Voice of Nursing Leadership Gone?

Rachel Bard and Hugh MacLeod

The Ghost of Healthcare Consciousness is waiting for us and states:  

“Wow, the conversations taking place on the ‘balcony of personal reflection’ most certainly speak to the patient mantra, ‘nothing about me without me.’ This confirms the importance of the nursing voice to the conversation.”

In days gone by, a critical position within the staffing hierarchy of a hospital was the head nurse. She or he played a lead role on hospital units or wards – a role characterized by coaching, managing, teaching and mentoring nursing staff, and by directing and coordinating the care they provided. An effective head nurse fostered high-quality patient care and a positive, safe workplace for patients, nurses and other members of the care team. This position carried significant authority and was a fundamental nursing leadership role within the accepted 24-hour care nurses provided to patients. 

Things changed, however, about 20 years ago, when the head nurse role evolved into the nurse manager role. This new position allowed for more decision-making responsibility at an administrative level as well as the authority to allocate and manage available resources. Individual nurse managers became increasingly responsible for financial and other administrative decisions both at the unit level and within the broader organization. With this change, nurse managers became formally situated as a part of middle management.

Out of nowhere, the Ghost of Healthcare Consciousness arrives once more and declares:

“Flatten, downsize and streamline … you know fat is out, and lean management is in! Some organizations look leaner, if a bit skinny, with limited energy. Look inside, the heart muscle is atrophied and the electrolytes are out of balance. Organizations need strong leadership that will support middle managers to spread the load, which will create some downtime for greater reflection to contribute to collective intelligence. Organizations need the creative process and the collective energy that proceed from people having the time and inclination to listen to one another, confront, challenge and play.”

Previously, the head nurse was responsible for the overall coordination of patient care, overseeing and directing the development of care plans with the nursing team and serving as the main point of contact for other healthcare providers. However, with the emergence of the nurse manager role within a primary nursing model, direct care RNs were assigned to specific patients, coordinating their care while communicating and collaborating directly with other healthcare providers within the care team.

So, how has this change affected quality of care in hospitals? We think it’s safe to say that, though the original goal may have seemed logical, there has been a serious loss in translation. Changes in administrative structures have resulted in nurse managers having as many as 100 direct reports. Under these conditions, administrative tasks consume a growing proportion of each day – leaving little time to lead knowledge translation, patient safety and quality improvement initiatives, and to oversee appropriate admission and discharge planning. Unfortunately, nurse managers often receive little formal management/leadership training and are insufficiently supported in the administrative and resource management demands that accompany their role.  

Meanwhile, clinical nurses on the unit have been given more autonomy and the capacity to work holistically with patients in order to achieve better individual patient outcomes. While this is an empowering and professionally important goal, one that would seem to benefit the patient, leadership challenges have been identified. These challenges relate to a lack of coordination regarding the continuity and consistency of care within the unit, the transfer of accountability, the clarity of care goals and the establishment of evidence-based practice cultures and healthy workplace environments.

Having 24/7 responsibility for a unit is an almost impossible situation if the nurse manager’s decisions are not taken into account or if they have limited ability to influence strategic and policy decisions that directly impact the day-to-day provision of care. Nurses at all levels report that they have fewer decision-making abilities when it comes to staffing levels, quality improvement and patient safety than they used to. They feel they have lost their voice. Failure to acknowledge this and take necessary corrective action will compromise the essential roles of teacher, mentor, director and care coordinator. Furthermore, those managers who are educated as nurses report feeling caught between administrative expectations and their professional standards and obligations.

There is another unfortunate consequence of distancing nurses in formal leadership roles from the clinical setting. To develop formal nursing leadership skills, along with management and leadership capacity, nurses need strong nursing leaders as positive role models to support and mentor them. Instead, they often see nurse managers in that moral bind between administration and clinical care, who are having difficulty juggling the conflicting priorities of their administrative and financial responsibilities with their professional standards. This situation does not inspire direct care nurses to seek formal leadership roles, and we see their unwillingness to move into management positions, especially if appropriate support and training is not offered.  

So, where do we go from here? The concept should be simple. Nurses understand what nursing care is about. CNA’s recent National Expert Commission unequivocally noted that a more effective use of nurses is key in transforming the health system – a system that provides better health, better care and better value for Canadians. To move convincingly in that direction, nurses, now more than ever, need to be positioned in roles that lead and coordinate exceptional patient care. Clinical nurses must be empowered to “Stop the Line” if they feel something isn’t safe or that the quality of care is being compromised. They need to have the time to reflect on care provided and patient outcomes as well as time to make appropriate changes to improve patient safety.

Adequately meeting the healthcare needs and expectations of patients within a person-centred system will be achieved through an empowered and engaged nursing workforce – one that is present and which partners with Canadians through their every interaction with the healthcare system. For this reason, nurses must be involved in decisions involving them, the care they provide and the health of the people they serve. Nurse managers working as members of high-performing, inter-professional teams, with appropriate spans of control, are essential resources that add value to organizations, employees and the people they serve.

What it comes down to is this: nurses at all levels must be acknowledged for their strong commitment to evidence-based practice and their understanding of the true art and science of patient care. Until that happens, nurse managers will continue to be caught in an untenable situation.

Three questions for your consideration:

  1. What is the dilemma at the core of this story?
  2. Who owns it?
  3. How can the system overcome it?

We close with a passage from the essay titled “Conditions Leaders Influence”:

“… whatever relationship challenges you face, as solid and as personal as they seemed to be systemic, they may have less to do with the personal characteristics than with the ‘conditions’ of the space that people are sharing.

“We must continually ask how can we as leaders meaningfully tap into and create a culture that encourages the expression of the intellect, passion, commitment and experience of frontline staff to make real changes that satisfy healthcare consumer needs and expectations. Excellence in healthcare services will result from employees’ pride in the work they do. We will get to a future state through clarity of purpose, alignment of effort, credibility of leadership, integrity in organization and accountability for performance.”

Integrity is brought through a number of care providers including the important voices from the physician community.

Join the conversation posted today: Three Care Provider Voices -  Art of Caring With the Science of Cure, Where Has the Voice of Nursing Leadership Gone, Unravelling and Reconfiguring 100 Years of Tradition

Click here
 to see the First Series of Ghost Busting essays.

Click here to see essays from the Second Series: The Ghost of Healthcare Consciousness.

About the Author(s)

Rachel Bard, CEO, Canadian Nurses Association – working to position nurses as leaders in the Canadian healthcare system, while defining and advancing the nursing discipline in the interest of the public. A tireless leader in driving forward policy agendas that focus on health resources, health system renewal, global health and social justice.
Hugh MacLeod, CEO, Canadian Patient Safety Institute … Patient, Father, Husband, Brother, Grandparent … Concerned Citizen.


The Canadian Patient Safety Institute (CPSI exists to raise awareness and facilitate implementation of ideas and best practices to achieve a transformation in patient safety. We envision safe healthcare for all Canadians and are driven to inspire extraordinary improvement in patient safety and quality. To help address many of the challenges mentioned in the essay above the Canadian Patient Safety Institute has tools and resources such as: Patient Safety Incident Analysis and Canadian Disclosure Guidelines. If you would like information about Patients for Patient Safety Canada – please contact  


MacLeod, H. and M. Davies. 2013. Web site posting on essay: “Conditions Leaders Influence.” Longwoods Ghost Busting Essays.  


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