Introduction

The global social upheaval caused by the COVID-19 pandemic coincided with the peak of the last wave of the baby boom generation moving into their sixties, quickly wreaking havoc among workforces and economies around the world. Canada's health system was no exception, and as demands for care far exceeded the capacity to deliver it, chaos, a frenetic pace and fear permeated every corner of healthcare within weeks.

Certainly, we saw the best and worst of healthcare emerge along with the pandemic spread: broken parts of the system were laid bare, and existing fault lines grew and left entire organizations and even systems teetering on the edge of collapse. But it was not all bad news. As the largest group of healthcare providers, nurses and their work came fully into the limelight. While they were frightened as individuals and soon exhausted as a workforce, the dedication, knowledge, skilled know-how and ability to innovate shown by nurses made clear the value of Canada's nursing workforce. For a long time, nurses really kept the system upright at a great cost to themselves.

When the foundations of a workforce the size of nursing are being rattled, then it is important to pause, rewind a bit where needed and have a hard look again at those foundations. What is the purpose of nursing? Is nursing achieving its purpose now and, if not, where are the barriers and gaps and what is causing them? What strategies could close those gaps in a timely way at costs the public systems are willing to bear?

Discussion

In her exploration of situated caring in nursing and the environment, Olga Jarrin, professor and director of Rutgers University's Multicultural Nurse Leadership Institute (Rutgers University n.d.) noted that a dominant theme in related literature

… was the primacy of the nurse-patient relationship, specifically teaching, caring, and mutual growth. The most interesting finding was how closely the work environment, including workplace culture, staffing, and availability of resources seemed to correlate with nurses' perceptions of what it was like to practice nursing” (Jarrin 2012: 2).

The Strengths-Based Nursing and Healthcare (SBNH)¹ philosophy aligns strongly with these observations and offers a path forward with its four foundations, namely, person-centred care, empowerment, relationships and innate capacities for health and healing, that are operationalized in eight core SBNH values (Gottlieb 2013; Gottlieb and Ponzoni 2015). For the discussion here, we need to consider that SBNH capitalizes on innate and acquired capacities and capabilities (i.e., strengths), noting that people are self-healers and are the most untapped, invaluable resource. It follows then that we need a healthcare system designed around discovering and supporting strengths, those innate and acquired capacities and capabilities of the people we care for, and capitalizing and developing the capacities and capabilities of those who provide care. In other words, having strengths as a focus contributes to optimizing function. Strengths can also be intentionally leveraged to contain, minimize, modify, neutralize and, where possible, even eliminate dysfunction.

Nurses and nursing are uniquely positioned to humanize healthcare and make for more responsive healthcare systems and services to meet the needs of people in the 21st century, offsetting the increased reliance on technology with its untoward effects of anomie, disconnection and fragmentation – in short, replacement of the existing healthcare system with a human-care system that has relationships at its core. Healthcare is human care and, as such, we need to create a healthcare system founded on core values of human dignity, civility, respect and trust that bring out our best instincts, our better angels, so to speak, rather than selecting for our most base instincts – our worst angels. SBNH provides the philosophical foundations with its value-driven approach to humanize and actualize a renewed healthcare system.

SBNH also holds promise to support leaders and all nurses in recasting healthcare systems as human-care systems because it is grounded in the very DNA of nursing and nursing leadership. It arises from the core of nursing that understands human beings are hard-wired for relationships that are caring and compassionate.

Nurses generally seem to love nursing and are committed to it, but where there is dissatisfaction, it can usually be attributed to aspects of their particular workplace environment, including the reality of ongoing organizational constraints. That is in no small part because nursing is often fairly well set up to meet the needs of organizations, but how well it meets the real needs of patients and families is far less clear. Take for example, the studies of missed nursing care in hospitals – or care left undone. Evidence makes plain that as staffing numbers drop and/or the number of temporary staff rises, care outcomes are worse. Jane Ball, a leader in workforce policy, along with her colleagues, studied necessary nursing care omitted as driven by time pressure missed care in England (Ball et al. 2014). With staffing levels and staffing mix impacting capacity to deliver care, most nurse subjects (86%) reported missing at least one aspect of care during their last shift due to time pressures. Most often missing were comforting and/or talking with patients (66%) and educating patients (52%) – precisely the activities we know that are very important to patients and that nurses value as an integral part of their role. While healthcare is filled with moral distress for all sorts of reasons, adding to them by creating working conditions where the goals of nurses are forced to clash with organizational expectations is an unacceptable yet fixable choice. One such choice is advocating for SBNH care and SBNH leadership to at least provide some balance to the constant drumbeat of inputs, outputs, efficiency and productivity. And a strengths-based approach to leadership may help nurses and teams to find more satisfaction in environments over which they may feel little control.

If nurses are striving to put patients in the best condition to self-heal, then surely it is the role of nursing leadership to put nursing in the best condition to support nurses in achieving the core purpose of the profession. With the celebration of the International Year of the Nurse and the Midwife in 2020 (WHO n.d.), there was unprecedented attention paid to nursing, with leadership identified as a linchpin to implementing solutions to stabilize and strengthen the profession. In a related 2020 editorial, Ball urged:

We need these calls, these rallying cries to be heard. Not just for our own professional self-interest and pride in nursing (although that's most definitely needed too). But because at a macrolevel, just as at microlevel, creating conditions that lead to nursing fulfilment means creating conditions for better care. Or put another way, both nurses and patients benefit when healthcare systems and society provide nurses with the resources and opportunities needed to plan, deliver, and lead care well. (Ball 2020)

Ball (2020) was blunt in her language urging organizations and funders to “create the conditions that allow professional nursing to thrive, for individuals to take satisfaction from ensuring care is delivered fully and well … rather than creating conditions that leave care undone and drive nurses out of the profession.”

The SBNH Leadership (SBNH-L)¹ value of goodness-of-fit environments would address the issues that Ball raises. Leaders need to ask: “How do we create goodness-of-fit environments that align with nurses' values and expectations and that capitalize on their knowledge and skills to enable them to practise to the full scope of their education and skill set?”

Why does all this matter so much? In one notable difference between baby-boom nurses and their youngest counterparts, many Generation (Gen) Z nurses, for example, are not willing to put up with the same conditions that many of us did for decades. They know they have choices, and they simply will not tolerate practice conditions that fly in the face of their core values and expectations. With the numbers of baby-boom nurses falling every year and with younger nurses also planning to leave, or who actually leave, the profession, organizations and systems are going to find themselves in a position of material risk. In fact, some organizations are already there – witness, for example, the number of emergency rooms across the country regularly closing for periods of time for the sole reason of not enough nurses.

Baby boomer, Gen X, millennial and Gen Z nurses are different, and they need different sorts of employment relationships and leadership skills and styles. What they require from leaders is flexibility and openness and a style of working in partnership to co-design a healthy and satisfying workplace environment together – another key SBNH-L value, namely, collaborative partnership.

Just as millennial, Gen X and Gen Z nurses recognize their power to make choices, SBNH reminds us that leaders too have the capacity to choose (the SBNH value of self-determination). Make no mistake: SBNH is a choice – a choice in the way one chooses to be. Choices come in many forms, such as the decisions that are made (or not), what we say and how we choose to say it, how we look at a situation and what we see – and whether we opt to see the negative – what is missing, or not working or whether we choose to also look for and see what is working. Leaders need to stop and question their underlying assumptions and biases if they are to see situations anew and expand and entertain other possibilities. These are embodied practices of SBNH leadership (Hubley et al. 2024).

The theme of Nursing Week 2024 in Canada is “Changing Lives. Shaping Tomorrow,” precisely what nurses and their leaders are being called to support in delivering 21st century healthcare (CNA 2024). What can nursing bring to the table to underpin solutions to that daunting challenge? We know from the results of the Canadian Health Leadership Network's (CHLNet 2020) Bench II survey of healthcare leaders, which included 920 nurses, that, among other findings:

[1] …[M]ore than 50% of respondents who perceive themselves as leaders came to the role with no leadership training … [2] Gaps between the leadership capabilities of current leaders and the skills needed by them to perform their jobs well and to anticipate and meet future challenges and reforms were reported as “large” or “very large” by nurses twice as often as the other leaders [and they] … [3] identified themselves as being the weakest at demonstrating systems/critical thinking (21%), self-awareness (25%) and encouraging and supporting innovation, including new technology (23%) – precisely the skill sets required for leaders to function optimally.” (Villeneuve 2021: 7–8)

SBNH represents a tested framework that can help to close this alarming gap.

Leaders who assume that an SBNH approach will help nurses rewind are leaders who think about what humans really need. An SBNH leader is well aware of weaknesses and dangers, but is strategic in paying attention and looking with intention for strengths that can be harnessed for the benefit of nurses and patients.

We have evidence that SBNH leaders can be created. The recently published results of a mixed-methods evaluation of the six-month SBNH-L training program found it had a positive impact on its participants; the quantitative measures found significant improvements in participants' leadership capabilities and work satisfaction and a reduction in perceived stress – even at the height of the COVID-19 pandemic (Lavoie-Tremblay et al. 2024a). In a follow-up at three months post training, participants reported the program had a sustained impact on their leadership style. Many reported being more attuned to relationships and to strengths, to seeking out different perspectives to work better as a team and to having the skills to create more positive work environments for staff (Lavoie-Tremblay et al. 2024b). Taken together, the quantitative and qualitative data offer evidence that those who have been trained in SBNH leadership engage, embrace, enact and embody this style of leadership. What is important here is that SBNH as a philosophy can be translated into a practical application that works.

Conclusion

We conclude our commentary by drawing inspiration from the words of Maya Angelou's epic poem, On the Pulse of Morning, that seem to have been written with us in mind:

Each new hour holds new chances
For a new beginning.
Do not be wedded forever
To fear, yoked eternally
To brutishness.
The horizon leans forward,
Offering you space to place new steps of change.

– Angelou (1993)

If this is to be nursing's hour, it will require – from us as individuals and as a profession – new boldness. Nursing leaders need to be examples of courage, conviction, imagination and compassion and have the skills and know-how to create a new space and offer a new beginning for nurses and the people for whom we care through our practice as SBNH leaders.

Correspondence may be directed to Laurie N. Gottlieb by e-mail at laurie.gottlieb@mcgill.ca.

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