The philosophy of “every nurse a leader” recognizes that all nurses possess leadership skills and abilities, emphasizing their role in influencing positive healthcare changes, advocating for patients and advancing the profession. This paper explores leadership as a core competency for registered nurses (RNs) in primary care and examines the opportunities and challenges they face in enacting leadership roles. Key opportunities include optimizing the scope of practice, interprofessional collaboration and policy advocacy. Challenges such as invisibility, workforce factors and financial constraints are addressed, presenting a vision for a future where every RN in primary care is empowered to lead and innovate.

Introduction

The philosophy of “every nurse a leader” emphasizes that leadership potential exists in every nurse, regardless of formal titles or hierarchical positions (Adams et al. 2018). This approach recognizes that every nurse can influence positive change, advocate for patients and contribute to the advancement of healthcare (Manion 2014). This philosophy shifts the perception of leadership in nursing from being a responsibility of a select few to being an inherent part of every nurse's daily practice (Robinson 2014). The evolution of leadership as a core competency for registered nurses (RNs) highlights its importance in delivering effective and patient-centred care, especially within the primary care setting. This paper explores the opportunities and challenges faced by RNs in primary care in enacting leadership roles and presents a vision for the future.

“Every Nurse a Leader”

Every nurse has the capacity to influence the health outcomes of their patients, the effectiveness of their teams and the functioning of the health system. Nurses, often on the front line of healthcare delivery, can identify gaps in care and opportunities for improvement. By fostering a culture where nurses feel empowered to propose and implement innovative solutions, nurses can continuously improve and adapt to changing healthcare needs. Nurses, as leaders, play a pivotal role in fostering cohesive, interprofessional teams that work together to provide comprehensive, patient-centred care (Adams et al. 2018). This collaborative spirit enhances communication, reduces errors and improves overall care delivery (Rawlinson et al. 2021). Embracing the philosophy of “every nurse a leader” entails a commitment to continuous learning and professional development. Leadership skills can be developed and refined through education, mentorship and practical experience.

Situating Leadership as a Core Competency

Leadership is increasingly recognized as a core competency for RNs globally. This recognition spans international definitions/guidelines (ICN n.d.; WHO 2021), national standards within Canada (CCRNR 2018) and primary care-specific competencies (Lukewich et al. 2021). The International Council of Nurses includes nursing leadership as a key element in its definition of nursing (ICN n.d.). The World Health Organization (WHO) also highlights leadership as a critical skill in its Global Strategic Directions for Nursing and Midwifery (WHO 2021). They call for strengthening leadership among nurses to achieve universal health coverage and improve health outcomes.

In Canada, leadership is embedded within the national framework for the practice of RNs (CNA 2015) and is an entry-level competency for RN practice. The Canadian Council of Registered Nurse Regulators (CCRNR) outlines entry-level competencies for RNs in Canada, which include leadership as a key theme. Within the leadership theme, the CCRNR defines 11 leadership competencies, and integration of these competencies contributes to safe, competent and evidence-informed nursing practice (CCRNR 2018).

Within primary care specifically, leadership has further been identified as a key competency domain for RNs. The Canadian Competencies for RNs in Primary Care consist of 47 competencies, organized according to six domains of practice (CFPNA 2019). The leadership domain outlines five competencies, further positioning leadership as a key element of practice for RNs in primary care across Canada. Leadership competencies for RNs in primary care reflect leadership at the level of the individual clinic or team, the health system and the broader society (Mathews et al. 2021). How the leadership competencies are expressed by RNs in primary care may vary by the nature of the nurses' employment, funding model and type of clinic (Mathews et al. 2021). Despite the capacity for leadership among RNs in primary care, they face a myriad of opportunities and challenges to enacting this aspect of their role.

Opportunities for RN Leadership in Primary Care

Optimizing and Expanding Scope of Practice

Scope of practice is defined as the activities nurses are legally authorized, educated and competent to perform, grounded in the knowledge base of the profession (Almost 2021). Legislated scope of practice refers to the outer limits of practice determined by legislation and professional regulation, whereas the actual scope of practice refers to the individual nurses' environment/setting, needs of the clients and nurse competence to perform the activities within the legislated scope of practice (Almost 2021). There is evidence to suggest variation in the scope of practice enactment for RNs in primary care, with some RNs working to their full scope of practice, while other RN roles are dominated by biomedical task-oriented activities (Braithwaite et al. 2022; Norful et al. 2017). In some areas of primary care, nurses are working below their professional full scope of practice, and their current roles are misaligned with the competencies (Braithwaite et al. 2022).

In addition, legislated scopes of practice for RNs are expanding with the addition of new regulatory authority to initiate controlled acts such as psychotherapy and pharmacotherapy prescribing (Almost 2021; CIHI 2022; Moody et al. 2020). This enables RNs to take on more responsibilities, thereby enhancing their leadership role in primary care. Empowering RNs to work to the full extent of their scope of practice and establishing primary care environments where full scope of practice can be enacted can improve access to care and address provider shortages. The shift toward optimization of the RN scope of practice in primary care and the current and future expansion of the RN legislated scope of practice may present opportunities for RNs to enact their leadership capacity in primary care.

Interprofessional Collaboration

Effective primary care requires collaboration across various health professions (Bouton et al. 2023), and RNs in primary care can leverage their leadership abilities to enhance this interprofessional collaboration. RNs are pivotal in fostering a collaborative environment, working alongside other healthcare professionals, and can proactively coordinate patient care, ensuring that all aspects of a patient's health are addressed comprehensively. This collaboration allows nurses to use their unique skill sets and extensive patient knowledge to deliver holistic care that addresses patient needs and preferences, influences decision-making processes, contributes to the development of care plans and ensures continuity of care, which are fundamental leadership functions. Through effective communication and teamwork, nurses can lead quality improvement initiatives, spearhead efforts to enhance patient safety and implement evidence-based practices. This collaborative approach would not only elevate the standard of care provided but also showcase the critical leadership role that nurses play in driving positive health outcomes.

Policy and Advocacy

Primary care nurses are well-positioned to understand patient needs and the challenges within the healthcare environment. By enacting leadership abilities, they can advocate for changes that enhance patient care, address health disparities and improve community health outcomes (CNA 2009). This involvement allows nurses to leverage their clinical expertise and firsthand experience to shape institutional and public policies that reflect the realities of patient care across various sectors.

Furthermore, leadership in advocacy empowers primary care nurses to serve as champions for their profession and the populations they serve. By participating in professional organizations, health policy forums, public consultations and legislative processes, nurses can raise awareness about critical health issues and advocate for resources needed to deliver high-quality care. This proactive engagement not only elevates the nursing profession but also fosters a culture of collaboration and innovation within the healthcare sector. Through their advocacy efforts, primary care nurses can drive systemic changes that lead to more equitable and efficient healthcare delivery.

Challenges Facing RN Leadership in Primary Care

Invisibility of Primary Care RNs

Although RNs in primary care are well-positioned to enact leadership within their professional roles, the invisibility of nurses within this sector and the public perception of nurses as subservient (Etowa et al. 2024; Lukewich et al. 2021) may jeopardize their ability to enact leadership in practice. In Canada, the term “community health nurse” is often used as an umbrella term that encompasses public health, community health, primary care and homecare nurses (Lukewich et al. 2021). Grouping these unique and distinct groups contributes to the invisibility of primary care nurses, and the lack of distinction between these areas of practice undermines the value of their expertise and their impact on the health system.

The invisibility of RNs in primary care is further exacerbated when RNs are grouped under the umbrella term “nurse.” In Canada, the term “nurse” is used to describe four designations of nurses, namely, nurse practitioners (NPs), RNs, licensed practical nurses/registered practical nurses and registered psychiatric nurses. The four designations of nurses each have distinct scopes of practice. The primary care NP role has received much attention in the literature over the past two decades, which aligns with the advancement and integration of this role into Canadian primary care teams. While all nurses are well positioned to support primary care transformation, each designation offers a unique role within the interprofessional team (Brousseau 2024). Given the variation in the respective scopes of practice, it is important to highlight these unique contributions and to further increase the visibility of RNs in primary care.

Invisibility can lead to fewer opportunities for nurses to participate in decision-making processes or to take on leadership roles and can hinder nurses' ability to drive system change (Lukewich et al. 2021). Addressing the invisibility of primary care RNs involves acknowledging their critical role in healthcare, providing opportunities for leadership development, ensuring representation in decision-making processes and fostering a culture that values and recognizes their contributions.

Workforce Factors

The nursing profession is facing significant workforce challenges, including shortages, high turnover and burnout. In 2022, the annual growth rate for the number of RNs in Canada slowed to 1.1%, resulting in shortages that are compounded by the increasing demand for healthcare services with the aging population (CIHI 2024). This exacerbates the challenges of accessing primary care, particularly given the existing shortages of primary care providers (Flood et al. 2023). Nearly half of the RN participants in a review intended to leave their current position in primary care (Halcomb et al. 2018). Similarly, a recent study conducted in Europe found that over 13% of nurse participants indicated an intention to leave the profession (Maniscalco et al. 2024). In an environment where there are fewer RNs to handle an increasing patient load, RNs may be overwhelmed with day-to-day clinical tasks, leaving them with reduced capacity to engage in leadership responsibilities and activities (e.g., mentoring, political advocacy, quality improvement initiatives). Workforce factors not only affect the delivery of patient care but also impede professional development opportunities, which are crucial for cultivating leadership skills (American Association of Colleges of Nursing 2024). Addressing workforce factors is paramount to empowering RNs to fully exercise their leadership potential.

Financial Constraints

Financial constraints pose a challenge for RNs in primary care seeking to enact leadership roles. Limited funding in healthcare often results in insufficient resources at the level of organizations for professional development, continuing education and leadership training programs. Without access to these essential opportunities, RNs may struggle to build on their foundational leadership knowledge and acquire advanced leadership skills. Financial constraints and budgetary limitations can hinder the implementation of innovative primary care funding models that include RNs and the expansion of RN roles within these models. Consequently, the potential for RNs to drive innovation and improvements in patient care may be diminished. Evidence demonstrating the cost-effectiveness of RN-led initiatives (Lukewich et al. 2022) and advocating for sustained investment in primary care is critical for overcoming these financial challenges. In addition, financial constraints can lead to understaffing and inadequate support systems within primary care settings, further impacting the workforce challenges noted earlier.

Vision for the Future

The vision for the future of RN leadership in primary care involves a transformative shift toward fully integrating and recognizing the critical role that RNs play in healthcare delivery, embracing the philosophy, “every nurse a leader.” A positive vision for the future includes a healthcare system where every nurse, regardless of position, is empowered to enact leadership roles, supported by robust professional development opportunities, as well as to being integrated into decision-making processes at all levels. By fostering a culture that values continuous learning, innovation and interprofessional collaboration, RNs in primary care can lead efforts to improve patient outcomes, enhance care quality and address systemic challenges within healthcare. To position every nurse as a leader in primary care, RNs are expected to actively participate in leadership to strengthen their practice, organization and/or the broader health system. To answer this call, RNs in primary care require psychologically healthy and safe work environments in which they can assert themselves as leaders (Atanackovic et al. 2024).

To realize this vision, it is essential to address the barriers currently hindering RNs in primary care from enacting their leadership skills and abilities. This includes tackling workforce shortages through strategic recruitment and retention initiatives in primary care, advocating for adequate funding to support advanced education and leadership training and ensuring that the unique contributions of RNs in primary care are visible and valued. By creating a supportive and inclusive environment that prioritizes nurse leadership, the healthcare system can benefit from the full spectrum of RN expertise and drive meaningful improvements in patient care and health outcomes. This future vision ultimately positions RNs in primary care not only as caregivers but also as leaders and innovators in the evolving Canadian healthcare landscape.

Conclusion

Every RN in primary care has the potential to advance primary care and the evolution of the health system. Opportunities for RN leadership in primary care include optimizing and expanding scopes of practice, interprofessional collaboration and policy and advocacy. However, challenges such as the invisibility of RNs in primary care, workforce factors and financial constraints must be addressed to enable nurses to enact their leadership skills and abilities. Ultimately, empowering RNs as leaders and innovators will drive meaningful improvements in patient care and health outcomes, positioning them as pivotal figures in the evolving landscape of primary care.

Correspondence may be directed to Suzanne Braithwaite by e-mail at suzannebraithwaite@trentu.ca.

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