Abstract
In Quebec, the strategic leadership of nursing directorates remains poorly documented despite its importance for the performance of their organizations. Using three focus groups and 31 individual semistructured interviews, a qualitative descriptive study was conducted, including 35 participants from 18 of the Quebec 34 health institutions created in 2015 by the last reform. Seven themes emerged: (1) taking ownership of the strategic positioning, (2) developing and communicating a vision, (3) making strategic, systematic, and measured choices, (4) reframing roles, (5) getting involved in the strategic decision-making processes, (6) developing the political capacity, and (7) building alliances. Four professional and organizational components influenced the nursing directorates’ leadership capacity: clinical credibility, a sufficient number of people educated at the graduate level, organizational culture, and size of the institution. It is expected that these results regarding nursing directorates’ exercise of strategic leadership will lead to better governance and quality of nursing care.
Context
In 2015, Quebec undertook a reform of its health and social services system that introduced significant organizational and governance changes. Following this, several hundred facilities and services of various types (hospitals, community health centres, seniors’ homes, rehabilitation centres, social work services) were merged into 34 institutions responsible for improving access to services, quality of care, and organizational performance for populations in geographically defined territories. 1 This reform also modified the system’s governance—hierarchically and transversally—exercised by directors of nursing as well as the structure of nursing management teams. The legal mandate of the director of nursing, defined 4 decades ago, remained centred on the quality of nursing care, as described in the current healthcare law (Table 1). 1
Legal mandate of director of nursing
a Adapted from Ministère de la santé et des services sociaux (2020). 1
This law requires that a nurse be appointed as director of nursing in each health institution, under the authority of the Chief Executive Director (CEO), but provides no specific information on how the nursing directorates should carry their quality of nursing care mandate within the institutions. Consequently, it has been observed that 2,3 : (1) responsibilities attributed to the directors of nursing vary significantly, depending upon the recognition of their legitimacy within the institutions, (2) lack of clarity concerning the roles and responsibilities of the nurses in leadership positions limits understanding of the director of nursing function, (3) nursing directorates’ participation in strategic decisions is not reflecting their real potential, and (4) nursing directorates are often ill-prepared to act strategically at this level of responsibility in the new institutions.
In the context of reform geared toward improvement of organizational performance, nursing governance needs to use strategic leadership,
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due to the major impact of nursing care on the overall quality of care and services in the organization.
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This article reports the major findings of a doctoral study
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which focused on the Quebec nursing directorates’ exercise of strategic leadership. The following research questions guided the study: – How do nursing directorates describe the exercise of their strategic leadership by using absorption, change, and managerial wisdom capacities, regarding the quality of nursing care in the healthcare organizations of Quebec? – What are the professional and organizational components, according to the nursing directorates, favouring or hindering their capacities to exercise strategic leadership in the healthcare organizations of Quebec?
Strategic leadership is defined here, following Boal and Hooijberg, as the set of capacities (absorption, change, and managerial wisdom) 4 needed by nursing directorates to work with other directorates to provide quality care, efficiently and effectively, for the persons and their loved ones given the contextual parameters suggested by Hambrick to improve organizational performance. 4,6 These elements inspired the conceptual framework 5 that guided this study (Figure 1).
Conceptual framework of the study.
Methods
This descriptive qualitative study 7 was conducted between August and December 2017. Choosing an intentional sampling approach, 35 participants (directors of nursing, associate directors of nursing, middle managers) from 18 nursing directorates among Quebec’s 34 health and social services institutions accepted to take part in the study. Three focus groups and 31 individual semi-structured interviews were conducted. Data analysis was carried out using a thematic content strategy. 7 To ensure anonymity, transcripts of individual interviews and group meetings were identified by alphanumeric codes. QDAMiner 4.1.16 was used for data management. The required ethics approval was obtained from the lead author’s university.
Results
Figure 2 5 illustrates seven themes that emerged regarding how strategic leadership was used by nursing directorates in relation to improvement of nursing care, according to the three capacities of the framework as well as the four professional and organizational components that were identified as modulating this use.
Components of the nursing directorates strategic leadership to improve the quality of nursing care.
Absorptive capacity
The absorptive capacity of strategic leadership relates to a vision, as well as a deep understanding of interrelationships and of the environment in an organization. 4 To exercise strategic leadership, we found that nursing directorates must take ownership of their strategic positioning, develop a precise vision of nursing care, and strategically choose how they can contribute to the organization from their quality of care perspective.
Theme 1: Taking ownership of the strategic positioning to influence the quality of nursing care
For most participants, the modifications to the institutions’ governance provided a wider scope of responsibilities of nursing directorates associated with the legal mandate of the directors of nursing, particularly with regard to quality of nursing care. However, some participants stressed the need for nursing directorates to quickly develop interactions with other directorates that did not necessarily see the relevance of their contribution. Participants’ opinions were divided regarding the position actually occupied by the nursing directorate: for some, it occupies a strategic place due to the large volume of nursing activities in the organization whereas, for others, it does not always occupy its proper position, hence not positioning itself to really influence the strategic level of the organization. I have never been in a position of influence as much as now, I have never had as much leadership to take and I do not always take it as it should be. (Focus Group-Director of nursing)
Theme 2: Developing and communicating a clear vision of quality nursing care
For the majority of participants, nursing directorates advocate a vision of quality of nursing care centred on the needs of the person and their loved ones. For some, this vision must influence beyond the quality of direct nursing practice as it is multidimensional, encompassing elements of clinical performance (eg, services offered), professional development (eg, competencies), and organizational performance (eg, costs of services) elements. For others, it is collaborative because it requires the contribution of numerous actors in the organization. If we really want to have strategic leadership, we must influence at all levels, so the vision gets integrated into our governance structures. (Interview-Associate director of nursing-1)
Theme 3: Making strategic, systematic, and measured choices grounded in the quality of nursing care to guide its contributions to the institution
Several participants maintained that in the context of the last reform, ministerial orientations take precedence over those of organizations and nursing directorates. For some, organizational decision-making was clearly based on political priorities rather than the needs of the clientele. Others indicated that the organizations are currently managed with a top-down approach, dictating to the nursing and other directorates what should be done and how to do it. This is clearly limiting these directorates’ margin of maneuver, their participation in decision-making, autonomy, and creativity. The orientations are coming now from the ministry; let’s say that our duties are well defined. Our originality can be exercised in our way of doing things but the things themselves are dictated. (Interview-Associate director of nursing-2) When we choose a strategy or an approach in a teaching hospital where we have a teaching mission, we should teach our reflective process, the choice we made and measure it, to be able to grow all together. It is not done. (Interview-Director of nursing-2)
Capacity to change
The capacity to change refers to the ability to perform multiple roles and to adopt different behaviors, allowing adaptation to different actors in the evolving context of an organization. 4 Understanding nursing directorates’ roles, their participation in strategic decision-making, and their political capacity allows describing how they fit into their changing organizations.
Theme 4: Reframing the roles to increase influence on quality of nursing care
The new governance framework of Quebec’s healthcare institutions has forced nursing directorates to clarify and reposition their hierarchical and transversal responsibilities relating to quality of nursing care. For some participants, this framework did not change their vision, role, and mandate, whereas for others it did. We have a challenge to reposition the quality component, among other components promoted by the nursing directorate, within the different clinical and administrative directorates so that we find our place and stopped being ignored. (Interview-Associate director of nursing-6) Our roles must be more strategic than they were before. (Focus Group-Associate director of nursing)
Theme 5: Getting involved in strategic decision-making processes
According to some participants, their nursing directorate contributes to different decision-making processes, especially in terms of professional practices and quality of care, but its influence varies according to the nature of the decision. Most participants nevertheless acknowledged that their nursing directorate usually has no influence on top-down organizational and ministerial decisions. Some participants pointed out that their directorate is involved in the strategic decision process; on the contrary, other participants mentioned that this is not always the case. It may happen that their nursing directorate is consulted but the final decision usually ends up in the hands of other people. I am involved in all of the organization’s strategic decisions, as director of nursing. (Focus Group-Director of nursing) We are not always in strategic decisions. (Focus Group-Director of nursing)
Some participants identified significant challenges regarding their strategic influence when for instance: (1) a director of nursing did not succeed in positioning nursing care issues with her CEO, (2) a decision was made in the presence of a professional group with more power of influence (eg, physicians), or (3) a decision involved several managers of other directorates.
Theme 6: Developing the political capacity to influence the quality of nursing care
For a majority of participants, nursing directorates are ill-prepared to deal with the political dynamics in their organization. According to one participant, the required political skills are about how to build a strategic discourse, formulating an argument based on convincing results in order to influence partners to initiate changes for the benefit of the clientele. For several participants, the development of political skills is necessary to better equip nursing directorates to make their voice heard and to exercise more leadership on quality of nursing care in the organization. For me, a political skill is to develop arguments to make a change for the well-being of my clientele but only if I have data, information, and a reason to ask. (Interview-Director of nursing-1)
Managerial wisdom
Managerial wisdom relates to an understanding of the social environment and the interrelations occurring in it. 4 It is a capacity allowing nursing directorates to establish strategic and collaborative alliances by mobilizing the emotional skills necessary to build the interactions to do so.
Theme 7: Building strategic and collaborative alliances to promote the quality of nursing care
According to several participants, the increased organizational complexity created by the reform has transformed the social environment and the interrelationships of nursing directorates. This is why they should develop strategic alliances, in particular with the CEO, to position the clinical component in the organization, and with the Director of Professional Services (DSP), to promote advancement of nursing practices and influence clinical orientations as well as strategic decisions pertaining to them.
A few participants mentioned that some nursing directorates are able to establish collaborative links with various other actors (eg, doctors, managers, professional advisors, unions), thereby increasing their capacity for action and power to influence the quality of nursing care. For some participants, it is essential for nursing directorates to develop skills associated with emotional intelligence, in order to fully understand their environment. If you want to build an alliance, start by being curious about the others, by taking the time to learn who they are and what are their priorities and challenges before thinking of [sharing] yours. (Focus Group-Director of nursing)
Professional and organizational components
Participants identified clinical credibility and a sufficient number of people educated at the graduate level as the professional components that heightened the use of strategic leadership by nursing directorates. For a director of nursing to be able to play her role fully, it takes a team educated at the master’s degree level. (Interview-Director of nursing-7) One of the real obstacles to the exercise of leadership by the nursing directorates since the implementation of [the last reform] is the monstrous size of the institutions that have been created. (Interview-Director of nursing-4)
Discussion
Our results first indicate that the nursing directorates, although theoretically well positioned in the new structures created by the reform, do not always fully occupy their strategic place. This is not particular to Quebec. To recognize and own the full leadership potential of nursing directorates remain a challenge in many organizations. 8 This research found that in order to exercise strategic leadership, nursing directorates need to capitalize on their relationships (eg, with the CEO, the DSP, and other directorates). Also, organizational factors (eg, the legitimacy granted to the legal mandate of the director of nursing, the nursing directorate’s participation in strategic decisions, and the organizational culture) influence the nursing directorates’ strategic leadership.
Secondly, we found that following the reform, the nursing directorates had to quickly reposition their responsibilities in relation to the quality of nursing care with the other directorates of the new institutions, so as not to be excluded from projects. This is in line with what other authors found about the lack of clarity regarding the roles of nursing directorates in their organizations 3 as well as the limited place given to quality of care in management committees of various hospitals elsewhere. 9 In this regard, our research suggests that nursing directorates need to rethink their roles and responsibilities in the governance structure introduced by the reform, develop a more strategic role, and measure their contribution in terms of quality of care.
Finally, we found that a real opportunity to improve the management skills of nursing directorates is by systematically developing their political skills, including emotional intelligence, 10 in order to increase their power and strategic leadership in their organizations regarding quality of nursing care.
Conclusion
This study highlights the relational and organizational factors that can have a significant influence on the fulfillment of the nursing directorates’ mandate and their optimal contribution in order to promote quality of nursing care. The collective gaze of 35 nursing managers of nursing directorates enabled us to draw up the first detailed portrait of how the nursing directorates’ strategic leadership is deployed in the new organizations created by the last reform in Quebec’s health system. This portrait can be useful not only to nursing leaders but also to other healthcare leaders, including members of the board of directors. It underlines the necessity to increase the centredness of quality of care in management teams’ priorities. 9 Hence, this portrait could help health and social services organizations to develop a strategic, reflective, and collaborative influence as well as a concerted vision on quality of care to improve organizational performance. The study also suggests that having a better understanding of the socio-cultural components of the strategic leadership, especially the gender one, could contributed to the understanding of how leadership is differentially exercised by women and men in complex health social services organizations. It points out to the necessity for nursing leaders to provide support for professional development regarding the strategic leadership capacities, particularly the political skills.
