Perspectives: New realities of leadership during the Year of the Nurse and Midwife

As I reflect on leadership, during the World Health Organisation's (WHO) Year of the Nurse and the Midwife, I am struck by how leadership can be displayed in any nursing role. Our professions have had lingering notions that leaders have formal positions or job roles. In reality, leaders are required everywhere. This has been especially true during COVID-19, when nursing hierarchies have suddenly flattened. Nurses have been redeployed, and pushed to learn new skills very quickly. There is also a need for local leadership to make decisions and adapt work minute-to-minute. I hope these shifts will change how we understand different nursing roles. The barriers between nursing roles have caused considerable problems in our professions, and the current climate is an opportunity for us to move past these divisions, once and for all.

After I transitioned from working clinically to working in other roles in nursing, I was asked, ‘Do you miss real nursing?’ This question came from well-intentioned members of the public, but also from nurses themselves. Two weeks after I started a management role, my colleagues from my previous clinical job would no longer associate with me. I had crossed over and joined the dark side, which meant I was no longer an ally in their work. Not only was this hurtful, it limited my ability to engage with my former colleagues, with genuine attempts to improve their working environments. The animosity between different nursing roles is pervasive, and does real damage as it stifles attempts to work together to support patients.

Sadly, these hierarchies are as old as the nursing profession itself. Florence Nightingale used a variety of strategies to give her fledgling profession more credibility, at a time when nursing was considered little better than prostitution (Wuest 1994). Nightingale recruited many of her middle-class friends to be nursing instructors and managers, trying to elevate the status of the profession. The majority of their pupils were working class; these women already did the bulk of caring work in society and were willing to do some of the more so-called distasteful work nursing involved. The class divide between instructors and pupils, and ward managers and nurses created animosity that has persisted in various forms ever since.

These arguments about being a ‘real nurse’ become even more perplexing, considering research on how status is allocated in modern hospitals. There is animosity directed at those who have left clinical work, for not being ‘real nurses’. However, studies suggest that the more a group touches patients, the lower their status (Van Dongen and Elema 2010). There are also race and class divides among nurses that are reflected in who does lower status work (Allen 2014; Smith 2012). There are examples of the black nurse washing someone while a white nurse is heading out to the helipad. These social hierarchies underpin who does what work, what is valued, and who is seen as a leader. The net result negatively impacts patient care, and all of us.

In modern nursing, these narratives reflect ideas of ‘they don’t understand our work’. I espoused these ideas as a clinical nurse, until I worked in a variety of roles myself. I realised the purpose of a management role was not to understand every aspect of clinical work. Rather, the role was to try and optimise the environment to support safe clinical work. I did not have the same clinical acumen as my former colleagues, but I was also expected to manage 300 emails a day – an experience that they didn’t understand, either. Devaluing each other’s work didn’t help anyone. The much maligned ‘middle managers’ of healthcare that I encountered worked hard to keep the place running, with little credit or recognition from others. At present, many nurses in managerial roles are frantically trying to access Personal Protective Equipment for colleagues, manage limited space, and protect their staff. No one is immune to the pressures in clinical environments, and there have been tears shed by nurses in every role. I hope our common humanity will help us see past titles, and recognise that everyone is working for the best possible outcomes, against tremendous adversity.

Our current challenges require our profession to move beyond these issues of who is a ‘real nurse’, and appreciate everyone’s contributions to our profession. Indeed, without our own research, policies, and education, we would cease to be a profession. Nursing needs all of us, now more than ever. Our call to leadership requires a firm focus on addressing complex problems together.