Topic analysis: Nursing leadership roles in health and care structures

We’re clear that nursing leaders must show compassion in their style and behaviour towards staff. Compassionate leadership creates a psychologically safe workplace culture. Staff feel safe to raise concerns, knowing they will be supported as a team or as individuals to pursue high quality standards of care.

Nursing staff have a fundamental role in the design, commissioning and delivery of health and care – as well as driving health policy, and leading transformation in both models of care and services. But any effort to support strengthened leadership and management approaches must be considered within a context of enduring pressure on the workforce and resources, as well as a target-driven culture, and compromises to patient safety.

In June 2022, our members passed a resolution at RCN Congress calling for all governments across the UK to recognise and champion the contribution and impact of nurse leadership at all levels, from the bedside to the boardroom. This was made particularly clear during the COVID-19 pandemic.

• We checked Integrated Care Boards (ICBs) to see whether they had a registered nurse member
• We compared nursing leadership roles to other professions
• We looked at trends within the progression of registered nurses

There will be fluctuations in these roles from time to time as staff members move on. We'll review integrated care board nursing roles every 6 months. The next review is due in June 2024.

Opportunities to develop, train and access leadership roles are inconsistent and uneven. Nursing staff working outside of the NHS have less access to these opportunities than their NHS counterparts. Internationally trained nursing staff face inequality when trying to access leadership opportunities. Their skills and experience before arriving in the UK are often disregarded. 

In some health and care organisations in England, the Director of Nursing role-holder can lack full budget-holding power and operational authority. Often, they’re pressured to act based on finance, rather than what’s required to ensure patient safety. Despite having accountability for safe and effective nursing care in services, registered nurse leaders are all-too-often dealing with significant system issues, including shortages and budget constraints, without the right tools and resources to address these challenges. All of the above presents incredibly challenging circumstances to nursing staff in less senior roles working in these conditions. 

Changes to the Chief Nursing Officer (CNO) for England’s role and position were introduced in 2011. Ever since, we’ve been publicly highlighting concerns about the CNO’s loss of influence in England.

Following the Health and Social Care Act 2012, the CNO for England has sat within NHS England, rather than within central Government. This is at odds with the CNOs in the other UK nations, which are situated within central government. Since then, we have called for the reinstatement of the CNO in England within central government. From 2015, there has also been a Chief Nurse for Public Health, and since 2020, a Chief Nurse for Adult Social Care. Both these roles sit within the Department for Health and Social Care but not at an equivalent level to the Chief Medical Officer (CMO).

With a lack of parity between the role, position and influence of the CMO and the CNO in England, nursing is missing a seat at the most senior levels of decision-making. While it’s positive that there are senior nursing roles across public health, the NHS and social care, without an overarching senior nursing role there is a risk of fragmentation and lack of oversight.

The UK government has rejected our calls to include nursing in the minimum requirements for Integrated Care Board membership. Doing so would have maintained the statutory regulations of the Health and Social Care Act (2012) which mandated that nurses would be part of the Clinical Commissioning Group (CCG) governing body.

We raised concerns that this could result in a lack of nursing representation at board level and in senior commissioning roles, and the overall uneven representation of nursing across senior levels.

In 2022 and 2023, an online search showed that each ICB did have a senior or chief nursing role. We’ll have to monitor this going forward. Without safeguards, there are risks that nursing roles could be lost overtime, particularly within the context of national policy decisions increasingly geared towards promoting support roles.  

Integrated Care System leaders should:

• Ensure that nursing leadership is represented in all regional health and care system structures, as well as within executive or decision-making functions. This will go some way to recognise their unique expertise in developing systems for enabling prevention, promoting health and supporting populations.

Service providers should: 

Use the RCN Workforce Standards to support a safe and effective nursing workforce, and ensure nurse leaders are involved in workforce planning, setting staffing levels and skill mix and developing individuals within their workforce.  

The relevant RCN Workforce Standards are:

• Have a registered nurse as part of the leadership team. This individual must have the authority and the responsibility to identify the nursing workforce required to meet the clinical need. They will identify mitigating action when real time and recurrent risks are identified. The RCN Workforce standards state that nurse leaders should be involved in workforce planning and setting staffing establishments and developing individuals within their workforce.
• Ensure that where registered nurses practise within a wider multi-disciplinary team and have a direct line manager who is not a registered nurse, a clear professional line to clinical registered nurse leadership must be available.
• Provide executive nurse leaders within health and care board structures with budget-holding status for the provision of their workforce; corporate health and care Board decision-making structures must consider the provision of nursing expertise, record the provision of this and the response as to whether to act or not on this advice.
• Include leadership and management training in all training sessions from undergraduate nursing degree to executive nurse levels. We recommend a continuous development approach, rather than purely identifying specific career points at which registered nurses and nursing support workers would benefit from investment and support for example, mid-career.