Nursing tropes in turbulent times: Time to rethink nurse leadership?

Internationally, health care is in turmoil. At the height of the pandemic, we argued that the social image of nursing remains overly hagiographical and idealized and that we need to progress to a radical new reality with contemporary nursing finding its own voice and leadership fit for its modern purposes (Bennett et al., 2020). As the profession contends with the aftermath of COVID-19, the cost-of-living crisis, and frustration with political systems that undervalue the status and power of the profession, it is sagacious to reflect on how far we have come in actualising these aspirations. Clark and Thompson (2022) recently adopted a sceptical stance on what they term the ‘leadership illusion’ that pervades modern nursing. The leadership industry has become a juggernaut that is seemingly unstoppable, with an ever-increasing audience seeking to become better leaders. This is perhaps a naive response of health systems and organizations facing highly complex challenges and workforce discontent, but also reflects the ambitions of those striving to make their mark in this field who realize the potential of effective leadership. For nursing, it is no different. The contextual dimensions of leadership, especially when applied in health systems under strain, are missing from the evidence base meaning that it is promoted only as an idealized conceptual skill, with few considerations of the ongoing compromised status of nursing in some situations. The rhetoric from idealized forms of leadership is promoted in an uncritical manner without acknowledging that practical demonstrations of the success or failure of leaders are shaped by a wider impacts; political events, organizational cultures driven by powerful elites, enduring human or physical resource shortages as well as the presence or absence of personal impact. We now require new perspectives and representations that respond to the challenges of healthcare systems and the complexities being faced. Nursing has perhaps been a ‘self-silencing’ profession, attempting to preserve its status without disrupting the perceptions of society originating from traditional gender stereotypes and vocational origins (Bennett et al., 2020). The decision to lead or to step up to complex health system challenges will be influenced by how nurses feel their voices are being heard, how they are perceived against others who may enjoy more agency, which will influence how they respond. Nursing has often preferred to absorb and repurpose leadership theories from other disciplines rather than shaping its own vision and concept of nursing leadership. Furthermore, many of those in positional professional leadership roles may have had little or no preparation in leadership development, and there is a tendency to assume that simply by attending one of the countless development courses available, an effective leader will emerge. Some now view developmental approaches to leadership as limited in value, asserting that only by combining such programmes with relevant theory and criticality, and a coalescing of tacit, implicit and explicit knowledge, can leaders really have impact (Henriksen & Børgesen, 2016). We argue that there exists a tendency for nursing and healthcare organizations to be lulled by the need for improvement, pacified by labels and titles while the significant and complex challenges, such as staff retention, remain unaddressed. Their adoption, however, also hints at naivety, without criticality. Leadership titles are attached without questioning the authenticity of intent or the limited agency attached to the role (Clark & Thompson, 2022). While leadership theories from other disciplines can be helpful, the consideration of nuanced, specific, socially derived, historical and cultural perspectives of nursing are also needed, so that nursing leadership models with utility for contemporary challenges can be re-conceptualized. Adoption of more critical theories of leadership, which take these contextual factors into account are needed to redress the overly theoretical and idealized nature underpinning the current nostrum. In our original editorial (Bennett et al., 2020), we conducted a Nexis UK search of print media headlines that referred to nursing, and found that, while the traditional sexualised tropes were absent, angelic references remained, alongside discourses around gendered roles, subordination and servitude. Three years on, we re-ran the search (1st January 2023–1st February 2023). Media coverage significantly exceeded pre-pandemic levels and was higher than pandemic levels (n = 13,478 hits, compared to n = 3744 and 10,770, respectively). Most significantly though, the messaging has changed significantly, with imagery of strength, autonomy and value now featuring more across the European and North American media. Headlines such as ‘Nurses have real solutions for health-care crisis’ (The Toronto Star, 1st January 2023) suggest a shift towards perceptions of agency and self-determination on the part of nurses. Sentiments of respect and support were also widely conveyed with headlines repeatedly referring to ‘Governments need to start listening to nurses’ (Edmonton Journal (Alberta), 25th January 2023) and ‘Intensive care nurse describes how she can ‘barely make ends meet’ (Standard.co.uk, 18th January 2023). There appears to have been a shift that presents nurses more as valuable professionals, worthy of respect and who function within increasingly complex health systems with unremitting levels of demand. Currently, a significant generational shift in how nurses perceive their worth and their expectations of nurse leadership is evident. In their literature review, Christensen et al. (2018) identified that the nursing workforce currently includes Traditionalists (born between 1922 and 1945), Baby boomers (1946–1964), Generation X (1965–1979), Millennials (1980–1995) and Generation Z (born after 1995). A key aim of their review was to highlight how each generation varies in their behaviours and expectations of nurse leadership. Millennials, or Generation Y, currently make up a significant proportion of the nursing workforce. They were taught to ask questions and are comfortable seeking the input of others in education settings, tending to emphasize teamwork in problem-solving. They want to understand why decisions are made, expect quick feedback and seek out mentoring. They are skilled multitaskers who seek a balance between work and home and expect work demands to be flexible. It is relevant to note, however, that the review identified that this generation can be difficult to retain and leaders need to provide prompt feedback and invite their input into decision-making. Members of Generation Z, nursing's most recent recruits, are described as the ‘new realists’ who use digital technology to answer questions, requiring less direction than previous generations. Like Millennials, they expect the workplace to be responsive to their needs. Against this context, it is striking that in the United Kingdom alone, two-thirds of nurses currently leaving the NHS are under age 45 years (Holmes, 2022); in other words, those from Generation Z and Millennials. Likewise, the American Nurses Foundation and Joslin Insight identified that approximately 60% of Generation Z and millennial nurses are planning or considering leaving their positions, with work–life balance, better pay, enhanced support and improved working conditions identified as common expectations in younger nurses (Bean et al., 2022). It is clear from the European and US literature that nurses from younger generations present specific requirements of nurse leaders and expect certain conditions to be met. We suggest that leaders need to be aware of these shifting expectations. Currently, in the United Kingdom, we contend that nursing has recently found a united voice and displayed agency through its trades union leaders, following years of exhausting pandemic turbulence. The threat from shifting political agendas in workforce planning risks manipulating and distorting nursing's image and its role in society in providing high quality care to the public, while also acknowledging its highly skilled safety critical status. As nurses seek representation and recognition, including adequate staffing numbers, effective retention, patient safety and future workforce planning, there is a need for meaningful action rather than rhetoric, and they have turned to their unions and responded with unprecedented industrial action. Currently public support appears to be weighted with UK nurses as they strike for improved wages and conditions. How long this will continue remains to be seen, especially as a command-and-control approach from the pandemic continues to be applied by politicians, and the growing public realization of the impact on an already understaffed health and social service manifests. In 2020, we asserted the need for a new image for nursing in the wake of COVID-19. The mobilization and reactive response by nursing to the pandemic galvanized our worth and invigorated our sense of agency and professional standing. However, the shifts in political depictions of nurses since then have weakened the opportunity to stop elevating nurses to the status angels with associated servile status, to vexatious protestors demanding what the UK Government considers ‘unreasonable’ or ‘unaffordable’ pay awards. The challenge for nursing now is not to adopt leadership as a panacea in an uncritical or idealistic way, but instead to acknowledge its role in solving complex, sometimes political problems, while also inspiring generations of future nurses. It is time for nursing to reassess its unique wealth of knowledge and experience and to approach leadership with a sense of confident criticality, which is the first step towards its effective application. Without this, there is a risk that models of leadership are promoted which fail to address the challenges facing nursing. By disrupting quixotism and creating new and more relevant concepts of nursing leadership, insights may emerge that can meet current challenges. This includes addressing expectations that different generations now have of their leaders, including the right to engage in political activism to achieve their goals. In turn, those in leadership positions should be aware of the restrictive nature of tropes and engage with nurses in more authentic ways that are fit for contemporary contexts, as well as for the future. Alison Heulwen James, Daniel Kelly and Clare L. Bennett made substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data, involved in drafting the manuscript or revising it critically for important intellectual content, given final approval of the version to be published. Each author should have participated sufficiently in the work to take public responsibility for appropriate portions of the content and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. No funding was attached to this submission. No conflict of interest to declare.

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