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A foot in two camps: An exploratory study of nurse leaders in universities
Nurse Education Today 33 (2013) 1342–1346
Contents lists available at ScienceDirect
Nurse Education Today journal homepage: www.elsevier.com/nedt
A foot in two camps: An exploratory study of nurse leaders in universities Fiona Ross ⁎, Di Marks-Maran, Christopher Tye Faculty of Health and Social Care Sciences, Kingston University and St George's, University of London, Cranmer Terrace, London SW17 0RE, UK
a r t i c l e
i n f o
Article history: Accepted 19 February 2013 Keywords: Nursing academic leadership Nursing deans Practice discipline University
s u m m a r y Background: Nursing education was fully absorbed into universities in the United Kingdom in the late 1990s and thus is a relatively young academic discipline. In contrast to a lively literature on clinical nursing leadership, little attention has been given to the leadership of academic nursing as these roles encompass contract management, research and teaching. Objectives: The purpose of this study was to explore the scope and meaning of leadership from the experience of nurse leaders in universities in the United Kingdom (UK). Design and Methods: The qualitative design used open ended telephone interviews. Interview transcripts were checked with participants. Framework analysis was used for capturing and identifying themes. Setting and Participants: A convenience sample of academic nurse leaders (responsible for a School, Department or a Faculty) was identified through the UK Council of Deans of Health. Results: All ten respondents were managing health care portfolios and running departments of various sizes and often with a mix of nursing and other health care disciplines. There was regional and country representation (England, Scotland and Wales) and half the respondents were employed at pre 1992 and half at post 1992 universities (the latter institutions that were previously polytechnics and gained university status in 1992). Three core issues emerged from the data: the leadership context; ways in which the deans articulated their leadership skills and the issue of legitimacy of nursing in higher education. Conclusion: Two important issues emerged for nursing deans, firstly the university as a knowledge producer and secondly the need to create strong academic and professional identities. The findings highlight role complexity as academic nurse leaders navigate the dichotomy between the different worlds of the university and health care practice. The legitimacy of nursing as a practice discipline in the university continues to be contested territory. There is an opportunity for nurse leaders to do more to develop a collective narrative about the contribution that academic nursing can make to the quality of the workforce. © 2013 Elsevier Ltd. All rights reserved.
Introduction The position of nursing as an academic discipline has had a contested history. While the first Bachelors degree in Nursing was offered by the University of Minnesota in 1909, it was another fifty years before Edinburgh University launched an integrated degree in nursing in 1965 and in 1971 established the first Chair in Nursing in the United Kingdom (UK) and in Europe. These significant developments came about through the efforts of many, such as the first Director of Nursing, Elsie Stephenson (Allen, 1990) and academic champions outside nursing. At that time the Dean of the Faculty of Arts at Edinburgh University was the eminent moral philosopher Professor John Macmurray. He argued that nursing, like education and medicine, is a profession grounded in a personal relationship and that the quality of the patient experience would be improved by nurses with degrees
⁎ Corresponding author. Tel.: +44 20 8725 2155; fax: +44 20 8725 2159. E-mail addresses: [email protected] (F. Ross), [email protected] (D. Marks-Maran), [email protected] (C. Tye). 0260-6917/$ – see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nedt.2013.02.008
and skills in reflective practice. He saw himself as the “godfather to the Nursing Studies Unit at its birth and during its earliest years” (113) and was fiercely proud of its achievements as it established itself as a practice discipline in the university (Costello, 2002). Following Edinburgh University's lead a handful of Russell Group universities established nursing degree courses in the seventies such as Manchester, King's College London and Southampton, but it was not until the 1990s following market-led reforms, introduction of the purchaser provider split and employer-led commissioning outlined in Working Paper 10 (Department of Health (DH), 1989) alongside Project 2000 (United Kingdom Central Council for Nursing, Midwifery and Health Visiting, 1986), that the mass move of nurse education from the NHS to universities was achieved (Burke, 2003, 2006). In 2012 there were 67 education providers (mostly universities) in the UK offering nursing programmes through contracts with the NHS. The expansion of student numbers in the nineties in response to acute workforce shortages has meant that the income from these contracts for mainly diploma routes to nurse qualification has been significant for the higher education sector. The move to all degree programmes has been slow with England
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(now due to implement fully by 2013) following behind the 3 other countries in the UK, and Scandinavia and North America. The rapid expansion and fundamental reforms of nursing education has inevitably meant that universities have developed academic structures with new academic leadership roles for nursing, which are often, but not exclusively occupied by nurses. Despite this growth, Meerabeau (2005) notes that the place of nursing within the academy is largely invisible, which is borne out by the lack of literature on academic leadership. There are a few exceptions to this, for example, Salminen et al. (2010) addressed the leadership challenges of harmonising nursing education across Europe, Rafferty and Traynor (2004) explored research leadership and the United Kingdom Clinical Research Collaboration (2007) explored the development of new clinical/academic career pathways. The paucity of attention to academic nursing leadership in the literature is an interesting contrast to the growing preoccupation with nursing clinical leadership, which is often considered a key component for quality and safety in England (DH, 2010; Wong and Cummings, 2007). It is timely then to consider the nature of leadership of nursing within higher education, especially given the size and complexity of the job to manage large education contracts, lead research, build and sustain employer relationships as well as to address external drivers facing universities such as funding, quality, social mobility and technology (Coffait, 2011). This paper reports on a study that explored the scope and meaning of leadership from the experience of nurse leaders in universities across the United Kingdom (UK). Background and Literature Review In the UK nurse education is delivered by universities through contracts with NHS bodies for example Strategic Health Authorities and their successor bodies (Local Education Training Boards from 2013) in England. Employer-led commissioning determines student numbers, which are subject to annual adjustments as workforce requirements change to reflect service need. Contracts are performance managed for quality, outputs and value for money, leaving universities to manage the risk to income, reputation and resources within the context of commissioning instability and a competitive market. This represents features of the quasi-market, which fit with the ideas of the new public management that emerged out of the UK Thatcher government in the 1980s and have become increasingly dominant in universities (Ferlie et al., 2008) and are likely to increase as governments withdraw public funding and destabilise the so called “slow-burn consequences of the growth of mass education systems” and knowledge society (Scott, 2011 p. 231). Therefore understanding the experience of nurse leaders has to be considered within the cultural and organisational context of this “new managerialism” (Deem, 1998). In the UK the academic workforce is ageing (Willis Commission, 2012), career pathways are poorly defined (Salminen et al., 2010) and generally there is a lower percentage of nurses with doctoral-level qualifications, compared with other academic disciplines (Jackson and Butterworth, 2007) as nurses entered academia later in their career, having already established themselves in a clinical field. Damico et al. (2003) explored issues around how academic leaders (deans) are prepared for the role and the experience of academic deans in the United States in terms of demands, burnout and how long they stay in the role. Damico et al. (2003) referred to stages in the cycle of being a dean from (1) taking hold, (2) immersion, (3) reshaping, and (4) consolidation and refinement. Our paper develops some of these ideas for a UK context. The impetus for this paper arose from the invitation to Fiona Ross to give the Elsie Stephenson Memorial Lecture at Edinburgh University. The idea was to explore the legacy of Elsie Stephenson's pioneering leadership in setting up the first university department of nursing through the views of present day nurse leaders (Ross, in press). In
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preparing this presentation, a study was set up which involved structured conversations with Deans and Heads of Departments to explore the scope of the role and the personal, professional and academic challenges for nurses in leadership roles in universities in the UK. It forms the preliminary study to a larger piece of work, which has subsequently been commissioned by the Leadership Foundation for Higher Education. Method A convenience sample of nurse leaders were identified through the Council of Deans of Health, which is a UK membership organisation of all universities providing education in nursing, midwifery and allied health professions. From a possible population of 67 education providers of nursing in the UK, informal approaches and invitations to heads/deans to participate were made in person or by email. Written consent was obtained from 11 people who agreed to participate and of these 10 took part in a telephone interview during late February/early March 2012. Data were collected through structured telephone interviews. Questions asked in the interviews explored with the deans and heads: • How they perceived their personal leadership role in the highly political worlds of the health service and higher education; • What makes colleagues in the health service and in the university take notice of nursing; • How they respond to challenges from higher education colleagues and from those in the health service; • How they get things done and what sorts of skills and relationships are required; • How they manage the tensions between the health service and the university and what advice they would give their successor. The telephone interviews were recorded using shorthand and transcribed immediately. Transcripts were sent to respondents asking for amendments, clarification or in some cases expansion of points, and amended transcripts were then returned. Ethical approval was obtained from the Faculty of Health and Social Care Sciences Research Ethics Committee. Results All the respondents were managing health care portfolios and running schools/faculties of various sizes — some were managing other professional disciplines, e.g., allied health professionals and social work. Job titles differed (dean/head of faculty/school) depending on the organisational structure of the university. For convenience in this paper we use the term dean to preserve anonymity. Half of the respondents worked in pre 1992 universities (the former polytechnics gained university status in 1992 and are known as post 1992 or often new universities). The respondents were spread across Scotland (2), Wales (1) and England (7). A decision was taken not to interview deans from London, because we were interviewing at the same time as the Strategic Health Authority was running a procurement exercise for the delivery of adult nursing and physiotherapy (although one recently retired dean from a large university in London, who was not involved in the tender, was interviewed as someone who could offer valuable insights from a long career in academic nursing). Some deans interviewed were longstanding and established in their role and some were very new in post. Two had wider corporate roles as pro vice chancellors, but either did this in a combined role with being a dean or had recently left that role behind. The transcriptions were analysed thematically using the Framework Method of analysis (Ritchie and Spencer, 1994). Three core issues/ themes emerged.
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• How the university or leadership context determines the leadership priorities • How the deans articulated their leadership skills • The issue of the legitimacy of nursing in higher education. These ideas were played out in different ways in the conversations, but were intertwined around the central theme of identity, of navigating different identities, having a foot in two camps or working in two worlds, for two masters, that is the NHS and the university. It also appeared that there were different issues emerging for deans from pre 1992 universities compared with post 1992. The Leadership Context — Navigating the Different Cultures and Politics of the Professions, Employers and the University As noted earlier nurse education is delivered through contracts with the health service. It is employer-led and determined by performance, e.g., recruitment, progression, attrition, employment and so forth. As well as meeting these targets, deans are responsible to their employer, the university, for meeting targets for performance on research outputs, student satisfaction, learning and teaching, widening participation and enterprise. The balance of these activities is not surprisingly prioritised in different ways depending on the mission, culture and priorities of the particular university. Many deans described managing the employer/university interface as a balancing act and needing skills of navigation to weave a path around both sets of agendas, able to “argue for – negotiate for – nursing” and find their way through both, which was described by one dean as: “leading from the front and pushing from the rear.” There were clear differences between deans working in the Russell group (pre 1992 universities in the UK) and those in post-1992 universities. For the latter, leadership was aligned to managing large and complex organisations in terms of personnel, budget, NHS contracts and so forth. As one dean stated: “My leadership is about knowing what I bring to the table and having the confidence to know what I am good at, e.g., managing a very large budget, managing NHS relationships, seeing students as a customer base.” Deans from pre-1992 universities, however, were more likely (but not exclusively) to delegate commissioning, NHS relationships and contracting activities, while they focused on the leadership of an academic and research portfolio. On the one hand this could probably be seen as a pragmatic strategy to enable focus on quality, but on the other could be seen as a personal distancing from the contract management in order to privilege the institutional research mission. “In Russell Group universities there is a research-obsessed agenda, with claims by the universities of being ‘dumbed down’ by the NHS agenda. In post-1992 universities the polarisation of agendas is about fulfilling the new universities' financial expectations (the money you bring in and student numbers).” Generally speaking, nursing deans in pre 1992 universities focused more on vision and creativity when describing their leadership roles, whereas, deans in post 1992 tended to describe their role as managers running a business. A dean from a post 1992 was quite clear about her different roles in both the political agendas of the health service and higher education: “At university level, I am involved in decision-making about university corporate affairs and issues, e.g., catering, estate, student numbers. I understand the political drivers that shape the direction of both the university and the NHS. At NHS level, I am very involved in shaping education and training for the workforce and future commissioning.”
“In academic terms we are perceived as the new kids on the block. I am not a researcher. But as a leader I know what I am not. Therefore I justify my place in H.E. in different ways. My leadership is about creating a framework for others working with me to advance the needs of the NHS, the university and the School.” Another post 1992 dean commented that the authority and credibility of nursing is related to student numbers and contract size: “In the beginning, nursing was small and invisible. Staff were practice/teaching orientated and nursing was not a big player in the organisation. When we won the tender which brought in a huge amount of money – nursing is now the largest income in the university – people in the wider university woke up to the importance of nursing in the university.”
Leadership Skills The second theme emerging from the data was the leadership skills seen by deans as necessary for the job. These were described as multifaceted, as deans struggled to manage complex boundaries and uncertainty, as well as working to sustain their own academic profile within the university. Three aspects came out strongly. Standing up and Speaking out Good leaders were described as speaking up for nursing, both in the NHS and the university, although this was not seen to happen enough. There was a feeling nurses often lacked academic confidence and at the same time were not “good at claiming and celebrating what they do.” “We do what we have to do but we often feel that we are not as good as other academics.” There was a feeling amongst some, they lacked the power and the authority to challenge, and having to work across many different agendas meant success was diluted or that some areas were not covered: “Leadership means having your eye on many balls and understanding many agendas. The successful Deans are those who are engaged in all (research, financial, corporate university). A few Deans can do this, but others are involved in some, but not all.”
Interpersonal Skills and Resilience Qualities embracing emotional intelligence, interpersonal skills, courage and tenacity were identified as important for nursing academic leaders. Interestingly these skills were seen to have been derived from, and learned during practice as a clinical nurse. They were acknowledged as invaluable and transferable to the role of a dean: “The skills are generalizable and transferable from one setting to the other. From a nursing background, [I bring] empathy (LEARNED) from a caring environment which brings something extra to HE. In addition, [I bring] communication skills from practice into HE and the ability to be intellectually critical.” Other qualities of leadership were described such as working with others and through others, being able to juggle with several things at once — “feet in many camps”, having resilience, “having common sense and being action/practically focused”.
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Pioneering and Breaking New Ground The notion of a leader as pioneer came out strongly and was seen as both about people “walking the talk and taking people with you” as breaking new ground. The early pioneers of nursing degrees were working at the top/elite end of university provision with small groups of students compared with today's mass system with annual intake of several hundred adult nursing branch students. Dealing with expansion of higher education and student numbers and the resulting organisational complexity was recognised as needing a different sort of leader, in that you can't do it alone and have to be in it for the long game: “You need to work together with others (e.g. Universities UK and Council of Deans). If you pioneer on your own you are a lone voice but with others behind you/with you your power increases and vulnerability decreases.”
Legitimacy of a Practice Discipline/Nursing in Higher Education The third and final theme that emerged from the data is the legitimacy of nursing as a practice discipline in universities. Whether or not nurses should have degrees has been disputed for over a century and can be traced back to 1901 and Mrs Bedford Fenwick, a nurse reformer. In establishing the degree in nursing at the University of Edinburgh 56 years later, Elsie Stephenson was challenging a “sacred cow” — the belief that nursing was purely a vocation, which does not need a degree. She believed that for nursing to grow it needed to be developed within the context of a university education. “what occupation more than nursing has allowed itself to be so routinised and thus allowed its enthusiastic young students to become dull, apathetic and subordinate?....it should today be a leader in the field of social science, instead it is fighting for recognition as a profession…to produce imagination, vision and thought, what better place than the university…..” (Allen, 1990, p. 111) Fifty years later this debate continues unabated, so much so, that the Royal College of Nursing commissioned a review of nurse education (Willis, 2012). However, there is, perhaps, a more worrying game being played out. In a shrinking economy where we have powerful employers wanting to reduce costs, they argue that degrees are not necessary, universities do not add value and it would be better and cheaper for nurses to be trained in hospital schools and learn on the job. As one post 1992 dean in this pilot stated: “With regard to the perception of the NHS to nursing education being in higher education, for the vast majority, they do not think nurses should be educated at university. In fact, there was discussion in this area related to local Trusts setting up their own “old style” school of nursing to run courses that they would get validated by our university.” Another dean, this time from a pre 1992 university elaborated: “It does not help that expectations of performance by newly qualified nurses are unrealistic. Medical students are not expected to be proficient when they qualify. They have a post-registration clinical career structure. Going back to “pioneering” — these are areas where pioneering is needed. Nursing needs to rethink its expectations of the newly qualified nurse and create a post-registration pathway like medics…”
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“Academic standards at university XXX are about grant income, completion rates of PhDs, number of doctoral fellowships funded externally and number of quality publications.”
“The university does not see nursing as being a legitimate part of an academic university. Universities are still male dominated institutions with deep-seated prejudice about nursing in universities.” Finally, it appears that deans in both pre and post 1992 universities were aware of the competing demands and contradictory values of the two cultures of higher education and the National Health Service, and described ways of navigating the different identities, demonstrating both depth and breadth of flexibility and resilience. Discussion Although this was a small study and a snap shot in time, it illuminates how nurse academic leaders make sense of their complex roles. The participants were generous with their time and frank in their responses to the open ended questions, which took a “conversational” form allowing for depth exploration of views. Only interviewing one participant from London, due to the competitive tender, may have been a limitation, although in our view reducing the possibility of a London centric bias can equally be seen as a strength. A large global city and the seat of government means that London has unique, often tense, political and commissioning relationships not found to the same extent elsewhere, which arguably could have swayed the findings. The findings from these interviews suggest a set of emerging ideas that will advance our understanding of academic nursing leadership as it manages the tensions of developing a practice based discipline within the university. As noted earlier there is a dearth of literature on nurse leaders in universities and therefore these findings provide some pointers for the future, both in the UK and internationally. The discussion focuses on two main areas. First there is the university as the institutional context for nurse leadership with its associated structures, hierarchies and mode of knowledge production. Secondly, and more importantly there is the interplay between the academic and professional identities as expressed through relationships with commissioners, employers and practitioners. These issues will be discussed in turn in relation to the data. The University as a Knowledge Producer Gibbons et al. (1994) have distinguished universities as producers of knowledge between Mode 1, defined by traditional scientific practice, unidisciplinary, formal structures based on authority and hierarchies, contrasted to Mode 2 knowledge, which is typically problem focused and is “legitimised by its utility in application” (Ternouth, 2012). The practice discipline of nursing seems to fit with the Mode 2 communities, which commonly crosses organisational boundaries and creates knowledge in partnership with the health service. Our findings show a clear difference between the experience of deans in pre 1992 universities, which could be said to display more Mode 1 characteristics compared with deans in post 1992, which on the whole may be more comfortable with applied knowledge, reflexivity and building employer relationships in the clinical setting. This is discussed further below in relation to identities. Academic and Professional Identities
While this debate is being played out in public, there are tensions within some universities as to whether it is “worth it” to have practice disciplines like nursing, which are seen as diluting academic esteem, research metrics and performance. As two deans in pre 1992 universities stated:
The second issue relates to the fundamental dichotomy between the university and practice, which sets up tensions between the dual identities (academic and professional) experienced by the nurse leaders, who feel they have a “foot in both camps”. The
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challenge of developing the personal academic identity for nurse educators has been described by Duffy (2012) and supports the wider higher education literature and is a good example of the expansion of academic identities as universities diversify and become involved in external relationships with employers (Whitchurch, 2012). As academic identities shift, it is not surprising if there are tensions and ambiguities reflected in the nursing discourse between the academic (theory) and clinical (practice). This ambiguity was seen through the uncertainty expressed by some deans about the future of university education for nursing. Some talked about the system getting smaller in response to NHS cuts in commissioning student numbers with the risk of universities disinvesting. Others talked about different sorts of risks to nursing in research intensive universities as the competition for resources grows and as the higher education sector continues to differentiate. On the other hand there was optimism expressed by those who had a wider vision for the future and wanted to refashion relationships with Trusts, build new partnerships for knowledge production, use evidence to lever change in practice and work across the boundaries of the health service and the university to shape innovative services for the future. This vision for engagement with the NHS will need “fast tracking” a development programme in practice, education and research, strengthening of clinical and academic pathways and developing new roles for clinical professors building applied research. There have been real advancements in academic nursing over the last fifteen years in education and research, but it is worrying that nursing as an academic discipline is not more secure in universities with threats from the NHS (nursing better taught in hospitals) and from some quarters of traditional and research intensive universities (nursing diluting research excellence). If academic nursing is to continue to flourish there are some important issues to confront. Firstly, this study suggests the place of nurse education within universities is contested and increasingly so. Nursing leaders need to face this head on and develop a collective narrative about the contribution that academic nursing is making to quality of care. As Florence Nightingale argued it is only through intelligent nursing that patients will get the best care. We believe the best nurses should be trained in the best places (university and in the clinical environment) where they can challenge, learn to think and shape solutions for the future. For this to happen academic nurse leaders have to have a foot firmly in both camps and effectively manage their dual identities to the benefit of the university and health care. Secondly there is a message here for universities. It is time that there was a proper valuing of nursing as a practice discipline within universities — and not just for the income derived from education contracts. Universities need to recognise the contribution of practice disciplines as a perfect fit with their agenda for civic and community engagement, as Wooldridge (2011) notes is increasing in prominence. Finally new types of leaders are needed to support research into practice, which will enhance health care and social capital. This will play to the strengths of those universities reaching into communities, building positive relationships with employers that demonstrate the value of mutual benefits of education, research and innovation to health communities and “clever cities”.
Contributors and Acknowledgements This paper is based on the Elsie Stephenson Memorial Lecture given by Professor Fiona Ross at Edinburgh University in March 2012. Di Marks Maran carried out the interviews and analysis. All authors contributed to interrogating the data in relation to the literature, provided insights to the analysis and were involved in drafting the paper.
References Allen, S., 1990. Fear Not to Sow — A Life of Elsie Stephenson. Patten Press and Jamieson Library, Penzance Cornwall. Burke, L., 2003. Integration into higher education: key implementers' views on why nurse education moved into higher education. Journal of Advanced Nursing 42 (4), 382–389. Burke, L., 2006. The process of integration of schools of nursing into higher education. Nurse Education Today 26 (1), 63–70. Coffait, L. (Ed.), 2011. Blue Skies: New Thinking about the Future of Higher Education. Pearson Centre for Policy and Learning, London. Costello, J., 2002. John Macmurray: A Biography. Floris Books. Damico, S., Gmelch, W.H., Hopkins, D., Mitchell, J.N., 2003. Seasons of a dean's life: passages for the profession. Paper presented at the 4th Annual Meeting of the American Education Research Association, Chicago, Illinois, April 2003. Deem, R., 1998. “New managerialism” and higher education: the management of performance and cultures in universities and the UK. International Studies in Sociology of Education 8 (1), 47–70. Department of Health, 1989. Education and training. Working Paper, 10. Department of Health. Department of Health, 2010. Front Line Care: Report by the Prime Minister's Commission on the Future of Nursing and Midwifery in England. DH. Duffy, R., 2012. Nurse to educator? Academic roles and the formation of personal academic identities. Nurse Education Today (published online ahead of publication, 23 August. At http://www.ncbi.nlm.nih.gov/pubmed/22922027. Accessed 11 November 2012). Ferlie, E., Musselin, C., Andresani, G., 2008. The steering of higher education systems: a public management perspective. Higher Education 56, 325–348. Gibbons, M., Limoges, C., Nowotny, H., Schwartzman, S., Scott, P., Trow, M., 1994. The New Production of Knowledge, the Dynamics of Science and Research in Contemporary Societies. Sage Publications, London. Jackson, C., Butterworth, T., 2007. Everyone's business, no-one's responsibility; reporting clinical academic research activity by nurses in the United Kingdom. Journal of Research in Nursing 12 (3), 213–223. Meerabeau, L., 2005. The invisible (inaudible) woman: nursing in the English Academy. Gender, Work and Organisation 12 (2), 124–146. Rafferty, A.-M., Traynor, M., 2004. Context, convergence and contingency: political leadership for nursing. Journal of Nursing Management 12 (4), 258–265. Ritchie, J., Spencer, L., 1994. Qualitative data analysis for applied policy research. In: Bryman, A., Burgess, R. (Eds.), Analysing Qualitative Data. Routledge, London, pp. 173–194. Ross, F., in press. Elsie Stephenson's Legacy: Nurse Leaders in Universities Today. Edinburgh University Press. Salminen, L., Stolt, M., Saarikoski, M., Suikkala, A., Vaatio, H., Leino-Kilpi, H., 2010. Future challenges for nursing education — a European perspective. Nurse Education Today 30, 233–238. Scott, P., 2011. Leadership in universities. The International Journal of Leadership in Public Services 7 (3), 229–234. Ternouth, P., 2012. Universities as knowledge producers. In: Temple, P. (Ed.), Universities in the Knowledge Economy. Routledge, London. UKCRC, 2007. Developing best research professionals. Report of the UKCRC Sub Committee for Nurses in Clinical Research. Department of Health. United Kingdom Central Council for Nursing, Midwifery and Health Visiting, 1986. Project 2000. A New Preparation for Practice. UKCC. Whitchurch, C., 2012. Expanding the parameters of academia. Higher Education 64, 99–117. Willis, P., 2012. Quality with compassion: the future of nursing education. Report of the Willis Commission. Royal College of Nursing. Wong, C., Cummings, G., 2007. The relationship between nursing leadership and patient outcomes: a systematic review. Journal of Nursing Management 15 (5), 508–521. Wooldridge, E., 2011. Leadership in higher education: some lessons from other sectors. The International Journal of Leadership in Public Services 7 (3), 245–250.
Contents lists available at ScienceDirect
Nurse Education Today journal homepage: www.elsevier.com/nedt
A foot in two camps: An exploratory study of nurse leaders in universities Fiona Ross ⁎, Di Marks-Maran, Christopher Tye Faculty of Health and Social Care Sciences, Kingston University and St George's, University of London, Cranmer Terrace, London SW17 0RE, UK
a r t i c l e
i n f o
Article history: Accepted 19 February 2013 Keywords: Nursing academic leadership Nursing deans Practice discipline University
s u m m a r y Background: Nursing education was fully absorbed into universities in the United Kingdom in the late 1990s and thus is a relatively young academic discipline. In contrast to a lively literature on clinical nursing leadership, little attention has been given to the leadership of academic nursing as these roles encompass contract management, research and teaching. Objectives: The purpose of this study was to explore the scope and meaning of leadership from the experience of nurse leaders in universities in the United Kingdom (UK). Design and Methods: The qualitative design used open ended telephone interviews. Interview transcripts were checked with participants. Framework analysis was used for capturing and identifying themes. Setting and Participants: A convenience sample of academic nurse leaders (responsible for a School, Department or a Faculty) was identified through the UK Council of Deans of Health. Results: All ten respondents were managing health care portfolios and running departments of various sizes and often with a mix of nursing and other health care disciplines. There was regional and country representation (England, Scotland and Wales) and half the respondents were employed at pre 1992 and half at post 1992 universities (the latter institutions that were previously polytechnics and gained university status in 1992). Three core issues emerged from the data: the leadership context; ways in which the deans articulated their leadership skills and the issue of legitimacy of nursing in higher education. Conclusion: Two important issues emerged for nursing deans, firstly the university as a knowledge producer and secondly the need to create strong academic and professional identities. The findings highlight role complexity as academic nurse leaders navigate the dichotomy between the different worlds of the university and health care practice. The legitimacy of nursing as a practice discipline in the university continues to be contested territory. There is an opportunity for nurse leaders to do more to develop a collective narrative about the contribution that academic nursing can make to the quality of the workforce. © 2013 Elsevier Ltd. All rights reserved.
Introduction The position of nursing as an academic discipline has had a contested history. While the first Bachelors degree in Nursing was offered by the University of Minnesota in 1909, it was another fifty years before Edinburgh University launched an integrated degree in nursing in 1965 and in 1971 established the first Chair in Nursing in the United Kingdom (UK) and in Europe. These significant developments came about through the efforts of many, such as the first Director of Nursing, Elsie Stephenson (Allen, 1990) and academic champions outside nursing. At that time the Dean of the Faculty of Arts at Edinburgh University was the eminent moral philosopher Professor John Macmurray. He argued that nursing, like education and medicine, is a profession grounded in a personal relationship and that the quality of the patient experience would be improved by nurses with degrees
⁎ Corresponding author. Tel.: +44 20 8725 2155; fax: +44 20 8725 2159. E-mail addresses: [email protected] (F. Ross), [email protected] (D. Marks-Maran), [email protected] (C. Tye). 0260-6917/$ – see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nedt.2013.02.008
and skills in reflective practice. He saw himself as the “godfather to the Nursing Studies Unit at its birth and during its earliest years” (113) and was fiercely proud of its achievements as it established itself as a practice discipline in the university (Costello, 2002). Following Edinburgh University's lead a handful of Russell Group universities established nursing degree courses in the seventies such as Manchester, King's College London and Southampton, but it was not until the 1990s following market-led reforms, introduction of the purchaser provider split and employer-led commissioning outlined in Working Paper 10 (Department of Health (DH), 1989) alongside Project 2000 (United Kingdom Central Council for Nursing, Midwifery and Health Visiting, 1986), that the mass move of nurse education from the NHS to universities was achieved (Burke, 2003, 2006). In 2012 there were 67 education providers (mostly universities) in the UK offering nursing programmes through contracts with the NHS. The expansion of student numbers in the nineties in response to acute workforce shortages has meant that the income from these contracts for mainly diploma routes to nurse qualification has been significant for the higher education sector. The move to all degree programmes has been slow with England
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(now due to implement fully by 2013) following behind the 3 other countries in the UK, and Scandinavia and North America. The rapid expansion and fundamental reforms of nursing education has inevitably meant that universities have developed academic structures with new academic leadership roles for nursing, which are often, but not exclusively occupied by nurses. Despite this growth, Meerabeau (2005) notes that the place of nursing within the academy is largely invisible, which is borne out by the lack of literature on academic leadership. There are a few exceptions to this, for example, Salminen et al. (2010) addressed the leadership challenges of harmonising nursing education across Europe, Rafferty and Traynor (2004) explored research leadership and the United Kingdom Clinical Research Collaboration (2007) explored the development of new clinical/academic career pathways. The paucity of attention to academic nursing leadership in the literature is an interesting contrast to the growing preoccupation with nursing clinical leadership, which is often considered a key component for quality and safety in England (DH, 2010; Wong and Cummings, 2007). It is timely then to consider the nature of leadership of nursing within higher education, especially given the size and complexity of the job to manage large education contracts, lead research, build and sustain employer relationships as well as to address external drivers facing universities such as funding, quality, social mobility and technology (Coffait, 2011). This paper reports on a study that explored the scope and meaning of leadership from the experience of nurse leaders in universities across the United Kingdom (UK). Background and Literature Review In the UK nurse education is delivered by universities through contracts with NHS bodies for example Strategic Health Authorities and their successor bodies (Local Education Training Boards from 2013) in England. Employer-led commissioning determines student numbers, which are subject to annual adjustments as workforce requirements change to reflect service need. Contracts are performance managed for quality, outputs and value for money, leaving universities to manage the risk to income, reputation and resources within the context of commissioning instability and a competitive market. This represents features of the quasi-market, which fit with the ideas of the new public management that emerged out of the UK Thatcher government in the 1980s and have become increasingly dominant in universities (Ferlie et al., 2008) and are likely to increase as governments withdraw public funding and destabilise the so called “slow-burn consequences of the growth of mass education systems” and knowledge society (Scott, 2011 p. 231). Therefore understanding the experience of nurse leaders has to be considered within the cultural and organisational context of this “new managerialism” (Deem, 1998). In the UK the academic workforce is ageing (Willis Commission, 2012), career pathways are poorly defined (Salminen et al., 2010) and generally there is a lower percentage of nurses with doctoral-level qualifications, compared with other academic disciplines (Jackson and Butterworth, 2007) as nurses entered academia later in their career, having already established themselves in a clinical field. Damico et al. (2003) explored issues around how academic leaders (deans) are prepared for the role and the experience of academic deans in the United States in terms of demands, burnout and how long they stay in the role. Damico et al. (2003) referred to stages in the cycle of being a dean from (1) taking hold, (2) immersion, (3) reshaping, and (4) consolidation and refinement. Our paper develops some of these ideas for a UK context. The impetus for this paper arose from the invitation to Fiona Ross to give the Elsie Stephenson Memorial Lecture at Edinburgh University. The idea was to explore the legacy of Elsie Stephenson's pioneering leadership in setting up the first university department of nursing through the views of present day nurse leaders (Ross, in press). In
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preparing this presentation, a study was set up which involved structured conversations with Deans and Heads of Departments to explore the scope of the role and the personal, professional and academic challenges for nurses in leadership roles in universities in the UK. It forms the preliminary study to a larger piece of work, which has subsequently been commissioned by the Leadership Foundation for Higher Education. Method A convenience sample of nurse leaders were identified through the Council of Deans of Health, which is a UK membership organisation of all universities providing education in nursing, midwifery and allied health professions. From a possible population of 67 education providers of nursing in the UK, informal approaches and invitations to heads/deans to participate were made in person or by email. Written consent was obtained from 11 people who agreed to participate and of these 10 took part in a telephone interview during late February/early March 2012. Data were collected through structured telephone interviews. Questions asked in the interviews explored with the deans and heads: • How they perceived their personal leadership role in the highly political worlds of the health service and higher education; • What makes colleagues in the health service and in the university take notice of nursing; • How they respond to challenges from higher education colleagues and from those in the health service; • How they get things done and what sorts of skills and relationships are required; • How they manage the tensions between the health service and the university and what advice they would give their successor. The telephone interviews were recorded using shorthand and transcribed immediately. Transcripts were sent to respondents asking for amendments, clarification or in some cases expansion of points, and amended transcripts were then returned. Ethical approval was obtained from the Faculty of Health and Social Care Sciences Research Ethics Committee. Results All the respondents were managing health care portfolios and running schools/faculties of various sizes — some were managing other professional disciplines, e.g., allied health professionals and social work. Job titles differed (dean/head of faculty/school) depending on the organisational structure of the university. For convenience in this paper we use the term dean to preserve anonymity. Half of the respondents worked in pre 1992 universities (the former polytechnics gained university status in 1992 and are known as post 1992 or often new universities). The respondents were spread across Scotland (2), Wales (1) and England (7). A decision was taken not to interview deans from London, because we were interviewing at the same time as the Strategic Health Authority was running a procurement exercise for the delivery of adult nursing and physiotherapy (although one recently retired dean from a large university in London, who was not involved in the tender, was interviewed as someone who could offer valuable insights from a long career in academic nursing). Some deans interviewed were longstanding and established in their role and some were very new in post. Two had wider corporate roles as pro vice chancellors, but either did this in a combined role with being a dean or had recently left that role behind. The transcriptions were analysed thematically using the Framework Method of analysis (Ritchie and Spencer, 1994). Three core issues/ themes emerged.
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• How the university or leadership context determines the leadership priorities • How the deans articulated their leadership skills • The issue of the legitimacy of nursing in higher education. These ideas were played out in different ways in the conversations, but were intertwined around the central theme of identity, of navigating different identities, having a foot in two camps or working in two worlds, for two masters, that is the NHS and the university. It also appeared that there were different issues emerging for deans from pre 1992 universities compared with post 1992. The Leadership Context — Navigating the Different Cultures and Politics of the Professions, Employers and the University As noted earlier nurse education is delivered through contracts with the health service. It is employer-led and determined by performance, e.g., recruitment, progression, attrition, employment and so forth. As well as meeting these targets, deans are responsible to their employer, the university, for meeting targets for performance on research outputs, student satisfaction, learning and teaching, widening participation and enterprise. The balance of these activities is not surprisingly prioritised in different ways depending on the mission, culture and priorities of the particular university. Many deans described managing the employer/university interface as a balancing act and needing skills of navigation to weave a path around both sets of agendas, able to “argue for – negotiate for – nursing” and find their way through both, which was described by one dean as: “leading from the front and pushing from the rear.” There were clear differences between deans working in the Russell group (pre 1992 universities in the UK) and those in post-1992 universities. For the latter, leadership was aligned to managing large and complex organisations in terms of personnel, budget, NHS contracts and so forth. As one dean stated: “My leadership is about knowing what I bring to the table and having the confidence to know what I am good at, e.g., managing a very large budget, managing NHS relationships, seeing students as a customer base.” Deans from pre-1992 universities, however, were more likely (but not exclusively) to delegate commissioning, NHS relationships and contracting activities, while they focused on the leadership of an academic and research portfolio. On the one hand this could probably be seen as a pragmatic strategy to enable focus on quality, but on the other could be seen as a personal distancing from the contract management in order to privilege the institutional research mission. “In Russell Group universities there is a research-obsessed agenda, with claims by the universities of being ‘dumbed down’ by the NHS agenda. In post-1992 universities the polarisation of agendas is about fulfilling the new universities' financial expectations (the money you bring in and student numbers).” Generally speaking, nursing deans in pre 1992 universities focused more on vision and creativity when describing their leadership roles, whereas, deans in post 1992 tended to describe their role as managers running a business. A dean from a post 1992 was quite clear about her different roles in both the political agendas of the health service and higher education: “At university level, I am involved in decision-making about university corporate affairs and issues, e.g., catering, estate, student numbers. I understand the political drivers that shape the direction of both the university and the NHS. At NHS level, I am very involved in shaping education and training for the workforce and future commissioning.”
“In academic terms we are perceived as the new kids on the block. I am not a researcher. But as a leader I know what I am not. Therefore I justify my place in H.E. in different ways. My leadership is about creating a framework for others working with me to advance the needs of the NHS, the university and the School.” Another post 1992 dean commented that the authority and credibility of nursing is related to student numbers and contract size: “In the beginning, nursing was small and invisible. Staff were practice/teaching orientated and nursing was not a big player in the organisation. When we won the tender which brought in a huge amount of money – nursing is now the largest income in the university – people in the wider university woke up to the importance of nursing in the university.”
Leadership Skills The second theme emerging from the data was the leadership skills seen by deans as necessary for the job. These were described as multifaceted, as deans struggled to manage complex boundaries and uncertainty, as well as working to sustain their own academic profile within the university. Three aspects came out strongly. Standing up and Speaking out Good leaders were described as speaking up for nursing, both in the NHS and the university, although this was not seen to happen enough. There was a feeling nurses often lacked academic confidence and at the same time were not “good at claiming and celebrating what they do.” “We do what we have to do but we often feel that we are not as good as other academics.” There was a feeling amongst some, they lacked the power and the authority to challenge, and having to work across many different agendas meant success was diluted or that some areas were not covered: “Leadership means having your eye on many balls and understanding many agendas. The successful Deans are those who are engaged in all (research, financial, corporate university). A few Deans can do this, but others are involved in some, but not all.”
Interpersonal Skills and Resilience Qualities embracing emotional intelligence, interpersonal skills, courage and tenacity were identified as important for nursing academic leaders. Interestingly these skills were seen to have been derived from, and learned during practice as a clinical nurse. They were acknowledged as invaluable and transferable to the role of a dean: “The skills are generalizable and transferable from one setting to the other. From a nursing background, [I bring] empathy (LEARNED) from a caring environment which brings something extra to HE. In addition, [I bring] communication skills from practice into HE and the ability to be intellectually critical.” Other qualities of leadership were described such as working with others and through others, being able to juggle with several things at once — “feet in many camps”, having resilience, “having common sense and being action/practically focused”.
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Pioneering and Breaking New Ground The notion of a leader as pioneer came out strongly and was seen as both about people “walking the talk and taking people with you” as breaking new ground. The early pioneers of nursing degrees were working at the top/elite end of university provision with small groups of students compared with today's mass system with annual intake of several hundred adult nursing branch students. Dealing with expansion of higher education and student numbers and the resulting organisational complexity was recognised as needing a different sort of leader, in that you can't do it alone and have to be in it for the long game: “You need to work together with others (e.g. Universities UK and Council of Deans). If you pioneer on your own you are a lone voice but with others behind you/with you your power increases and vulnerability decreases.”
Legitimacy of a Practice Discipline/Nursing in Higher Education The third and final theme that emerged from the data is the legitimacy of nursing as a practice discipline in universities. Whether or not nurses should have degrees has been disputed for over a century and can be traced back to 1901 and Mrs Bedford Fenwick, a nurse reformer. In establishing the degree in nursing at the University of Edinburgh 56 years later, Elsie Stephenson was challenging a “sacred cow” — the belief that nursing was purely a vocation, which does not need a degree. She believed that for nursing to grow it needed to be developed within the context of a university education. “what occupation more than nursing has allowed itself to be so routinised and thus allowed its enthusiastic young students to become dull, apathetic and subordinate?....it should today be a leader in the field of social science, instead it is fighting for recognition as a profession…to produce imagination, vision and thought, what better place than the university…..” (Allen, 1990, p. 111) Fifty years later this debate continues unabated, so much so, that the Royal College of Nursing commissioned a review of nurse education (Willis, 2012). However, there is, perhaps, a more worrying game being played out. In a shrinking economy where we have powerful employers wanting to reduce costs, they argue that degrees are not necessary, universities do not add value and it would be better and cheaper for nurses to be trained in hospital schools and learn on the job. As one post 1992 dean in this pilot stated: “With regard to the perception of the NHS to nursing education being in higher education, for the vast majority, they do not think nurses should be educated at university. In fact, there was discussion in this area related to local Trusts setting up their own “old style” school of nursing to run courses that they would get validated by our university.” Another dean, this time from a pre 1992 university elaborated: “It does not help that expectations of performance by newly qualified nurses are unrealistic. Medical students are not expected to be proficient when they qualify. They have a post-registration clinical career structure. Going back to “pioneering” — these are areas where pioneering is needed. Nursing needs to rethink its expectations of the newly qualified nurse and create a post-registration pathway like medics…”
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“Academic standards at university XXX are about grant income, completion rates of PhDs, number of doctoral fellowships funded externally and number of quality publications.”
“The university does not see nursing as being a legitimate part of an academic university. Universities are still male dominated institutions with deep-seated prejudice about nursing in universities.” Finally, it appears that deans in both pre and post 1992 universities were aware of the competing demands and contradictory values of the two cultures of higher education and the National Health Service, and described ways of navigating the different identities, demonstrating both depth and breadth of flexibility and resilience. Discussion Although this was a small study and a snap shot in time, it illuminates how nurse academic leaders make sense of their complex roles. The participants were generous with their time and frank in their responses to the open ended questions, which took a “conversational” form allowing for depth exploration of views. Only interviewing one participant from London, due to the competitive tender, may have been a limitation, although in our view reducing the possibility of a London centric bias can equally be seen as a strength. A large global city and the seat of government means that London has unique, often tense, political and commissioning relationships not found to the same extent elsewhere, which arguably could have swayed the findings. The findings from these interviews suggest a set of emerging ideas that will advance our understanding of academic nursing leadership as it manages the tensions of developing a practice based discipline within the university. As noted earlier there is a dearth of literature on nurse leaders in universities and therefore these findings provide some pointers for the future, both in the UK and internationally. The discussion focuses on two main areas. First there is the university as the institutional context for nurse leadership with its associated structures, hierarchies and mode of knowledge production. Secondly, and more importantly there is the interplay between the academic and professional identities as expressed through relationships with commissioners, employers and practitioners. These issues will be discussed in turn in relation to the data. The University as a Knowledge Producer Gibbons et al. (1994) have distinguished universities as producers of knowledge between Mode 1, defined by traditional scientific practice, unidisciplinary, formal structures based on authority and hierarchies, contrasted to Mode 2 knowledge, which is typically problem focused and is “legitimised by its utility in application” (Ternouth, 2012). The practice discipline of nursing seems to fit with the Mode 2 communities, which commonly crosses organisational boundaries and creates knowledge in partnership with the health service. Our findings show a clear difference between the experience of deans in pre 1992 universities, which could be said to display more Mode 1 characteristics compared with deans in post 1992, which on the whole may be more comfortable with applied knowledge, reflexivity and building employer relationships in the clinical setting. This is discussed further below in relation to identities. Academic and Professional Identities
While this debate is being played out in public, there are tensions within some universities as to whether it is “worth it” to have practice disciplines like nursing, which are seen as diluting academic esteem, research metrics and performance. As two deans in pre 1992 universities stated:
The second issue relates to the fundamental dichotomy between the university and practice, which sets up tensions between the dual identities (academic and professional) experienced by the nurse leaders, who feel they have a “foot in both camps”. The
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challenge of developing the personal academic identity for nurse educators has been described by Duffy (2012) and supports the wider higher education literature and is a good example of the expansion of academic identities as universities diversify and become involved in external relationships with employers (Whitchurch, 2012). As academic identities shift, it is not surprising if there are tensions and ambiguities reflected in the nursing discourse between the academic (theory) and clinical (practice). This ambiguity was seen through the uncertainty expressed by some deans about the future of university education for nursing. Some talked about the system getting smaller in response to NHS cuts in commissioning student numbers with the risk of universities disinvesting. Others talked about different sorts of risks to nursing in research intensive universities as the competition for resources grows and as the higher education sector continues to differentiate. On the other hand there was optimism expressed by those who had a wider vision for the future and wanted to refashion relationships with Trusts, build new partnerships for knowledge production, use evidence to lever change in practice and work across the boundaries of the health service and the university to shape innovative services for the future. This vision for engagement with the NHS will need “fast tracking” a development programme in practice, education and research, strengthening of clinical and academic pathways and developing new roles for clinical professors building applied research. There have been real advancements in academic nursing over the last fifteen years in education and research, but it is worrying that nursing as an academic discipline is not more secure in universities with threats from the NHS (nursing better taught in hospitals) and from some quarters of traditional and research intensive universities (nursing diluting research excellence). If academic nursing is to continue to flourish there are some important issues to confront. Firstly, this study suggests the place of nurse education within universities is contested and increasingly so. Nursing leaders need to face this head on and develop a collective narrative about the contribution that academic nursing is making to quality of care. As Florence Nightingale argued it is only through intelligent nursing that patients will get the best care. We believe the best nurses should be trained in the best places (university and in the clinical environment) where they can challenge, learn to think and shape solutions for the future. For this to happen academic nurse leaders have to have a foot firmly in both camps and effectively manage their dual identities to the benefit of the university and health care. Secondly there is a message here for universities. It is time that there was a proper valuing of nursing as a practice discipline within universities — and not just for the income derived from education contracts. Universities need to recognise the contribution of practice disciplines as a perfect fit with their agenda for civic and community engagement, as Wooldridge (2011) notes is increasing in prominence. Finally new types of leaders are needed to support research into practice, which will enhance health care and social capital. This will play to the strengths of those universities reaching into communities, building positive relationships with employers that demonstrate the value of mutual benefits of education, research and innovation to health communities and “clever cities”.
Contributors and Acknowledgements This paper is based on the Elsie Stephenson Memorial Lecture given by Professor Fiona Ross at Edinburgh University in March 2012. Di Marks Maran carried out the interviews and analysis. All authors contributed to interrogating the data in relation to the literature, provided insights to the analysis and were involved in drafting the paper.
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