There are plenty of senior managers in occupational health. Many OH, safety and wellbeing services, some in very large organisations, are led by nurses. These are influential positions that make important contributions to the corporate culture and the employee reward package. But despite the number of OH nurses in senior roles, very few make it into executive director positions.
When the NHS was re-organised into semi-autonomous trusts in 1991, many nurse executive director (NEDs) posts were generated. This trend has continued with the need for executive nurse leadership in the new primary care trusts (PCTs) and especially foundation trusts. There are at least 500 executive nurse roles in the NHS, and these positions are held by nurses from all types of clinical backgrounds.
In the North West area alone, positions in hospital trusts are held by nurses from backgrounds ranging from midwifery and neo-natal care to community nursing (albeit health visiting, not OH). One NED’s background is in management consulting rather than hospital management, and the chief nurse of West Lothian Care Partnership has past experience in OH, although she is not an executive director.
These examples demonstrate that the absence of a hospital track record is not a barrier to joining the board of NHS hospital trusts, and that nurses from a community public health nursing background can compete for these posts (in addition to those in PCTs). Many NHS chief executives originated in nursing. Despite the pool of able OH nurse leaders, and the potential for all nurses to rise to the board of NHS employers, at present, there are no NHS NEDs from an OH background.
Beyond the NHS
Outside the NHS, the story is similar. Even in the largest OH organisations, nurses have not consistently been appointed to the UK leadership teams. Neither of the two biggest OH providers, Atos Healthcare and Capita, currently have a nurse on their UK management teams. Of course some providers are set up, owned and directed by OH nurses, but these are small companies by comparison.
In the NHS, there are likely to be many factors explaining why OH nurses have not risen to NED roles. The most ambitious nurses probably do not see OH as the best step on their race to the top, possibly because some managers may not see it as core NHS business.
OH nurses’ proficiency in managing health services and ‘outpatient’ clinics effectively and efficiently may not be recognised immediately. Other nurses will have been at least partly attracted to OH to get away from shift work and some of the most intense operational pressures, and so may not aspire to the most senior roles. The reasons in commercial OH provision are less easily explained, especially as there are numerous OH nurses who are directing their own businesses.
Despite the challenges, the opportunity clearly exists for OH nurses to take their seat on the board. The skills required differ from those needed to provide operational leadership. It is not always clear what attributes are important, and so which need to be developed by senior operational nurse managers and, more importantly, need to be presented clearly on application forms for NED posts.
There has been very little research into NED effectiveness. Most of what has been done has been carried out in the US, with little UK research. The nursing press is full of the personal opinions of past or present NEDs, and there is a steady flow of conferences where these opinions are shared. It is rarely clear on what basis the speaker or writer has reason to believe they are or were an effective executive.
A systematic review of NED effectiveness literature identified 24 studies published in the past 25 years.1 The quality of the design and data management in most of these studies has had significant flaws. However, a number of common themes do appear. Nine arose that appeared in studies in both the US and Europe, or in at least three distinct studies, and had appeared in one or more studies since 2000:
Powerful influential operator
Knowledge of nursing
Human management skills
Total organisation view, visionary
Collaborate effectively in multi-disciplinary teams
Providing nurses with the right tools and resources to do their jobs.
While researchers keep reporting these same nine themes, and OH nurses might use them as a starting point for personal development, more work is needed to clarify just how important they are. The most recent UK research from Sue Antrobus and Alison Kitson is now almost a decade old.2 While it considered effectiveness, it did not try to measure it or identify measures of it. The research pre-dates significant changes in OH nursing professionalism and health services provision, and the validity of these themes has not been tested with current NEDs. Current research is addressing these issues.
A quick glance at the themes shows that only one is specific to nursing. This is a prominent theme in American research, where it has been consistently ranked as the most important. This probably reflects subtle differences in the executive nurse role in the US. As NEDs have become more established in the UK over the past 15 years, there is emerging evidence that nursing knowledge has become far less important. The range of nursing specialisms from which the current populations of hospital directors are drawn illustrates this very well. The nurse executive director in Leeds, the largest hospital trust in England, has a background in community nursing.
Some of the themes have been more frequently reported than others. It is easy to understand why a nurse executive needs to be influential, visionary, collaborative, a good communicator, and a good people manager. With increasing competition in health services, including the NHS, the need for business astuteness seems relevant.
All these NED themes can and should be developed by OH nurses. Many are directly reflected in the RCN document Competencies: An integrated career and competency framework for occupational health nursing. For example, OH nurses should:
Develop and maintain communication with people on complex matters, issues and situations (Communication)
Develop a culture that improves quality (Quality management)
Work in partnership with others to develop, take forward and evaluate direction, policies and strategies (Collaborate effectively in multi-disciplinary teams).
Occupational health has operated for many years in a competitive market. Within the NHS, for example, OH managers are almost unique in having long experience of winning and managing true commercial contracts. With a trend towards increased competition in the NHS, this commercial awareness should be a distinguishing characteristic for OH leaders. OH has much greater interaction with human resources than any other nursing specialty, providing advice and influencing action. People management skills should be another distinguishing attribute.
OH nursing may not be seen by some as the fast track to executive roles, but this can change. More than most operational nurse managers, OH nurse leaders are well placed to practise their strategic influencing and network with key stakeholders. It is important that they draw attention to their transferable skills in CVs and applications for senior posts, giving prominence to leadership competencies.
The recent appointment of Dr Tony Stevens as medical director in Belfast should give encouragement to OH nurses aspiring to executive roles. Dr Stevens is an accredited specialist in occupational medicine, and was until recently consultant in OH and deputy medical director of the Royal Hospitals. He is now executive medical director of the Belfast Health and Social Care Trust. This is the largest trust in the UK, significantly larger than any in England, employing nearly 22,000 people (one in 30 of the total Northern Ireland workforce), and providing services for more than 340,000 people in Belfast and regional services to the whole of Northern Ireland.
Further research will clarify the key personal attributes of current nurse executives that are most relevant in 2007. There is already persuasive evidence of important attributes and the most effective OH nurse leaders will already be using and developing these, preparing themselves for executive roles. Sufficient examples exist to suggest there are no insurmountable obstacles in front of OH nurses aspiring to join the board.
Helen Kirk is a nurse consultant. She is a public governor and chair of the Board Appointments Committee of the UHSM NHS Foundation Trust. She has an honorary research contract with the Christie Hospital NHS Foundation Trust, where she is carrying out research into nurse executive director effectiveness. Kirk would be very pleased to hear from anyone who knows of nurse executive directors who have a background in OH nursing.
1 Kirk H Nurse executive director effectiveness: a systematic review of the literature. Journal of Nursing Management 2007 (in press)
2 Antrobus S, Kitson A. (2000) Nursing leadership: influencing and shaping health policy and nursing practice. Journal of Advanced Nursing 29 (3), 746-753