Exploring the role of effective nurse leadership during COVID-19
Intended for healthcare professionals
Evidence and practice    

Exploring the role of effective nurse leadership during COVID-19

Barry Gerard Quinn Senior lecturer, Queen’s University Belfast, Belfast, Northern Ireland
Catherine McLaughlin Nurse, Queen’s University Belfast, Northern Ireland
Anna Bunting Nursing student, Queen’s University Belfast, Belfast, Northern Ireland
Lynsey McLaughlin Nurse, Queen’s University Belfast, Belfast, Northern Ireland
Susanna Scales Clinical lead, school of nursing, Derbyshire Healthcare NHS Foundation Trust, Derby, England
Stephanie Craig Nursing student, Queen’s University Belfast, Belfast, Northern Ireland
Shannon Copeland Nursing student, Queen’s University Belfast, Belfast, Northern Ireland

Why you should read this article:
  • To enhance your knowledge of the importance of leadership in nursing

  • To familiarise yourself with the pressures of leading during the COVID-19 pandemic

  • To develop your understanding of the role of communication in leadership

The role of leadership in nursing and healthcare is continuously being examined, and has undergone increasing public and media scrutiny due to the coronavirus disease 2019 (COVID-19) pandemic. This article details a project that brought together five final-year nursing students and two experienced nurses who had all worked as part of the early response to the pandemic. Meeting regularly online, the participants sought to explore the literature on nursing leadership as well as their own clinical experience and personal reflections of leadership during the pandemic.

This process, which took place over a period of four months, also enabled the participants to examine their own leadership style. Four themes emerged from the group discussions: learning about and building on the history of nursing, the participants’ role in nursing leadership, effective leadership during times of uncertainty and the role of communication in effective leadership.

Nursing Management. doi: 10.7748/nm.2021.e1984

Peer review

This article has been subject to external double-blind peer review and checked for plagiarism using automated software

Correspondence

barry.quinn@qub.ac.uk

Conflict of interest

None declared

Quinn BG, McLaughlin C, Bunting A et al (2021) Exploring the role of effective nurse leadership during COVID-19. Nursing Management. doi: 10.7748/nm.2021.e1984

Published online: 18 May 2021

The role of leadership in nursing is continuously being examined, and has been under scrutiny from the public and the media during the uncertainty caused by the coronavirus disease 2019 (COVID-19) pandemic (Charles 2021). As part of the UK-wide response to COVID-19, final-year nursing students have had the opportunity to be placed on a temporary register to practise as a nurse and support qualified nurses. In turn, this has exposed them to examples of nursing leadership during the pandemic.

Démeh and Rosengren (2015) recommended that nursing students should be introduced at an early stage of their training to the idea of leadership to prepare them for the reality of practice. That reality is of a caring profession but one that is experiencing increasing workload, tired colleagues and increasing nursing vacancies (Buchan et al 2019). A newly qualified nurse who has been supported and prepared to demonstrate qualities of leadership can play an important role in raising team morale and promoting partnership working (McKibben 2017).

Nursing students have previously reported that despite their training they felt unprepared to undertake a qualified nursing role, leaving them with low levels of confidence in both themselves and their competencies (Whitehead 2001). Others have reported that they do not consider leadership to be an essential skill on qualifying, and that there are occasions where leaders abuse their position to favour certain members of the team (Francis-Shama 2016). The experiences of newly qualified nurses and the increasing challenges experienced by the profession in retaining nurses show that more needs to be done to engage with nursing students and newly qualified nurses in terms of their leadership role (Ekstrom and Idvall 2015).

This article describes a project that explored the meaning of effective leadership during the uncertainty caused by COVID-19. It involved investigating the literature and engaging with the experiences of nursing students and qualified nurses. The idea for this work was developed during a series of coproduction workshops involving final-year nursing students, who had begun to explore the recurring theme of leadership during their exposure to practice. Amid the changes to nursing brought about by the COVID-19 pandemic, some nursing students reported witnessing strong and supportive leadership, while others described not feeling valued by leaders. Similar observations were reflected in a UK survey carried out among nurses by the Royal College of Nursing (RCN) (RCN 2020), which detailed how some nurses had chosen to leave a nursing role or the nursing profession because of the lack of support they had experienced.

Key points

  • As part of the response to COVID-19, final-year nursing students were asked to practise as qualified nurses, requiring them to demonstrate leadership skills

  • Many nursing students have reported, however, that they do not consider leadership to be an essential nursing skill

  • Communication is vital to effective leadership, as is an ability to remain approachable and support colleagues

  • It is important that health services engage with nursing students and newly qualified nurses to promote their role as leaders

Method

Participants

Final-year nursing students from the authors’ university were invited to state an expression of interest to collaborate and explore ideas concerning strong leadership amid uncertainty, with the idea of coproducing an article that could add to the existing literature on leadership. Five nursing students voluntarily came forward to take part in the project. Two of them described themselves as mature students who had worked in previous jobs before beginning their nursing studies and had children. The other three had commenced their nursing courses directly from secondary school and had no dependents. All were female, with an age range of 23-35 years.

In addition, two experienced nurses (one female, one male), each with over 30 years’ experience, were invited to be part of the group. One of these nurses worked with young people and families in a community service and the other worked in cancer and palliative care in the community and hospital settings. Both held senior leadership and management roles. Although one of these experienced nurses took a guiding role in the project, the focus was on the nurses and nursing students working together to coproduce an article that included any new insights and/or learning points.

Group working

Due to social distancing, the team met using an online platform every two weeks over a period of four months, from May to August 2020. The focus of the group meetings was to examine the existing literature on leadership and nursing, critically reflect on the ongoing changes in practice, share any personal observations about their experience of leadership, and critically explore and reflect on effective leadership and what might be required of nursing leaders in a modern healthcare service. One important component of the project was that each member of the group should examine their own role as emerging leaders. During this four-month period, the five nursing students and two nurses continued to support patients with COVID-19 in a range of health and social care trusts and services across Northern Ireland and England.

Literature search

Working together, the first step was for the group members to examine the existing literature on leadership. The group met to discuss the focus of the literature search. This included examining the literature on nursing and nursing leadership, nursing leadership during uncertain and challenging times, and the skills and qualities that enabled nurse leaders to be supportive and visible in times of stress.

The group members agreed to work in pairs to share the workload and to focus on these aspects of the literature. Since the five nursing students had recently completed a module on leadership they were able to return to this learning and present their insights on leadership styles and theories. This initial critique and review led to a further exploration of the literature, including an examination of the history of nursing leadership in uncertain times. The findings and themes from the literature were shared, examined and discussed each time the group met, and the members analysed the themes for commonalities and differences with a focus on how their findings related to leadership in practice during the COVID-19 pandemic.

Issues raised during group meetings

One of the first questions to emerge from the group meetings was what qualities make a nursing leader effective in uncertain times. This question was to remain a focus throughout the project. Previous surveys and literature had revealed that nurses, including newly qualified nurses, had at times demonstrated their frustration with suboptimal leadership and a lack of support by choosing to leave their positions, or in some cases leave the nursing profession altogether (Ekstrom and Idvall 2015, Quinn 2017, Buchan et al 2019, RCN 2020). With this insight in mind, the group members began to critically explore what factors constitute effective nursing leadership during a time of uncertainty.

An important part of each meeting involved the nursing students and nurses sharing reflections from their ongoing practice during the COVID-19 pandemic. As the seven participants were working in a variety of hospital and community settings, this provided an opportunity to explore commonalities and differences in their experiences of leadership in action.

Themes and discussion

Over the four-month period of group meetings and discussions, recurring themes began to emerge from the literature and the group discussions, namely: learning about and building on the history of nursing, the participants’ role in nursing leadership, effective leadership during times of uncertainty and the role of communication in effective leadership.

Learning about and building on the history of nursing

The literature review involved the group members exploring the history of nursing. This revealed that although the COVID-19 pandemic had involved rapid changes in the way nurses cared for patients, this was not the first time that nurses had been exposed to challenging and dangerous situations. During previous periods of uncertainty, two early nursing leader exemplars emerged. Mary Seacole, the daughter of a Jamaican healer, left home for Panama in 1851 to nurse those with cholera and later in her life travelled back to Jamaica to nurse those with yellow fever. Florence Nightingale, a daughter of the English nobility, travelled with nursing colleagues to Turkey in 1854 to care for soldiers injured during the Crimean War (Rafferty at al 1997). Both women and their colleagues left the safety of their homes to risk their lives in the service of others, thereby demonstrating leadership by their visibility and role modelling. These concepts of visibility and role modelling were to become central to the group’s exploration of effective leadership.

More recent examples of nursing leadership during uncertainty can be found in the nursing response to the severe acute respiratory syndrome (SARS) and Ebola outbreaks (Loeb et al 2004, Sagar 2015, Catton 2020). The group also reflected on more recent events in the UK, including nurses who responded to poisonings with the nerve agent Novichok in Salisbury in 2018, and those who experienced terrorist attacks in London in 2005 (Parish 2005, Jones-Berry 2018, Rubin et al 2020). In all of these challenging situations it was recognised that nursing leaders, including nursing students preparing to join the profession, had taken risks, left their families to work alongside colleagues, and adapted to uncertain, challenging and dangerous situations.

Through reflecting on these historic events, alongside their own personal and professional experience, the nursing students and nurses began to understand their own role in responding to COVID-19. They had become part of a history of nursing that involved individual nurses responding to those in need amid uncertain events. However, the group members also recognised that what distinguished the COVID-19 pandemic from previous events was the very public call for assistance from nursing and midwifery students, and a recognition of the vital role of those who were preparing to qualify. All five nursing students felt that the important input of nursing students was not always recognised or valued, with one stating:

‘I do not think that our nursing colleagues always see what new insights we can bring to a clinical situation.’

Both nursing students and nurses reflected on how their own life experience had enabled them to prepare for their roles in nursing. Whitehead et al (2013) estimated that approximately 60% of the nursing workforce comprised those new to the profession. The nursing student members of the group reflected on the vision, passion and commitment that they and other nursing students brought to the profession. The two mature nursing students felt that their previous experiences of challenging life events had contributed to their resilience and enabled them to reach out and support younger nursing students. While each nursing student discussed how they continued to learn from experienced colleagues in practice, conversely both nurses in the group discussed how they continued to learn from their student colleagues, reflecting findings from earlier literature (Xyrichis and Ream 2008). Overall, the nurses and nursing students in the group recognised and valued their part in the long history of nurses responding to urgent need in challenging circumstances.

Participants’ role in nursing leadership

The literature and the lived experience of the nurses and nursing students in the group demonstrated that effective leadership in nursing can be revealed through the individual interactions and encounters in everyday clinical practice, for example one person supporting another towards an agreed and valued goal (Quinn 2017, Ward 2020). This suggested a more inclusive approach to leadership, which is clearly articulated in recent Nursing and Midwifery Council (NMC) (2018) standards for education and in a global statement on the future of nursing and midwifery (World Health Organization 2016).

Reflecting on the literature and their own practice, the group members recognised that the question of what constitutes an effective nurse leader is not a new one, and that leadership approaches and styles continue to be debated. While some of the literature may suggest that leadership is an inherent skill that nurses may or may not possess, this contrasts with the concept that leadership skills can be developed through reflection and attainment, as evidenced by programmes such as the NHS Leadership Academy (NHS Leadership Academy 2013), or the NMC’s standards for education (NMC 2018). There was a consensus in the group that supporting leadership development among nursing students and those taking their first steps in the nursing profession was vital to the future of nursing care.

Unfortunately, there have been several high-profile cases in the UK that have demonstrated suboptimal nursing leadership, for example the reports of failures of care at the Mid Staffordshire NHS Foundation Trust (Francis 2013). In addition, some nursing behaviours, such as suboptimal communication and teamwork, can act as barriers to others’ participation in leadership (Daly et al 2014, RCN 2020) rather than supporting and encouraging those new to the profession.

An interesting discussion emerged among the group concerning how leadership was perceived as being closely associated with management, which in turn led to a discussion of who and what comprises a leader. Swanwick and McKimm (2011) suggested that while leadership involves inspiring individuals by setting a vision and direction, a manager’s responsibility is focused on directing people and resources in an attempt to achieve the goals laid out by the leader.

The group members recognised that while some of the skills required of managers are closely linked with leadership, there was a need to recognise the leadership capability and responsibility of individual nurses. Figures such as Martin Luther King or Mother Teresa, were not necessarily remembered for their ability to manage, but their ability to inspire others. While these leaders may not be renowned for their ability to manage, they will be remembered for their teachings about the commitment of visible leadership and courage. These leaders follow a long history of those who continue to be respected for their ability to show courage and lead by example, and for their selfless commitment to others. While an effective leader may not always be an effective manager, the group members agreed that an effective manager should always be able to display effective leadership skills.

The nursing students in the group explored their experience during the pandemic, moving the focus of the discussion away from management responsibilities and onto the role of every nurse, midwife and nursing student and how leadership forms part of their daily practice. When the nursing students began to reflect on their role in coming forward to support patients, families and colleagues during COVID-19, they began to recognise how they, in their own roles as leaders, had contributed to important changes during individual nursing encounters. In some cases, this had involved rethinking service development and delivery. Students were able to give examples of supporting family members who were unable to visit a parent through facilitating the use of technology and supporting rapid discharges home.

Reflecting on the work of renowned nursing leaders from the past, the group members found there were countless personal stories of nurses and nursing students who had recently stepped forward during challenging events. For example, one of the nursing students in the group recalled caring for an older frightened man:

‘He was an elderly gentleman who lived independently at home. Following a fall he lost his confidence, fearing he would fall again. He was very frightened of coming into contact with COVID-19. He felt isolated from his family and neighbours. We worked together and developed a plan of care, assuring him that he would walk again and get home.’

The nursing student was able to confirm that the man had returned home safely after two weeks in hospital, and the entire care episode encapsulated the nursing qualities of working together, person-centred care, compassion and responding to patients’ needs.

The process of recollecting these real-life examples from their own practice enabled the nurses and nursing students in the group to recognise their own leadership potential. The group members shared many similar accounts of ‘hidden’ leadership, including holding the hand of an anxious woman, taking time to make a cup of tea for a man who could not sleep, and supporting a fellow nursing student who was concerned about her elderly father at home. During times of uncertainty, these simple acts demonstrated examples of the group members’ commitment to lead and to care.

Effective leadership in times of uncertainty

Reflecting on the review of the literature, and of their experiences of leadership during the COVID-19 pandemic, the nursing students and nurses in the group agreed that an effective leader was someone who demonstrated empathy, not only to the person in need but also to other members of the team. One nursing student outlined recent circumstances that required leadership:

‘During the pandemic, information, guidance, policies and procedures were rapidly changing, staff were feeling confused about what was required of them while worrying about their families at home.’

In this case, the need for support, assurance and empathy from an effective leader was evident. However, other accounts from nursing students and nurses revealed examples of leaders who were absent, and appeared to spend much of the day in an office or at meetings.

Both the nurses and nursing students recognised that during the pandemic various leadership approaches and styles were required, for example: an autocratic leader who directed an emergency situation, a transactional leader who dealt with daily staffing shortages, and a leader who reassured staff that they would ‘come through the pandemic together’ as a team.

Both the literature and group members’ personal reflections led to an examination of the ‘servant leadership’ approach (Greenleaf 2015). According to this theory the leader is perceived as someone whose role is one of serving the team, and role modelling effective behaviour in practice (Quinn 2017). The nursing students felt that by adopting this approach they might achieve recognition and respect as leaders, even though they were not in management roles. By acting as servant leaders, both nurses and nursing students felt that they could reach out to those who needed to know that their voices were being heard and that their concerns are being addressed. One nursing student provided an example of servant leadership from her experience:

‘A daily briefing was held for the ward team, enabling the leader to update staff on any changes and to allow staff to voice questions or concerns.’

This type of leader was perceived as one who supported and nurtured colleagues during an uncertain time such as the COVID-19 pandemic. Similarly, the idea of a servant leader who demonstrated empathy was welcomed by the group members. Such leaders should also be able to show compassion, which is a quality that enables them to engage and connect with team members on an emotional level and with authenticity. During times of uncertainty, a compassionate servant leader can enable staff to feel that their concerns have been addressed (Quinn 2017). These qualities of empathy and compassion were seen by the nursing students and nurses as a means of promoting high-quality nursing practice and encouraging such leadership in others. The nursing students and nurses felt that the servant leader epitomised the concept of nursing as a whole. One nursing student stated that:

‘Those who truly serve may not have the noisiest voice, but perhaps displayed the loudest example of caring practice’.

Another nursing student referred to the poet and activist Maya Angelou, who stated that people may not remember the name of those who cared for them, nor the details of what was said or done, but they would remember how they were made to feel valued and heard. These were qualities that this nursing student aspired to in her care.

While recognising that various leadership approaches were required, the qualities of the servant leadership approach represented a leader who the nursing students and nurses wanted to emulate. Central to these qualities was the ability to communicate in a caring manner. For example, one nursing student recalled how a colleague managed to communicate their concerns about COVID-19:

‘There was an awareness that their own practice could expose themselves and those they loved to risk.’

Both nursing students and nurses agreed that an effective leader should be sensitive to the personal lives of those they led. One nursing student recalled an example from her recent practice:

‘The nurse leader demonstrated that they were available for support and advice. We were given longer breaks away from the ward to rest and relax, helping to enhance team morale and staff support.’

However, while both nursing students and the nurses in the group were committed to this type of leadership, the nurses described their own challenges in maintaining a servant leadership approach in practice, with the constant demands placed on them by their role.

Role of communication in effective leadership

Throughout the ongoing uncertainty and challenges brought about by the COVID-19 pandemic, it became apparent through nurses’ practice experience and through a recent RCN survey that communication was central to effective leadership (RCN 2020). For example, a lack of communication could lead staff or patients to believe they were not being cared for. Not being cared for included uncertainty about the risks of COVID-19 to themselves and their families; times where support, leadership and direction was not clear; and not being asked about their children and family situation.

Many nurses have previously expressed their frustration at not being heard or valued, or not being provided with clear instructions (Sohmen 2013, Quinn 2020, RCN 2020). This lack of communication can lead to a belief that those who lead and manage do not always care, leaving staff to feel they do not matter at a time of great uncertainty. The group members agreed that a lack of communication did not reflect the concept of person-centred care, which is the foundation of optimal health and social care (Manley and McCormack 2008, Gluyas 2015).

The nursing students and nurses in the group were able to give examples of not being cared for in their workplaces. One nursing student recalled how she sometimes felt like she was being ‘thrown to the wolves’, alluding to the fact that during the uncertainty of the COVID-19 pandemic she felt unsupported. However, the group members also stated that being thanked by a colleague at the end of the shift was a simple but powerful way of communicating recognition and that nurses valued each other’s work.

The nursing students explained that nursing during the current pandemic was stressful and that they were having to undertake their new nursing role against a backdrop of ongoing debates concerning the direction of the profession and the value of nursing students, recent pay negotiations, issues with staff retention and ongoing nursing vacancies. The nursing students recalled that some nurses they had worked with had reported feeling burnt out and exhausted. The nursing students were clear that their resilience alone was not enough and that a supportive team and a safe environment were required for them to function effectively.

Each of the group members recognised that for them to continue to demonstrate the empathy and support required of the effective servant leader they needed to care for themselves. This included taking time off, having opportunities to share with other students and colleagues, and supporting one another.

In addition, the group members had observed that leaders who demonstrated openness and an ability to receive support and to learn from others were regarded as more approachable by colleagues. These leaders were seen as being well-equipped to connect with and inspire team members by demonstrating a human side and developing their professional relationships. These observations were supported by studies of newly qualified nurses who reported that such leaders were more able to support nurses with the pressure of being new to the profession (Gerrish 2000, Kaihlanen et al 2013).

Communication was seen by the group members as an umbrella term possessing several dimensions. For example, communication could either contribute to positive and effective relationships and care episodes or represent a negative experience for nursing students, nurses and the people they were supporting. Simple acts such as paying attention to colleagues, asking colleagues how they were, and demonstrating approachability and a willingness to listen and learn were seen as important communication traits in an effective leader.

Strong and caring leaders were perceived by the nursing students as those who were able to recognise the needs of their team members. One nursing student described a strong and caring leader as one ‘who is mindful of our elderly parents and children at home, who we and our colleagues will return to after our shift’.

Overall, the nursing students and nurses reported feeling safe and supported by leaders who strived to understand their needs, who communicated concern, and who inspired them by being passionate about their role and about nursing care.

Conclusion

Effective leadership during periods of uncertainty such as the COVID-19 pandemic requires nurses to recognise their own role as a leader in clinical practice and in every encounter with a patient or colleague. Being an effective leader also requires individual nurses to acknowledge and celebrate the history of nursing as well as their place within it.

The nursing students and nurses who were part of this project concluded that the core of effective leadership is the ability to communicate with compassion and a willingness to serve.

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