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• To increase your awareness of district nurses’ views and experience of leadership
• To understand the need for greater visibility of district nurses in strategic level leadership roles
• To acknowledge that district nursing education needs to better prepare district nurses for strategic leadership roles
District nurses have a pivotal role in the NHS but lack visibility at executive board level. This narrative review of the literature aimed to describe what is known about leadership in district nursing and to better understand why district nurses need to be more visible in leadership roles at strategic level. A database search for qualitative studies generated only eight studies for inclusion in the review, which shows that the evidence on leadership in district nursing is limited. The findings show that district nurses have attributes which make them compassionate and transformational leaders, but that they need to increase the visibility of their profession and articulate its patient-focused vision. Investment in training is crucial to develop leadership within district nursing and in the NHS more widely.
Primary Health Care. doi: 10.7748/phc.2024.e1841
Peer reviewThis article has been subject to external double-blind peer review and checked for plagiarism using automated software
Correspondence Conflict of interestNone declared
Kelly H, Finlayson J, Halcro K (2024) District nurses as leaders within their profession and in the NHS: a narrative review. Primary Health Care. doi: 10.7748/phc.2024.e1841
Published online: 07 August 2024
Leadership can be described as a process that aims to develop a vision for the organisation, align people with that vision and motivate them to act with a view to achieving a common goal (Algahtani 2014). The NHS requires strong leadership across its services to withstand crises, overcome challenges and provide high quality care to the populations it serves.
One style of leadership championed in many areas of the NHS, but not yet fully realised, is transformational leadership (Lumbers 2018, Department of Health and Social Care 2022, Kok et al 2023). Under a transformational leader, staff work in collective harmony and there is equal appreciation for the skills and talents of all.
Working in healthcare presupposes a desire to work with others and to be caring, so compassion is an important value to hold and implement (West 2020). To reduce the levels of stress and distress that staff are exposed to and ensure patients receive high quality care requires a compassionate workplace culture, and compassionate leadership must become the predominant leadership style (de Zulueta 2020). Compassionate leaders prioritise staff well-being and promote staff development, problem resolution, delegation and autonomy (Bailey and West 2022). Transformational and compassionate styles of leadership are required to overcome resistance to change and transform services (Lumbers 2018).
Healthcare in the UK is continuously evolving and in the first decade of the 21st century there was a major policy shift from hospital-based to home-based care (Haycock-Stuart et al 2010), traditionally the domain of district nursing. District nurses are highly skilled and autonomous healthcare professionals who lead and coordinate teams of community nurses, healthcare support workers and support staff from voluntary organisations to provide complex care to patients and families in their homes (Royal College of Nursing (RCN) and Queen’s Nursing Institute (QNI) 2019). Without the skills, knowledge and leadership of district nurses, many people with long-term conditions or complex health issues would be unable to continue to live at home (QNI 2019, 2024). For example, advanced practitioners working in the community have been shown to have a crucial role in the effective management of adults with chronic kidney disease (McCrory et al 2018). In a survey of district nurse team leaders in the UK, the QNI (2024) noted that district nurses were responding to the increasing complexity of their work by developing more advanced nursing skills.
Nurse leaders can provide invaluable advice to executive boards regarding patient safety and care quality (Jones et al 2016, RCN 2024), but there is growing concern about unfilled nurse leader roles in the NHS (Cabral et al 2019), with a limited pool of talent and a limited appetite among nurses to take up these roles (Sessler Branden and Sharts-Hopko 2017). Maybin et al (2016) advocated for district nurse leaders to be more actively involved in service redesign and policymaking, while Bain (2015) argued that strategic leaders with a vision specific to district nursing practice are critical for the future of community nursing.
The aims of this narrative review of the literature were to describe what is known about leadership in district nursing, understand why district nurses need to be more visible in leadership roles at strategic level and determine how they may become so.
Searches were conducted in November 2023 on the Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE and ProQuest databases using the keywords ‘community nurs* or district nurs*’ and ‘lead* or leadership’. Box 1 shows the inclusion criteria. A total of 151 studies were located via the database searches. Following removal of duplicates, screening by title and abstract and assessing eligibility, eight studies remained for inclusion in the review. The reference lists of these eight articles were checked to identify other studies of interest, but none were found. The methodological quality of the eight studies was assessed using the Mixed Methods Appraisal Tool (MMAT) (Hong et al 2018). Table 1 gives an overview of the eight studies included in the review.
During the first decade of the 21st century there was a major policy shift from hospital-based to home-based care in the UK, for which the development of leadership roles in community nursing was recognised as crucial (Haycock-Stuart et al 2010). That shift was driven by the need to lower costs, decrease unscheduled hospital stays and improve patient care (Imison et al 2017).
The studies by Haycock-Stuart et al (2010) and Cameron et al (2012), published around that time, found that community nurses perceived themselves as invisible, but that strong leadership within their profession could help increase their visibility. However, there was a dearth of strategic leadership in community nursing, which senior nurses attributed to self-sabotage or blockage from within the profession. Community nurses viewed their leaders positively if they listened, consulted and explained before implementing change. Effective leaders were described as ‘having a vision’, but there was confusion about what the future of community nursing would be, signifying a lack of vision, while being patient-focused was considered evermore important (Haycock-Stuart et al 2010, Cameron et al 2012).
However, when participants in Cameron et al (2012) described their experiences of leadership, the examples they gave, such as low absences, low attrition, improvements in skill mix and improved team morale, related mostly to individual staff members or the team rather than to patients. In terms of leadership qualities, emphasis was placed on the need for leaders to establish strong personal working relationships with their teams, a characteristic described as ‘the team is a family’ (Cameron et al 2012).
Participants in Cameron et al (2012) found it difficult to distinguish between leadership and management, with only senior nurses able to distinguish between the two; these senior nurses also perceived leadership as transformational. In terms of barriers to effective leadership, senior nurses cited size and complexity of caseloads, staff shortages and lack of IT support. The pressure of heavy caseloads led senior nurses to perceive that their leadership role was considered an ‘add on’ to their other duties (Cameron et al 2012).
• District nurses possess desirable attributes for transformational and compassionate leadership within their profession and at a more strategic level
• To establish themselves as strategic leaders, district nurses need to change their view of themselves as an invisible profession
• District nurse leaders need to develop a vision and articulate a strategy that reflect their profession’s focus on patients
• Knowledge and skills regarding politics, government, lobbying and negotiation are relevant for nurse leaders at strategic level
In the study by Ali and Terry (2017), leading compassionately was found to be a central aspect of participants’ roles. All participants perceived that compassionate leadership was about finding a balance between kindness, honesty, consistency and the courage to challenge. They highlighted the need for compassionate leaders who ‘lead with their heads and their hearts’ and ensure that patients and families feel cared for, not merely treated.
Ali and Terry (2017) identified ten different leadership styles, one of which was distributional leadership, which is often adopted in schools and higher education institutions. Distributional leaders often operate across multiple sites, so this style requires consistency in leadership approach. Ali and Terry (2017) suggested that it would be challenging to implement distributional leadership in the NHS because current leaders lack the required consistency. Another style identified was gritty-authentic leadership, where the emphasis is on achieving goals and which often leads to staff’s needs being overlooked and reduced staff engagement. This contrasts with compassionate leadership and transformational leadership, where staff take priority (Bakker et al 2023).
Some participants in Dickson et al (2020) were in a team-leading role, which involved managing a team of an average of five staff and a caseload of approximately 96 patients. Others were in advanced practice roles, which meant they managed and coordinated care but did not manage a team, and adopted a shared leadership approach to co-manage a caseload of approximately 110 patients (Dickson et al 2020). Participants described their experiences of leading and coordinating teams of health and social care professionals as being like the ‘conductor of an orchestra’ and described managing patients’ care as navigating a path of complexity towards solutions in a range of health and social care issues (Dickson et al 2020). Participants also described the challenges of achieving a balance between the clinical and business parts of their role. Those in team-leading roles perceived the weight of clinical and management responsibilities as burdensome, which was not the case for those in advanced practice roles. There was evidence of directive leadership in some accounts of participants who felt the weight of responsibility (Dickson et al 2020).
In the UK there are various senior leadership development programmes, but few are bespoke to district nursing. The District Nurse Specialist Practitioner Qualification (DNSPQ) was created around 30 years ago to allow district nurses to obtain a recognised qualification demonstrating their ability to work at an advanced level of practice (UK Central Council for Nursing, Midwifery and Health Visiting 1994). DNSPQ training programmes are offered in 32 universities across the UK, with around 650 students enrolled in total (QNI 2023). The DNSPQ programme, which is viewed as transformational (Bliss and Dickson 2016, Marshall and Sprung 2023), enables district nurses to consolidate their skills so they can lead a team autonomously. However, there are ongoing concerns regarding central government funding of the programme (QNI 2023).
Some participants in Carlin and Chesters’ (2019) study did not think the DNSPQ programme had enough content on leadership, particularly leadership in district nursing, and suggested that further leadership training could be necessary. Nevertheless, all participants acknowledged the need for succession planning in district nursing and felt that the DNSPQ provided an effective way of achieving this (Carlin and Chesters 2019). In an evaluation of the DNSPQ programme, Green (2018) reported that analysis of interviews revealed certain aspects of leadership or leadership qualities. In addition, some participants said they had experienced an ‘I can do this’ moment during a module on developing leadership skills, while others felt they had developed their team management skills.
A national leadership training programme for district nurses in the Netherlands, the Ambassador Project, was implemented from 2013 to 2018 (the programme is no longer running). Box 2 provides an overview of the syllabus.
• Topic 1: personal leadership
• Topic 2: nursing leadership
• Topic 3: history of district nursing care
• Topic 4: trends in district nursing care
• Topic 5: healthcare finance
• Topic 6: strategy and communication
• Topic 7: politics and government
• Topic 8: lobbying and negotiation
(Adapted from Wolbers et al 2021)
Wolbers et al’s (2021) evaluation of the Ambassador Project found that the self-perceived leadership abilities of participants had increased as a result of the programme. Stakeholders, who included chairpersons and managers of home care organisations, hospital consultants and health insurers, confirmed that participants had developed courage, assertiveness, professional pride and confidence. District nurse participants had learned to represent district nursing at local, regional, organisational and societal levels and had become more able to translate policy into practice. In terms of blending their caring work with their ambassador role, participants’ views were mixed, with many still finding it challenging to identify and negotiate a satisfactory balance with their employers. Stakeholders recognised the pivotal role of district nurses in attracting and retaining newcomers to the profession, but that this part of their leadership role had not yet been realised. Some stakeholders recommended that district nurses themselves should raise awareness of the positive aspects of their profession.
Participants in Veldhuizen et al’s (2021) study, who had completed the Ambassador Project, explained that the coronavirus disease 2019 (COVID-19) pandemic had required them to provide strong leadership, but some noted that following the pandemic there was a return to old leadership structures, with a more authoritarian leadership style at senior level.
The findings of this narrative review provide rich insights into district nurses’ views and experiences of leadership. The review only included eight studies, which shows that evidence on leadership in district nursing is only starting to emerge.
District nursing appears to require and develop transformational and compassionate leaders who can ‘lead with their heads and their hearts’ (Ali and Terry 2017) and establish strong personal working relationships with their teams (Cameron et al 2012). The evidence suggests that district nurses possess desirable attributes for transformational and compassionate leadership, within their profession and at a more strategic level. However, for district nurses to establish themselves as strategic leaders they need to change their view of themselves as an invisible profession. It could be argued that this self-limiting belief is a form of self-sabotage (Haycock-Stuart et al 2010, Cameron et al 2012) and that district nurses need to do more to make themselves visible beyond the circles closest to their profession. Furthermore, district nurse leaders need to develop a vision and articulate a strategy that reflect their profession’s focus on patients.
Green (2018) showed that the DNSPQ training programme can instil a can-do attitude in district nurses and increase their confidence and assertiveness, while participants in the study by Carlin and Chesters (2019) highlighted the value of the programme for achieving succession planning, but pointed out that it did not include enough about leadership.
The Ambassador Project in the Netherlands was beneficial to district nurses, notably in terms of developing as leaders, translational mobilisation and building connections and influence beyond the profession (Wolbers et al 2021). There may be lessons for the UK from the Ambassador Project which included content on politics, government, lobbying and negotiation; knowledge of and skills in these areas are relevant for nurse leaders at strategic level (Clarke et al 2021).
The COVID-19 pandemic put the NHS under unprecedented levels of stress and nurse leaders were required to respond to it dynamically (Rosser et al 2020). However, as Veldhuizen et al (2021) showed, a return to previous hierarchical structures and more authoritarian leadership can occur in the aftermath of such crises. As Kline (2019) argued before the pandemic ‘command and control are deeply embedded in senior NHS leadership behaviours’. Hierarchical and managerial control are major threats to compassionate leadership and transformational leadership (Pattison and Corser 2023). A compassionate and transformational model of leadership in district nursing, within and beyond the profession, must be robust enough to withstand crises.
Based on the findings of the review, the authors suggest that:
• District nursing should foster the characteristics of compassionate leadership and transformational leadership.
• District nursing, and community nursing more widely, needs to become more visible in the NHS.
• District nurses need to articulate the patient-focused vision of their profession to communicate their professional identity to others.
• District nurses need to be equipped and feel empowered to take on strategic leadership roles.
• District nurses need to collaborate with lobbyists for their profession, notably the QNI, to promote the leadership roles they could take up in the NHS.
• District nursing education should include topics such as politics, government, lobbying and negotiation.
District nurses are compassionate and transformational leaders but need to articulate and promote their profession’s patient-focused vision. District nurses have a pivotal role in the NHS and therefore need to increase their visibility as potential nurse leaders at strategic level. District nursing education needs to better prepare district nurses to take on strategic leadership roles.
01 October 2024 / Vol 34 issue 5
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