Leadership skills for the multi-tiered nursing team
Intended for healthcare professionals
Evidence and practice    

Leadership skills for the multi-tiered nursing team

Ali Richards Senior lecturer and programme lead, assistant practitioner programme, Institute of Health, University of Cumbria, Lancaster, England

Why you should read this article
  • To enhance your knowledge of the roles of nursing associate and assistant practitioner

  • To reflect on the leadership skills needed by various members of the multi-tiered nursing team

  • To improve your understanding of relational leadership styles, in particular compassionate leadership

In a challenging global healthcare climate, new workforce models are required to address the ongoing shortfall in the number of nurses. One way of addressing the workforce crisis in the NHS has been to introduce the roles of nursing associate and assistant practitioner, which are designed to support registered healthcare professionals in their work and ‘bridge the gap’ between registered professionals and support workers. This article examines the leadership skills required of nurses when seeking to embed these roles in practice, and the leadership skills assistant practitioners and nursing associates themselves need to take their place in the team. The author also discusses the need for nurses to adopt a relational leadership style, hone their delegation skills and foster a climate of psychological safety for their assistant practitioner and nursing associate colleagues.

Nursing Standard. doi: 10.7748/ns.2023.e12202

Peer review

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

@alirichards15

Correspondence

ali.richards@cumbria.ac.uk

Conflict of interest

None declared

Richards A (2023) Leadership skills for the multi-tiered nursing team. Nursing Standard. doi: 10.7748/ns.2023.e12202

Published online: 27 November 2023

Since 2010, reductions in spending on health and social care have contributed to significant shortfalls in the number of NHS staff. The nursing workforce has been particularly affected by the staffing crisis and there is a need to identify short and long-term strategies to improve nurse recruitment and retention (Ham 2023). Nurse shortages are a global issue: the World Health Organization (2020) has estimated that an extra six million nurses will be needed globally by 2030 to meet the demand for healthcare.

Nurses in England increasingly feel the pressure of working in a health system where there is a widespread decline in the standards of care (Ham 2023). In its 2022 shift survey, the Royal College of Nursing (RCN) invited nurses and midwives to share their experiences of the last time they were at work.

The survey, which received 20,325 responses, showed that only 25% of shifts had the required number of nurses on duty. Furthermore, only 28% of nurse respondents said that their clinical setting had the appropriate skill mix to manage patient care safely and effectively (RCN 2022).

One way the healthcare sector and UK government have sought to address the workforce crisis in the NHS is by introducing the roles of nursing associate and assistant practitioner (NHS Employers 2023), which are designed to support nurses in their work. Nursing associates and assistant practitioners can undertake more complex tasks than support workers – such as healthcare assistants, nursing assistants and maternity support workers – but do not have the same scope of practice and responsibilities as nurses (NHS England 2023a).

There is a need for leadership, both from nurses responsible for overseeing the practice of these members of the team and from nursing associates and assistant practitioners themselves. Effective leadership is required to embed these nursing roles in clinical practice and ensure that care quality and patient safety are maintained. This article discusses the specific leadership skills needed in the multi-tiered nursing team.

Nursing associates and assistant practitioners

Nursing associates exist only in England and are registered with the Nursing and Midwifery Council (NMC) (2023a), which oversees and regulates their education (NMC 2023b). Assistant practitioners exist across the UK and are not registered with a professional body but must adhere to standards set by Skills for Health, a not-for-profit organisation committed to the development of an improved and sustainable healthcare workforce in the UK (Institute for Apprenticeships and Technical Education 2023, NHS Employers 2023). Assistant practitioners can work in professions such as radiography, occupational therapy, physiotherapy and midwifery as well as in nursing.

Nursing associates and assistant practitioners undertake a two-year apprenticeship culminating in a foundation degree – or, in the case of assistant practitioners, a higher national diploma (HND) or national vocational qualification (NVQ) (Skills for Health 2015). The skills, knowledge and behaviours associated with each role are set by the Institute for Apprenticeships and Technical Education (2022, 2023) in collaboration with the NMC (for nursing associates) or Skills for Health (for assistant practitioners). Both roles are usually renumerated at Agenda for Change band 4 level, although there are examples of assistant practitioners on higher pay bands based on their education and experience.

Many trainee nursing associates are former healthcare assistants, and they undertake their apprenticeship in the setting where they were already working. Similarly, many trainee assistant practitioners already work in the NHS, for example as healthcare assistants, dietetic assistants or maternity support workers. The NHS Long Term Workforce Plan (NHS England 2023b) stated that if the aim of the NHS was to recruit and retain more support workers, then some provision needed to be made to ensure they would have career development opportunities. The nursing associate and assistant practitioner roles represent such opportunities.

According to Kessler and Nath (2019), the nursing associate and assistant practitioner roles complement each other. Nursing associates work in nursing whereas assistant practitioners can work in a range of professions, so nursing associates tend to have a wider knowledge of nursing. With additional training, nursing associates and assistant practitioners can go on to become nurses (NHS Employers 2023) and Kessler et al (2022) found that the nursing associate role represented a route for many healthcare organisations to recruit nurses internally.

At the time of writing, there were 4,600 nursing associates working in the NHS in England, with plans to increase their number to 64,000 by 2036-37 (NHS England 2023b). Figures detailing the number of assistant practitioners in the UK were not available, partly because the role is not registered.

Implementation of the nursing roles

The roles of nursing associate and assistant practitioner have been in place for some years and many employers consider them viable paths for support workers to develop their career and a means to widen the entry gate into nursing as a degree-only profession (Lucas et al 2021). However, the nursing associate and assistant practitioner roles have been criticised and the debate around apprenticeship routes into clinical practice is ongoing, with the recent announcement of an apprenticeship route into the medical profession (Ireland 2023).

In a study by Lucas et al (2021), 33 healthcare staff representing various disciplines gave their views on the implementation of the nursing associate role in an acute care setting. Respondents felt that the implementation of the role had been too rapid, poorly planned and not effectively communicated to the wider team. One specific limitation of the role identified by respondents was a lack of skills in intravenous (IV) medicines management. Nurse respondents also expressed concerns over the level of patient acuity that nursing associates would be able to manage (Lucas et al 2021). In a review of the literature on the nursing associate role since its implementation in England in 2017, Thurgate and Griggs (2023) found that some nursing associates felt a lack of respect from colleagues and that some nurses saw the role as a threat.

In a study of 19 nurses and assistant practitioners, Henshall et al (2018) found that some assistant practitioner roles were not clearly defined and that there was uncertainty regarding their accountability and purpose. While new nursing roles can enable managers to reorganise the way in which teams are structured – for example, freeing nurses to focus on care coordination – any blurring of boundaries between the different nursing roles can lead to confusion and hamper effective practice (Henshall et al 2018).

Organisations have chosen to implement the assistant practitioner role in a variety of ways (Kessler and Nath 2019). For example, assistant practitioners working in residential care settings can often administer medicines and act as shift leader under the direction of a nurse. However, in Kessler and Nath’s (2019) survey of the members of an assistant practitioner network, half of the 100 respondents stated that assistant practitioners could administer medicines while the other half stated that they could not.

Leadership skills for nurses in a multi-tiered team

Effective nurse leadership is essential for high-quality patient care and optimal patient outcomes, and it also contributes to workforce retention (Cummings et al 2021). Given the ongoing workforce crisis, it is crucial that nurses develop skills that enable them to take a leadership role in an evolving nursing team, which now often includes assistant practitioners and nursing associates as well as support workers.

Nurses in leadership positions need to understand the principles of skill mix and what tasks an assistant practitioner or nursing associate has the competence to undertake. They need to understand the scope of practice of assistant practitioners and nursing associates (Crevacore et al 2023). By role modelling the skills and behaviours required to provide compassionate care, nurses can contribute to create safe and effective workplaces (King’s Fund 2022, RCN 2022, British Medical Association 2023). By developing a positive work environment, nurses can support assistant practitioners and nursing associates to raise any concerns they may have, including if they think they are being given tasks they do not feel competent to undertake.

To manage a changing workforce and find viable alternatives to traditional ways of working, nurse leaders need to:

  • Adopt a relational leadership style.

  • Delegate appropriately.

  • Foster a climate of psychological safety.

Adopting a relational leadership style

Nurse leaders need to be able to manage the complex interrelationships between the various roles in the multi-tiered nursing team, enabling each team member to develop decision-making and assessment skills (Walker et al 2021). Relational leadership styles encompass compassionate, collective and transformational leadership, as well as authentic leadership (Cummings et al 2021, Pattison and Corser 2023). Nurses who adopt a relational leadership style can contribute to an environment where assistant practitioners and nursing associates flourish professionally (NMC 2018).

In relational leadership styles, the focus is on developing positive relationships between staff members to promote collaboration and effective communication, as opposed to top-down leadership styles where the leader gives orders that are carried out unquestioningly – and often without scrutiny (Maritsa et al 2022). Cummings et al (2021) stated that the main aims of modern nurse leaders were optimal staff health and well-being, productive relationships between staff members, high productivity and a caring environment, and a relational leadership style is essential to achieve these aims.

Delegating appropriately

One of the main questions is how nurses can delegate tasks to nursing associates and assistant practitioners so that they can, in turn, contribute to patient care safely and effectively. The ability to delegate appropriately is a primary skill for nurses, particularly in the multi-tiered team with its mix of roles. As such, it is vital for nurses to learn the skills that underpin effective delegation, which include communication, critical thinking, prioritisation and decision-making.

When leading a team comprising a variety of staff, such as assistant practitioners and nursing associates, nurses’ relationships with these team members are central to effective delegation (Shore et al 2022). Delegating requires a culture of trust between the person who delegates and the staff members who are delegated to (Walker et al 2021, Shore et al 2022). It requires nurses to promote openness by clearly communicating their care decisions to the team members that care tasks are delegated to (Walker et al 2021). Similarly, it is important that staff members who are delegated to have a clear idea of their role, responsibilities and scope of practice (Crevacore et al 2023).

There is some evidence that delegating is something newly registered nurses can find challenging and often feel ill-prepared for (Clarke 2021). A newly registered nurse may therefore adopt a delegation style that is not conducive to effective team working – such as the ‘do-it-all’ nurse who completes most of the work themselves or the ‘inspector’ who constantly checks the work of others (Magnusson et al 2017). Skills in delegation can be acquired through observing colleagues in clinical practice and through ongoing training and education. Nurse educators have an important role in ensuring that nurses work on leadership skills such as communication, critical thinking and decision-making as part of their continuing professional development.

Fostering a climate of psychological safety

Alongside adopting a relational leadership style and delegating appropriately, nurses also need to focus on creating an atmosphere of psychological safety. The concept of psychological safety is based on the theory that teams and organisations should operate in an open and inclusive climate where each staff member feels comfortable asking questions and voicing any ideas and concerns (Jamal et al 2023). Studies into clinical error reporting have suggested that teams with leaders who develop positive relationships, expectations of excellence and supportive leadership styles also have high levels of adverse incident reporting (Nembhard and Edmondson 2006, Wawersik and Palaganas 2022). Enabling staff members to ‘speak up’ and feel that they will not be blamed for reporting near misses or errors is essential to the provision of safe and effective care.

Key points

  • The roles of nursing associate and assistant practitioner are meant to help address staff shortages and ‘bridge the gap’ between registered professionals and support workers

  • Nurses need to develop the skills to take a leadership role in a team that may include assistant practitioners and nursing associates

  • In a multi-tiered nursing team, nurses need to adopt a relational leadership style, be able to delegate and foster a climate of psychological safety

  • Assistant practitioners and nursing associates need to develop the skills to delegate to other staff and contribute to optimal relationships within the team

  • Compassionate leadership supports the main functions of assistant practitioners and nursing associates within the team

There is also evidence that fostering a climate of psychological safety at work prevents nurses from developing burnout and thereby leads to increased patient safety. Preventing burnout and increasing staff satisfaction are further important components in the effective leadership of a multi-tiered nursing team (Sherf et al 2021).

The fundamental components of psychological safety are set out in Table 1.

Table 1.

Fundamental components of psychological safety

ComponentContributory factors
Leadership component
  • Positive relationships at work, including effective peer support

  • Relational leadership style

  • Clarity regarding the role of different staff members

  • Supportive work environment, including information sharing and continuous learning

  • Performance at work, promoting job satisfaction and thereby improving performance and commitment

Organisational and management component
  • Open, positive relationships with staff

  • Visible senior leadership team in the organisation

  • Clear scope of practice and job descriptions for staff

  • Optimal skill mix

  • Policies and systems that foster staff learning

  • Events where learning is shared

  • High rates of adverse incident reporting and learning from these

  • Feedback on adverse incidents as learning opportunities rather than blame

  • Low rates of never events

  • Low rates of sickness and high rates of staff retention

(Adapted from Frazier et al 2017)

Leadership skills for assistant practitioners and nursing associates

Like nurses, assistant practitioners and nursing associates are required to demonstrate leadership skills such as role modelling, coaching, mentoring and teaching, since it will be part of their role to supervise and delegate to staff members such as support workers or nursing students. During the two-year apprenticeship trainee assistant practitioners and trainee nursing associates undertake, leadership is one of the standards set by the Institute for Apprenticeships and Technical Education (2022, 2023). Addressing leadership in these roles is a fundamental part of their respective training programme, as is understanding how these nursing roles function in relation to nurses, patients and the wider multidisciplinary team.

‘Team care’

Monitoring the performance of other staff such as support workers and nursing students is a central aspect of leadership expected from assistant practitioners and nursing associates. Both roles have to oversee and deliver high-quality care for patients, which Pattison and Corser (2023) noted is a challenge for anyone in a leadership position at any level.

Assistant practitioners and nursing associates can also assist in the development of a nursing team where optimal relationships between staff are fostered through the sharing of information and experience, contributing to a culture of learning and development. This ability to develop relationships is another standard of apprenticeship training for assistant practitioners and nursing associates, with both roles expected to share their learning and experience with colleagues.

For example, an assistant practitioner working in a stroke ward may have learnt how to undertake a swallow assessment and have been judged by a nurse as competent in this task. They would then be expected to share this knowledge with support workers and nursing students, who in turn would have their competency assessed by a nurse.

These attributes all form part of what Fox et al (2023) called ‘team care’.

Compassionate leadership

Following their training, assistant practitioners and nursing associates would be expected to understand the various styles of leadership and consider which one is best suited to their role in the team. For example, if nurses have adopted a relational leadership style, assistant practitioners and nursing associates should be able to align with that style to contribute to the development of a cohesive team.

Compassionate leadership, which is one style of relational leadership, has four primary elements: attending, understanding, empathising and helping. These core elements of compassionate leadership support the main functions of the assistant practitioner and nursing associate role, such as applying the fundamentals of care, supporting other staff, and delegating in a clear and considered way (West 2021). By following the principles of compassionate leadership, assistant practitioners and nursing associates can contribute to the overall efficiency of the nursing team.

Table 2 details the core elements and principles of compassionate leadership and how these relate to the associate practitioner and nursing associate roles.

Table 2.

Core elements and principles of compassionate leadership and how these relate to the associate practitioner and nursing associate role

ElementPrincipleRole of assistant practitioners and nursing assistantsIn-practice example
AttendingBeing present – taking time to listen
  • Making sure there is time and space for listening

  • Using effective communication skills

  • Noticing issues such as a colleague or patient in distress

In the case of a support worker who needs to ‘offload’ about a challenging situation, the leader would give them an opportunity to be heard by taking them to a quiet space where they could discuss the support worker’s concerns without pressure
UnderstandingAppraising situations – engaging in an open dialogue and avoiding imposing one’s own understanding of events
  • Considering events from every angle and taking into account colleagues’ and patients’ points of view

  • Avoiding judging others or blame

In the case of a care home resident who is keen to walk the grounds and becomes distressed when prevented to do so, the leader would take time to consider the resident’s circumstances, background, usual routines, and general mental and physical health
EmpathisingUnderstanding other people’s perspective
  • Ensuring that any conversation with a colleague or patient is paraphrased and reflected back to them to check understanding before proceeding with any action

  • Using a calm tone of voice and non-verbal communication such as reassuring touch where appropriate

In the case of a support worker with personal issues at home, the leader would express concern, demonstrate sensitivity to the situation and show respect by providing space for the support worker to discuss their concerns
HelpingTaking considered action to remove obstacles to care and meeting the needs of others
  • Using problem-solving strategies and being prepared to escalate any concern

  • Adopting a flexible attitude to care delivery and the ability to adapt ways of working

In the case of a support worker who is overwhelmed by providing one-to-one care to a patient showing distressed behaviour that the support worker finds challenging, the leader would consider moving the support worker to another task and relieving them of the pressure they are experiencing

(Adapted from West 2021)

Conclusion

Providing competent leadership when working as part of a multi-tiered nursing team is vital to providing safe and effective care for patients. By combining a relational leadership style with clear decision-making and appropriate delegation, nurses can contribute to a culture of psychological safety at work and nursing associates and associate practitioners can take their place in the team and care for the staff members they delegate to. Experienced nurse leaders who focus on relationships and on developing a caring team will contribute to reducing burnout and stress among team members, which will assist in promoting positive patient outcomes and staff retention.

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