Chief nurses: between a rock and a hard place

Linda Belardi speaks to former senior health department advisers to talk about leadership, policy and perceptions of the profession.

Questions of power and influence are central to the profession’s ability to persuade and advise governments, so how is nursing perceived in the upper echelons of politics and what does nursing need to do to be more influential?

Nursing Review spoke to former state and territory chief nursing and midwifery officers to reflect on their tenures as advisers to government.

Professor Ged Williams served as the Northern Territory’s principal nursing and midwifery adviser between 2000 and 2003 under both Country Liberal and Labor party territory governments.

He says the chief nurse is ultimately only one influence on a very complex health system with many competing and powerful interests.

“The chief nursing officer operates in a highly volatile, political environment with very complex agendas, personalities and lobby groups to manage, inform and where possible influence.”

He says the potential of the role is significant but can be limited by the professional bias or perceptions of senior health department executives who choose or choose not to engage with the Office of the Chief Nurse.

“If you have an executive team, particularly the director-general, who value nursing and the office of nursing then you’re in a really good position of influence. If you are not in that situation then you have to use your personal influencing skills to try and win that credibility and influence.”

One of the greatest barriers, he says, was having other senior executives within the department presuming to know the answers to key nursing questions.

“Ignorance is such a dangerous thing in politics, so you can get highly influential people – they might work in finance, human resources or some other part of the department, and they presume to be able to answer for nursing and sometimes they answer very wrongly. It’s like asking an engineer to answer for the Chief Medical Officer. It can be done but it is such a dangerous way in which to manage,” says Williams.

“I think people sometimes don’t respect the importance of the profession of nursing and how much information and wisdom can come from a well-informed nursing perspective.”

To overcome these barriers, political influence then often comes down to the personal influencing style of the chief nurse and their ability to develop strategic relationships with the power brokers: the director-general, the deputy director-general and key advisers to the health minister.

Dr Greg Rickard, who only last year stepped down from the role after eight years in the NT, agrees some members of the executive team take the role more seriously than others.

The personality of the health minister and the department chief executive would affect the way that the Office of the Chief Nurse was perceived and listened to, he says. “It was challenging at times to have a voice and to be heard, but with other health ministers there was an assumption that you had a very important role to play.”

But deeper than some of these attitudinal barriers, he says, the role was hampered by a structural governance problem that favoured financial and corporate efficiency over a clinical governance model. “There was a greater concern for corporate governance, and the contribution of the clinical team – both doctors and nurses – was not really acknowledged.”

However, there have been recent discussions within the department to establish a clinical governance body, which Rickard says will help to redress this imbalance and put the department’s focus back on patient outcomes and quality and safety.

While financial pressures were always a reality, Rickard says he was able to tap into health as a public and political priority to secure additional resources. These complex and political roles also require consistency of leadership to maintain the momentum beyond the electoral cycle, he says.

“Sometimes when the chief nurse is only there for a four- or six-year period they have only seen the political cycle once and they are unable to achieve some continuity with a number of health ministers and department executives.”

Engaging with the industrial and professional bodies to create a “concerted wall of action” irrespective of the political context is also critical, he says.

Competing and powerful interests

Upon commencing with the NSW Health Department in 2003, Professor Mary Chiarella says she learnt very quickly about the role’s potential but also some of its limitations.

While it is the role of the chief nurse to give the minister “frank and fearless advice”, it is up to the minister and the government to accept that advice and ultimately to implement policy, she says.

“The chief nurse is there to advise the minister with the best available evidence and in full knowledge of what the professional issues are, but the important thing that is often not understood is that the government doesn’t have to take that advice.

“The government might be getting advice from the chief nurse on one hand and the AMA on the other, and it might think that the advice of one is more salient than the other.”

But when the evidence and the political environment do align, a policy window opens up and the evidence supporting a particular policy platform becomes acceptable.

During her time as chief nurse, she says two significant policy windows opened up; the first was having the minister agree to establish a working group to implement publicly funded state homebirth services, and the second was to create nurse practitioner positions across NSW to address significant workforce issues in the state.

With a background in law, ethics and policy, Chiarella stepped into the position as the state’s second chief nursing officer, following Judith Meppam’s 12-year tenure. But she says her tenure was anything but typical. During her time, public inquiries into safety and quality care at Campbelltown and Camden hospitals dominated, and its contents filled the front pages of the state’s newspapers on a daily basis.

Chiarella reflects on her time as chief nurse as something akin to being a chief nurse during wartime. The media frenzy, misinformation and intense political pressure consumed the minister’s time and the political agenda. She says the media’s role in circulating misleading and inaccurate information was very destabilising for the public and the profession.

How the policy process works

On the use of evidence, Ged Williams says that while it is accepted and used to inform policy, there are many other influences that might discount evidence, especially people’s strongly held personal beliefs. “Evidence isn’t enough to convince them,” he says.

“One of my personal worries is that in management, people try to find the evidence that supports their hypothesis and when presented with evidence that is contrary to their idea, they will try anything to ignore it.”

For example, the US government’s reliance on false and overstated intelligence on Iraq’s weapons of mass destruction represents a form of political behaviour that is not uncommon elsewhere in government, he says.

Adjunct Professor Kathy Baker, who served as the NSW chief nurse between 2004 and 2006, agrees that political priorities or popular opinion can often overshadow evidence.

“I think policy is more likely to be evidence-based if the evidence is available and accessible at the time it is needed, if the evidence fits with the political vision or can be made to fit, and if the evidence points to actions for which the resources and infrastructure are available.”

Indeed, as has often been the case, not even support from the profession is a prerequisite for policy, especially when the political will of governments is strong, she says. For example, the heated and controversial debates over skill mix and the use of healthcare assistants have continued to pit governments against the profession.

This is why Baker says it is critical for the profession to be proactive in developing policy positions and solutions that are negotiated amongst nurses before change is forced on the profession from the outside.

Rickard says that while research does not often influence policy, when policy is evidence-based, it produces long-term results that survive long after the politics. “When policy is driven by personality or by a particular professional group – that is often not the best policy and overtime it withers away.”

Looking to the future

If nursing is to strengthen its political and policy voice, Chiarella says the profession needs to talk health not just nursing. “Fundamentally, governments are interested in nurses and midwives as a vehicle for delivering good healthcare, and we can either be part of the solution or part of the problem.

“If we are going to be part of the solution, then we need to develop key strategic health policy directions and provide solutions. That requires us to think critically and strategically from the nursing and midwifery perspective,” she says.

Rickard agrees. The profession needs to get better at thinking of the broader health picture if it wants to be noticed and listened to by governments. “Often the big issues like long-term health gain, developing capacity within the community and social capital are not the priority for health professionals and their membership-based organisations,” he says.

“But governments are looking to get the ‘biggest bang for the buck’ and we lose out because we are not thinking strategically about how we can address issues confronting the health system. We are still only interested in fostering our professional interests.”

In particular, Rickard points to the challenges of an ageing population and the strategic place of nurses to deliver key solutions.

“In the aged care sector, most nurses still see themselves in aged care facilities rather than supporting people in their own homes. And in acute care, we’re still coming to terms with the reality that 80 per cent of patients in hospitals are over the age of 65 but still nurses are very much focused on acute care interventions.”

Picking a side: inside or outside government?

Is it easier to influence and implement change inside or outside government? For Chiarella, change is most successful when both the political and professional forces inside and outside government are working together.

“You need really strong and united voices and policy direction on the outside, so that the people on the inside can respond and advise appropriately to government. The minister will be influenced by public opinion and the strength of the workforce.”

Williams says neither environment is more influential than the other.

“When working outside government, you have the ability to speak freely and openly in public and in the media but you have absolutely no control over the allocation of resources. On the inside, you are very constrained by protocol, who you can talk to and what you can say, but you have the ability to shift resources and to directly impact upon the system.”

Unity versus diversity

If nursing is to be influential with government does the profession need to speak with a single voice?

Williams says he contest the idea. He says what is really important here is leadership not consensus.

“Very good nursing leaders, just like very good political leaders, can pull together people with very diverse views and help them to come up with a consensus solution to a problem. If they can take that forward in a united way, withstanding the fact that not everyone will be happy with the final detail, then that’s the best we can ever hope for.

“But we have to be careful about always thinking that we should have one voice or one solution because diversity can be a good thing.”

Diversifying the views that a chief nurse is exposed to also helps to make for well-rounded and well-informed decision making.

This means not only canvassing the views of the well-organised and empowered nursing lobby groups but also nursing groups that don’t have a professional college or the resources to access government. “If you don’t widen your access to a broad range of perspectives, you run the risk of having a blinkered or out-of-touch perspective,” says Williams.

Strengthening the role

For Chiarella, nursing and midwifery is primarily a clinical role rather than a management role, and therefore, if the chief nursing and midwifery officer were to have an operational portfolio as well as the leadership of nursing and midwifery, it should be one that relates directly to the influence of nurses and midwives – which is why the clinical safety and quality portfolio would be so appropriate, whilst acknowledging the importance of a multi-disciplinary team.

“I think particularly in acute care, it is nurses and midwives who do hold the key to many safety and quality issues, and to have oversight of a major clinical issue such as safety and quality would be critical and more influential than just a pure advisory role. I would also argue that the reason that many nurses leave the profession is because of the clinical situations they find themselves in and concerns over patient care.”

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