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Higher level nursing: influencing care at all levels of the organisation

Eileen Padmore

In the previous article of this series (Padmore, 2000), the issue of higher level nursing was placed in context and competencies were discussed. In this article, the way in which higher level nurses can improve care is considered. This will involve empowering patients, undertaking research and applying evidence-based practice. In addition, there is a need for leadership and change management skills operating across boundaries such as those that exist between the traditional professional territories, and between primary and secondary care. In every aspect of the role, the focus must continue to be on the care of patients and communities.

The higher level nurse will need to possess a wide range of skills to optimise diabetes care. The Higher Level of Practice pilot standard (UKCC, 1999) emphasises the importance of:

  • Patient empowerment
  • Holistic assessment of individuals
  • Negotiation with patients
  • Ethical-based decision making
  • Using knowledge and expertise relevant to the area of practice.

These characteristics are remarkably similar to the key attributes of the ‘expert’ nurse as identified by Benner (1984) and Benner and Tanner (1996). According to the UKCC document, the work of the higher level nurse will focus on clients, patients and communities with the aim of maintaining health in the well person, as well as to recognise and treat disease. Thus, we may deduce that in order to achieve the best deal for individuals and communities, this nurse will need to make an impact at strategic, organisational and operational levels within the employing organisation and across other agency boundaries.

Skills profile of new role
Leadership and change management
The strategy document, Making a Difference (DoH, 1999a), reveals professional leadership as one of the key responsibilities of the proposed new nurse consultant. A health service circular (HSC 1999/217) for NHS executives on the establishment of nurse, midwife and health visitor consultant posts, further describes the need for ‘leadership and change management skills of the highest order’. The circular also advises against wider corporate or management responsibilities because they are likely to detract from the role (DoH, 1999b).

Leadership styles
There are many different leadership styles and definitions and much of the research has tended to focus on people appointed to high level positions, e.g. managers (Hosking, 1997). Therefore, the approach has tended to be top-down. This is clearly not the style envisaged by the DoH for the new nurse consultants. It would seem that a bottom-up approach — one that separates leadership processes from the leader — would produce practitioners who influence their fellows more than they are influenced by them (Gibb, 1969) and who consistently make effective contributions to social order (Hosking and Morley, 1985).

Hosking (1997) points out that organisational leadership has an entity that exists independently of the members of the organisation and is top-down. The bottom-up approach requires leaders to transform the organisation from within and calls for skills in social interaction. Barnard (1997) identifies the personal qualities required in a leader as: vitality and endurance; decisiveness; persuasiveness; responsibility; and intellectual capacity. Given that most higher level clinical nurses will be working within complex, bureaucratic organisations, these leadership traits and personal qualities will be essential to enable them to become change agents (as required by Making a Difference) to develop services that involve patients as active partners in their treatment (DoH, 1999a).

Knowledge and skills base
At operational level, the advanced practitioner will need a sound knowledge base with expert skills developed through experience of applying theory to practice and practice to theory. This will help to attain credibility with colleagues and patients, an essential precursor to effectiveness. There is also a responsibility to ensure practice is evidence-based and that research is used, undertaken and disseminated. The expert clinical nurse has the advantage over a newly qualified doctor of being able to synthesise hard data through the lens of practical experience.

A broad ‘teaching’ role
So how do advanced practitioners pass on their knowledge and skills to those from other disciplines or to less experienced nurses? In McGee’s (1998) view, it is via a broad teaching role, which encompasses both formal classroom education and interpersonal educational processes such as mentoring and coaching. In his book on quantum physics, Zukav (1979) describes an expert as someone who ‘dances’ with the student — there is no formal teaching but the student learns. This most closely resembles the role model approach that Benner (1984) found to be a particularly effective method of passing on expertise in her research with advanced clinical nurses.

Exposure to different settings
Many higher level nurses have a community/ hospital remit which gives them a unique overview of the healthcare context of the patient. The expert clinical nurse should not be tied to a department but allowed to move freely within the organisation and beyond. In this way such nurses become available and accessible to a range of professionals, patients, carers, teachers, employers and many others as a consultant in the field of expertise.

One of the social forces that preceded the development of areas of nursing specialisation was response to public interest and need. The social work model, which includes the concept of ‘community work’, is also quoted as a direction for specialisation (Peplau, 1965). This gives the opportunity to identify social issues of care which may involve political lobbying, usually through the medium of professional organisations. For example, diabetes specialist nurses (DSNs) recognised the need for pen injector needles to be available free on prescription. There was particular concern for the elderly and disabled whose only hope of self-injection was using certain pen injectors whose cost was prohibitive because of the needles. The cause was taken up by DSNs with other professionals and patients through the British Diabetic Association (BDA). Several years of lobbying Westminster have now been successful (BDA, 2000).

Impacting on the organisation
Communications and IT systems
In order to communicate and network efficiently at all levels of the organisation the higher level nurse will need to keep up to date with the use of the latest communications and information technology systems.  This will be particularly helpful at the tactical level of the organisation where face to face contact is not as frequent but close involvement is essential. Skilled use of medical and nursing databases is also needed to seek out the requisite evidence base for issues and priorities which need to be brought to the attention of middle managers.

Pathways of influence
In the key role of change agent, the higher level nurse will need to understand the power structure of the organisation. In the NHS, a structural analysis of power might identify the dominant group as doctors, the challenging force as managers and the repressed group as the workers. In the typology used by Foucault (1986), the higher level practitioner will come from the focal standpoint of the workers’ struggle against submission but will also be involved in resisting both exploitation at the organisational level and political domination at the strategic level.

There is currently contention in diabetes nursing about whether taking on management responsibilities enhances one’s ability to effect change. It would seem that there is a growing body of evidence to indicate that this is not the case and that power by virtue of position is not necessarily as influential as personal power that arises from having a vision and the passion to pursue it against the odds (Robbins, 1996). Burke (1986) relates this concept to the differences between management and leadership, stating as his central thesis that effectiveness in empowering others and thereby influencing change is considerably stronger in leaders than in managers. This theme is developed further by Wortman (1982) who sees leaders as being charismatic, inspiring, and flexible, with the skills to challenge others to accept change, take the initiative and take risks.

The tactical level
Several qualities will be needed by the expert clinical nurse to be effective at the tactical level of the organisation. These include excellent communication skills and the ability to prioritise issues, informing middle management constantly of the clinical implications of decision making.

An understanding of the driving forces behind management agendas will also be essential. In today’s political environment this is most likely to be the budget.

If the practitioner can address a key organisational agenda at the same time as the need for a change in practice at grass roots level, there is a greater likelihood of success. An example of this is the development of a patient education programme to reduce hospital bed days.

Strategic input
The greatest battle for resources takes place at the strategic level in the organisation. The higher level nurse will need to understand the driving forces behind policy decisions and have a sophisticated awareness of the multiplicity of overt and hidden agendas held by different pressure groups.

It may seem as though the language is that of audit, research, clinical effectiveness, clinical governance, efficiency and cost savings — to the exclusion of patient-centred care. At this level, the advanced practitioner will need to act as the patient’s watchdog and advocate within the organisation by using the clinical methodologies of audit and evidence-based practice, as well as the latest tools of technology.

There is a need to be passionate about clinical need and to communicate these convictions. Skilled networking tactics will be required.

Taking a national profile within the area of clinical expertise might help wield more power. Upper-level decision makers find it difficult to ignore the nurse who is publishing in leading journals, being invited to speak at national conferences and who gains credibility and respect in the wider field of health care.

In conclusion, the higher level nurse will need to be a sophisticated performer in many arenas while maintaining a clear focus on the needs of patients and communities.  In order to act as change agent on behalf of the ‘consumer’, the expert nurse will need ground level leadership skills of a high order.

There will need to be an understanding of the conflicting agendas of the various pressure groups within the organisation and an ability to network between these as well as between other organisations.

A sound research knowledge base is essential to inform care and achieve credibility with others and this needs to be grounded in experience and clinical practice.

It is unlikely that the higher level nurse will be successful in this role unless there is a strong passion for meeting the clinical needs of patients. This nursing expert will not merely provide care but will improve care: not the kind of care that is distinct from cure but one that subordinates cure to its domain.


Barnard C (1997) The Nature of Leadership  In: Grint K (ed) Leadership. Oxford University Press, Oxford
Benner P (1984) From Novice to Expert. Addison Wesley Publishing Company, Reading, Massachusetts
Benner P, Tanner C (1996) Expertise in Nursing Practice: Caring, Clinical Judgement and Ethics. Springer Publishing Company, New York
British Diabetic Association (2000) BDA wins pen needles battle. Balance 174 BDA, London
Burke WW (1986) Leadership as Empowering others.  In: Srivastva S (ed) Executive Power: How Executives Influence People and Organisations. Jossey-Bass, San Francisco: 51–7
Department of Health (1999a) Making a Difference. DoH, London
Department of Health (1999b) Nurse, Midwifery and Health Visitor Consultants (HSC 1999/217). DOH, London
Foucault M (1986) The Uses of Pleasure. (Translated by  Hurley R) Vintage Books, New York
Gibb C (1969) Leadership. In: Linzey G, Aronson E (eds) The Handbook of Social Psychology, 2nd edn Addison Wesley, Reading, MA
Hicks D (1999) Clinical practice is the starting point (letter). Journal of Diabetes Nursing 3(6):168
Hosking D (1997) Organizing Leadership and Skilful Process. In: Grint K (ed) Leadership. Oxford University Press, Oxford
Hosking D, Morley I (1985) Leadership and Organization, Processes of Influence, Negotiation and Exchange. Unpublished working paper. Warwick University
McGee P (1998) Advanced Practice in the UK. In: Castledine G and McGee P (eds) Advanced and Specialist Nursing Practice. Blackwell Science, Oxford
Padmore E (2000) Competency and context for the higher level nurse. Journal of Diabetes Nursing 4(2): 40–3
Peplau HE (1965) Specialisation in professional nursing. Nursing Science 3: 268–87
Robbins SP (1996) The Essentials of Organisational Behaviour. Prentice Hall, Upper Saddle River, NJ
United Kingdom Central Council (1999) A Higher Level of Practice. Pilot standard. UKCC, London
Wortman MS (1982) Strategic management and changing leader-follower roles. Journal of Applied Behavioural Science 18: 371–83
Zucav G (1979) The Dancing Wu Li Masters. Rider & Co, London

Further reading
Brykczynska G (1997) Caring: the Compassion and Wisdom of Nursing. Edward Arnold, London
Chinn PL, Kramer MK (1995) Theory and Nursing: A Systematic Approach (4th edn). Mosby, St Louis.
Edwards S (1998) Philosophical Issues in Nursing. Macmillan, London
Fawcett J (1995) Analysis and Evaluation of Theories of Nursing. FA Davis, Philadelphia
Gray G, Pratt R (1995) Scholarship in the Principles of Nursing. Churchill Livingstone, Edinburgh.
Grintk (1997) Leadership: Classical, Contemporary and Critical Approaches. Oxford University Press, Oxford
Marks-Maran D, Rose D (1997) Reconstructing Nursing Beyond Art and Science. Baillière Tindall, London
Rabindra N, Mendon AM (1998) Ethical Dimensions of Leadership. Sage Publications, London
Rodgers B, Knaff K (1993) Concept Development in Nursing. WB Saunders Co, Philadelphia
Rocchicciol J (1998) Clinical Leadership in Nursing. WB Saunders Co, Philadelphia
Stevens-Barnum B (1998) Nursing Theory: Analysis, Application, Evaluation (5th edn). Lippincott, Philadelphia

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