The Leadership Practices of Nurses in the New Zealand Hospital Ward: A Focused Ethnography

At a time when healthcare is experiencing a global shortage of nurses, and safety culture permeates hospitals compounding the challenges in caring for patients, nurses are responding using nursing leadership practices to influence and lead each other, to protect nurses and nursing identity and respond to safety culture expectations.

Leadership is a social practice of influence. Nursing leadership has long been associated with the formal nursing roles within the profession. Through survey, interviews and case studies, leader-centric research has focused on nursing leaders, their styles, qualities, traits, and functions and has been associated with positive patient outcomes, reduced errors and nursing satisfaction and retention. Little is known about how nursing leadership practices occur in the hospital ward nursing team and the situations and context in which this happens. The purpose of this research was to describe and explore how nursing leadership practices were occurring in contemporary hospital wards in Aotearoa New Zealand. Through the lens of leadership-as-practice, this focused ethnography utilised 18 months of episodic fieldwork observations in four wards of a hospital, individual discussions with nurses, and a collection of artefacts. Qualitative analysis revealed the setting that was simultaneously complex and mundane and that nurses engaged in leadership practices in various moments. What nurses said about leadership varied from the activity and performance of leadership practices. Crucially leadership was not the sole practice of those named in formal roles. Informal leaders or those nurses without formal leadership titles led others.

This thesis describes distinct new understanding about collective nursing leadership practices at all levels of the nursing team. Being present, being alongside, being apart, and role-modelling and enabling followership were patterns of leading that emerged within the data. Safeguarding practices of leadership occurred in response to the safety conscious context which exposed nurses to vulnerabilities and perpetuated the leadership practices. These safeguarding practices anticipated, shielded, and protected patients and nurses. In turn, nurses adapted and developed resilient leadership practices to maintain wellbeing, and the identity of nurses and the nursing team so that both nurses and patients would be safe. Nursing leadership practices are visible at all levels of the nursing team in response to the hospital ward. These collective practices have implications for healthcare practice, for nursing education and the profession of nursing.