Whether under the official title of “nursing” or not, the profession of nursing has been present since the dawn of time. Ancient healers with experienced eyes roamed forests and habitats in search of herbs and provisions from the earth to cure their sick and tend to their ailing. These healers were respected members of their communities and were looked to for their wisdom and curative powers.
This lent these people by proxy leadership roles in their tribes, villages, and communities. The art of healing, especially in the West, changed dramatically at the dawn of scientific and now technology-based medical practice. Following this more male-oriented basis in science, much of the art of combining these herbs and elements into medicines became the work of doctors. From this point, the dominant leadership role of the nurse as primary healer shifted to physicians. Nurses then, who were mostly assistants to doctors and overwhelmingly female, were relegated to the role of helpers in the main quest for cures, but for patients requiring care and tending, nurses became integral members of the medical community and developed their own systems of theory and leadership for the profession. With an emphasis more on how the past shaped the present landscape of nursing leadership (rather than offering a straight detailed history of nursing) this paper seeks to explore the theoretical foundations of a leadership in a profession that requires extraordinary skills of adaptation and negotiation, among others.
One of the most famous nurses in history, Florence Nightingale, was convinced of the power of excellent leadership skills for nurses. As her teachings and insights on the profession so often shaped the discourse and educational principles for new nurses, it is fair to suggest that her thoughts on leadership carried through and affected several generations of nurses. In her book, Notes on Nursing, Nightingale devotes an entire chapter to what she terms, “Petty Management” which, despite the word “petty” in the title, is about rather significant matters. She states, “All results of good nursing, as detailed in these notes, may be spoiled or utterly negated by one defect; in petty management, or in other words, by not knowing how to manage that what you do when are there shall be done when you are there” (Nightingale, 1912, p. 35). While she is imparting this wisdom to existing nurse leaders, she goes to discuss several important ways nurses can fall short of the ability to self-manage and thus lose the ability to exercise self-leadership and also addresses the catastrophic this can have on other nurses. These words were written by Nightingale long before the advent of “leadership studies” (which itself is a relatively new phenomenon) but it contains many of the central elements that are held to be most vital to all persons in leadership roles and for these purposes, it should be recalled that every nurse is a leader.
Nurses, simply by fact that patients are reliant on them for the majority of their needs, are leaders by nature. They make critical decisions and evaluations for and with the patients, as well as in tandem with other medical and hospital staff and they work together, independently—guided by both their own skill, knowledge base, and personal leadership. Throughout the history of nursing, particularly as it became more organized into a profession, rather than the loosely-define trade that fell in the “domestic servant” category and “handywoman” arena where it remained until the mid 1800s (Dingwall, Rafferty and Webster, 1988). Before this time where nursing became a more structured profession that required demonstrated and proven knowledge of skills and credentials, nursing in this freelance capacity required its own set of leadership skills. Nursing at this early point was often something did within a private home and required great investigation ability as such women were to pull together the collected knowledge from books and other women. Furthermore, at times of war, women were conscripted and also volunteered to serve as battle nurses, which meant not only being in intense high-action settings and crowded, difficult to manage hospital wards that sometimes held as many men. Leadership ability, especially in the context of thinking and acting quickly, was of the utmost importance .
At the beginning of the 20th century well into the era of the Great Depression, due to a rapid increase in the numbers hospitals and new, experimental management styles, the role of nursing leadership shifted rather dramatically. Much of the change in nursing theory occurred parallel to a rise in practical management theory within nursing staff at hospitals. Instead of being more in charge of their own care-centered domains within a hospital setting, this new paradigm, called “scientific management” placed doctors at the top, followed by hierarchal list of nurses in management position order under him. Adrist, Nicholas and Wolf (2006) discuss how this change in management structure for nurses at hospitals was welcome among many because it finally offered them (as women) to have a chance to be upwardly mobile and experience professional advancement. Women could now strive toward greater positions within their hospitals and be given greater leadership roles, but those at the low end of the chain were often not allowed to apply their educational backgrounds and were relegated to tasks that did not allow them to become practiced. One negative consequence of this arrangement that emphasized doctors at the top followed by just one or two head nurses, was that it made many nurses “unable to gain control over access to patients, use of technology, or application of knowledge” (p. 310). As a hospital management style, this might have worked, but it quelled the voices and leadership abilities of many young nurses who spent the better part of their careers unable to demonstrate their leadership and other abilities.