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«The ideal attributes of Chief Nurses in Europe: A Delphi Study for WHO:Europe Project commissioned by Ainna Fawcett-Henesy Regional Advisor Health ...»

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The ideal

attributes of Chief

Nurses in Europe:

A Delphi Study

for WHO:Europe

Project commissioned by

Ainna Fawcett-Henesy

Regional Advisor

Health Systems Organization and Management

Unit Head, Health Systems Policies

WHO Regional Office for Europe



Advancing the role of the Chief Nurse in member countries of WHO: Europe

will necessitate the systematic selection and recruitment of suitable postholders, together with a critical pathway for development both of new recruits and existing personnel. To inform this process, it is essential that the attributes considered to be important in a Chief Nurse are identified. To this end, a Delphi study was initially undertaken of 22 member states. Consensus was reached by the second round, in which 12 countries participated. Sixteen qualities were deemed to be important and these are listed in rank order


1. Communication 9. Decision-making/problem solving

2. Team-working 10. Personal qualities

3. Strategic thinking 11. Promotion of nursing

4. Professional credibility 12. Good management

5. Leadership 13.5 Conflict resolution

6. Political astuteness 13.5 Information handling

7. Decency/integrity 15. Research skills

8. Innovation 16. Physical characteristics Of the 9 countries for which statistical analysis of the degree of agreement was possible, 8 demonstrated a significant level of accord (Belgium, Denmark, Netherlands, England, Iceland, Sweden, Hungary and Switzerland), with only Finland showing no intra-country accord.

The qualities identified can be used to inform the future development of the Chief Nurse role in Europe.

Keywords NURSE ADMINISTRATORS – standards



EUROPE © World Health Organization – 2001 All rights in this document are reserved by the WHO Regional Office for Europe. The document may nevertheless be freely reviewed, abstracted, reproduced or translated into any other language (but not for sale or for use in conjunction with commercial purposes) provided that full acknowledgement is given to the source. For the use of the WHO emblem, permission must be sought from the WHO Regional Office. Any translation should include the words: The translator of this document is responsible for the accuracy of the translation. The Regional Office would appreciate receiving three copies of any translation. Any views expressed by named authors are solely the responsibility of those authors.

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Page Background

The Delphi Technique

Anonymity of response


Obtaining large data sets

Validity of the technique

Sampling criteria

Sample size

Validity of results

Reducing bias









Annex 1

Background Several World Health Assembly resolutions have urged its Member States to “encourage and support the appointment of nursing/midwifery personnel to senior leadership and management positions to facilitate their participation in the planning and implementation of their countries health activities”. (Tornquist, 1997 p82)1 Furthermore, “Member states have (also) been urged to strengthen managerial and leadership capabilities and reinforce the position of nursing and midwifery personnel in all health care settings”1 (ibid p2) Despite this, few countries in Europe have nurses playing a full part in making policy decisions at all levels of the health services and many nurses believe that they have to continually fight to have their voices heard. Nearly all countries find it difficult to ensure that nursing issues are taken seriously (Tornquist, 1997).

One means by which the nursing profession can make itself more prominent is through having representation on the most senior government bodies.

For example, many governments appoint chief nurses to their Ministries of Health. A number of countries in Europe (for example Belgium, Denmark, Iceland, Turkey, Portugal, the Netherlands and the UK) have actually established the Chief Nurse’s position as a formally recognized role.

These nurses advise on nursing and midwifery issues and frequently carry out a range of other functions. Their roles are, however, diverse and may include working in a nursing or human resources or education department;

similarly, they may work full, or part-time and they may have a very large budget, or none at all. Not only does there appear to be no standard practice between countries, but moreover, the picture changes frequently.

Tornquist (1997) notes that in some countries the government does not Tornquist, E. (Editor) 1997. Nursing Practice Around the World. WHO/HDP/Nur-Mid/97.5 Geneva: Nursing/Midwifery Health Systems Development Programme.

see policy-making as an appropriate nursing role and in others the role is limited to providing advice on nursing issues only. Nevertheless the nurses themselves are beginning to demand a much more active policy role.

In order to capture a snapshot of the current position with regard to both nursing representation at senior and government levels in Europe, as well as the development of nursing care and midwifery nationally, the Ministry of Social Affairs and Health in Finland and the Regional Office for Europe of the World Health Organization conducted a survey early in 1999 (Ministry of Social Affairs and Health, 1999). The questionnaire was sent to all 51 Member States of the World Health Organization European Region and twenty-seven countries responded. The questionnaire had a number of sections. Of particular relevance to this Delphi study was the section on nursing management. Questions in this part referred to the existence of a nurse manager’s post, the nurse manager’s involvement in the decision-making process, the nurse manager’s independent decisionmaking power and the existence of a national strategy for the promotion of nursing development.

Overall, the results suggested that seventeen of the 28 countries had a nurse manager’s post at central government level. In 11 countries these nurse managers are involved in decision-making as the head of nursing units in Central Government. In 13 countries, the nursing managers have independent decision-making power at central government level about nursing services, and in seven countries they have responsibility for personnel; seven other countries claimed that they had no independent decision-making power. Generally, nurses at this level also claim that they have few opportunities to make a contribution about other health service policy or economic administration.

The data also demonstrated geopolitical variations. For example, the senior nurses in the governments of the countries of Central and Eastern Europe (CCEE) have very different roles in the national policy decisions.

In 1997, Hungary instituted a new ministry of nursing department with 11 staff, responsible for all nursing affairs except education. The Ministry of Education covered the latter. Hungary’s Nursing Department was the second largest Ministry Nursing Department in Europe (Tornquist, 1997).

Furthermore, at the time of the survey, the Newly Independent States (NIS) did not acknowledge that nurses had a legitimate role in policymaking or management. There were few recognized nurse leaders and very few formal educational opportunities for senior nurses. They appeared to lack professional knowledge and had few skills in management and leadership. This limited their ability both to contribute to policies that changed or modified the health system and to develop nursing care.

Despite this, in some of the NIS countries the Ministers and the nurses themselves recognized the need to have nurses in policy-making positions.

Further geopolitical variations in the policy-making role of nurses were found in the countries of Western Europe. In some countries, for example the UK, nurses were actively involved and took the lead in policymaking about the nursing profession. In others e.g. France and Italy, nurses only had a consultative function. In Austria, Germany, Italy, Malta, Norway, Sweden, Switzerland and elsewhere, the nursing function at ministry level was limited. Some of the reasons for this include nurses being dispersed through different directorates; the federal government structure which diminishes the role of nurses at the centre; and the perception that nursing is simply not seen as important enough to be represented.

Clearly, the picture of leadership in nursing throughout Europe is a disparate one, founded on multiple understandings of the role of senior nurses and their impact on policy and practice. If nursing, as a profession, is to be advanced and developed systematically in an international context, then it would be useful to have a shared perception of the role of government senior nurses in Europe and the attributes that are required of such a post-holder. Moreover, this information could be used to create a critical pathway for development of Chief Nurses across Europe. To this end, a Delphi study was undertaken to collect views of salient stakeholders in European member states, in order to arrive at a consensus position regarding the most important qualities for Chief Nurse posts. The results of this study can then be used to guide and inform subsequent critical pathway development.

The Delphi Technique The aim of the Delphi Technique is to arrive at agreement amongst experts within a particular field of research, using a systematic tiered approach to gathering opinion. It is defined by Bowles (1999) as;

‘a multiple iteration survey technique that enables anonymous, systematic refinement of expert opinion, with the aim of arriving at a combined or consensual position’ (p32) The method has been adapted and varied since its inception in the 1950s,

but all variants on the approach have the following features in common:

A panel of experts is used as the respondents · Exercises are conducted in writing, using sequential questionnaires · There is an attempt to reach a consensus of opinion · The respondents’ identities and their statements are guaranteed · anonymity There is use of iteration and controlled anonymous feedback · Agreement is sought using a series of rounds of questionnaire · distribution; each round presents a summary of previous findings to the experts for their comment.

(Beretta, 1996) Although the technique has undergone numerous transformations, the basic principles of the procedure remain the same. Experts in an identified field are sent a survey form which invites their opinions on a given topic. The comments on the returned forms are distilled by the researcher to a list of the most frequently expressed themes. These are then sent back to the original respondents, asking them to express their level of agreement with these themes. The responses from this round are further distilled and returned to the sample, in successive iterations, until consensus has been achieved within the panel of experts.

Its use within health care research has been extensive (see Bowles, 1999;

Crisp et al, 1999; Williams and Webb, 1994; Jones and Hunter, 1995), since it is a particularly appropriate means of capturing expert opinion to inform policy and decision making in areas where insufficient information or empirical data are available. Moreover, the Delphi method has the capacity to motivate respondents to promote change through what has been termed ‘catalytic validity’ (Bowles, 1999).

Of particular relevance to the present study are those Delphi studies that have sought to establish essential characteristics of the roles of groups of health care professionals. The following are some examples of

its use in this way:

Kirk et al (1997) - the changing role of the nurse teacher following · the implementation of Project 2000 in the UK Sentell and Finstuen (1998) – a forecast of leadership skills and · associated competencies of naval hospital administrators in the USA Novak (1998) – the core competencies of the role of the nurse case · manager in the USA Macdonald et al (2000) – the requirements for occupational · medicine training in Europe White and Wilkes (1999) - the role of the specialist breast care · nurse in Australia.

The research noted above demonstrates not only the viability of the Delphi technique for establishing core attributes for various occupational roles in the health care domain, but also its international applicability. For these reasons it was deemed to be the most appropriate methodology for collating expert opinion on the most salient competencies required of Chief Nurses in European countries.

The acknowledged advantages of the Delphi technique are as follows:

Anonymity of response While the outcomes of other consensus methods, such as focus groups, can be distorted by the influence of a single, powerful, vociferous individual on group opinion, the Delphi method is conducted anonymously by post. This affords respondents the opportunity to present their views without inhibition, pressure or intra-group conflict. The range of languages of the experts used in the present study would have precluded the use of other group consensus methods.

Cost Because the Delphi uses postal questionnaires, no interviewers or meetings are required and no travelling is involved; hence it is a low-cost methodology. In this regard, it has the advantage over other consensus methods. The European perspective essential to the current study would have incurred significant resource allocation had alternative forms of data collection been used.

Obtaining large data sets The Delphi Technique is particularly suited to collecting subjective, rather than objective, assessments on a given topic. Moreover, because the respondents are all experts, but have a diverse range of qualifications and experience, the quality and richness of the database are maximized.

To obtain a comparable wealth of information using other consensus methods would be impossible from a practical perspective.

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