leadership and innovation in nursing seen through a
TRANSCRIPT
Seediscussions,stats,andauthorprofilesforthispublicationat:http://www.researchgate.net/publication/259243872
Leadershipandinnovationinnursingseenthroughahistoricallens
ARTICLEinJOURNALOFADVANCEDNURSING·DECEMBER2013
ImpactFactor:1.74·DOI:10.1111/jan.12325·Source:PubMed
READS
61
3AUTHORS,INCLUDING:
RuthHarris
KingstonUniversityandStGeorge's,Univer…
45PUBLICATIONS378CITATIONS
SEEPROFILE
FionaRoss
KingstonUniversityLondon
140PUBLICATIONS934CITATIONS
SEEPROFILE
Availablefrom:FionaRoss
Retrievedon:20October2015
ORIGINAL RESEARCH
Leadership and innovation in nursing seen through a historical lens
Ruth Harris, Janette Bennett & Fiona Ross
Accepted for publication 7 November 2013
Correspondence to R. Harris:
e-mail: [email protected]
Ruth Harris MSc PhD RGN
Professor of Nursing Practice and
Innovation
Faculty of Health, Social Care and
Education, Kingston University and
St George’s, University of London, Surrey,
UK
Janette Bennett BA PhD RGN
Formerly Honorary Research Fellow
Faculty of Health, Social Care and
Education, Kingston University and
St George’s, University of London, London,
UK
Fiona Ross BSc PhD RGN
Dean
Faculty of Health, Social Care and
Education, Kingston University and
St George’s, University of London, London,
UK
HARR I S R . , BENNETT J . & ROSS F . ( 2 0 1 3 ) Leadership and innovation in
nursing seen through a historical lens. Journal of Advanced Nursing 100(0), 000–
000. doi: 10.1111/jan.12325
AbstractAim. To explore nurses’ archived accounts of Matron Muriel Powell’s
management and leadership style and the impact of this on the implementation
and sustainability of innovation in the workplace.
Background. In popular discourse, the matron has become an emblem of
leadership. Although the title disappeared in the UK in the late 1960s as part of
the re-organization recommended by the Salmon Report, it re-appeared in 2002
in an attempt to improve care standards by reasserting a strong nursing presence
and clinical leadership role.
Design. Secondary data analysis using qualitative thematic analysis.
Methods. This paper draws on interview data held in the ‘Nurses Voices’ archive.
The interview transcripts of 132 nurses who trained or worked at St George’s
hospital in 1920–1980 were analysed in depth between March 2011–January
2012 and themes were generated inductively by grouping together emergent codes
in the data with similar meaning.
Results. Looking back, the nurses recalled strong memories of the leadership of
Matron Powell. Her presence emerged as a significant influence throughout the
interviews. Two resonant themes were identified: innovation and open
communication.
Conclusions. Through her visibility and direct access with patients and staff,
Dame Muriel Powell showed what we would now call transformative leadership
qualities. Her leadership created a culture of open communication and innovation
that initiated change in the organization and the nursing workforce. Looking
back and learning from historical figures can deepen understanding and provide
pointers for the nurse leaders of today.
Keywords: historical research, innovation, leadership, matrons, nurses, nursing
Introduction
Nursing work is increasingly contested in the aftermath of
failures in care and growing public concern internationally
(Francis 2013, Levinson 2013). A solution often proffered
is to strengthen nursing leadership at the frontline of care.
However, the practical application and meanings of leader-
ship in the turbulent and uncertain world of nursing and
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
© 2013 John Wiley & Sons Ltd 1
JAN JOURNAL OF ADVANCED NURSING
JA
N1
23
25
Dispa
tch:
21.11.13
CE:Sup
riya
JournalCode
ManuscriptNo.
No.
ofpa
ges:
10PE:
health care are elusive. We rarely take the long view and
consider the challenges of the day in an historical context.
As a result, nursing neglects its legacy and reduces the
opportunity to demonstrate its contribution to the develop-
ment of health care, thus weakening its social legitimacy
(Fealy et al. 2013). This paper sets out to fill this gap and
reports on oral histories of nurses, who worked in the post-
war period at St George’s Hospital, London. When we
began to listen to the Nurses’ Voices archive, we were inter-
ested in exploring issues related to the nursing workforce
and nursing innovation in general, but it became clear that
a powerful and unifying thread to the oral histories were
the stories shared about Matron Muriel Powell, her
personal impact and leadership as the NHS was evolving.
Background
Muriel Powell was a British nurse, hospital matron at
St George’s Hospital London and briefly, Chief Nursing
Officer (CNO) for the Scottish Home and Health Depart-
ment (SHHD). In 1947, aged 32, Miss Powell was the
youngest matron ever to be appointed to a London teaching
hospital since nurse registration had been introduced early
in the 20th century (Scott 2000). Her appointment report-
edly ‘raised eyebrows’ and some consternation among the
medical establishment, who doubted anyone so young could
do the job. This was a time of political change and opti-
mism that followed the creation of a comprehensive social
welfare programme, including the NHS (The NHS Act
1946), to improve poverty, education and health. Employ-
ment opportunities for women were increasing slowly and
acute shortages of nurses for the new NHS promoted inter-
national migration. During the 1950s–1960s, drugs and
medical treatments were improving and hospital organiza-
tion was changing, e.g. creation of medical specialty divi-
sions, although services were by no means as highly
specialized or complex as current times. Strict hierarchy
was the norm. Matron and ward sisters were very power-
ful. In some hospitals, staff nurses were not permitted to
speak to them unless first addressed and doctors did not
enter a ward without their approval (O’Dowd 2008a,b).
During her time at St George’s, Dame Muriel Powell ‘mod-
ernized’ nursing practices and identified many areas for
development and improvement. She can be best described
as an influential role model, an influential leader and a
spokesperson of her profession. After 22 years, she left St
George’s in 1969. In 1968, Muriel Powell was bestowed
the honour of Dame of British Empire in recognition of her
services to nursing (Powell 1975).
Striking and always elegant, she could be described as an
‘innovative’ leader in advance of her time, who did much
to improve patient care, raise the profile of nursing in
general and the aspiration of individual nurses. She was a
member of the Salmon Committee that recommended a
new structure of nursing management and ironically was
instrumental in policies that led to the disappearance of the
role of matron. She also served on the Platt Committee that
produced important reforms in nursing education in 1964
and maintained that education was the key to better nurs-
ing. Significantly, she secured funding from the Ministry of
Why is this research needed?
• Effective leadership of nursing is crucial to provide high-
quality, competent and compassionate care to patients.
• Inspirational nurse leaders have had a big impact on the
development of nursing throughout the last century
although specific accounts of their influence are rare, which
weakens the influence and social legitimacy of nursing.
• Nursing as a profession and a discipline will be advanced
by a better understanding of its unique contribution to the
development of healthcare systems and the delivery of care
to patients.
What are the key findings?
• An account of the work of one inspirational leader who
had an enormous influence on the development of innova-
tive nursing practice and policy nationally and internation-
ally from the perspectives of the clinical nurses who
worked directly with her.
• Muriel Powell was effective because she was visible to staff
and patients and directly accessible, which had a pervasive
influence on workplace culture, nurses’ morale and care
delivered to patients.
• When Muriel Powell saw a problem, she had the vision
and freedom to deal with it to improve the experience of
patients and staff who, as a result, felt valued and sup-
ported and loyal.
How should the findings be used to influence policy/practice/research/education?
• A senior nursing presence should be visible and directly
accessible to patients and staff in healthcare organizations
and trusts.
• Nursing leaders should be freed up to lead nursing activity
to inspire the nurses they have responsibility for to realize
the potential of nursing to improve patient outcome and
experience.
• The experience of patients, service users and staff should
be central to all leadership priorities and activities.
2 © 2013 John Wiley & Sons Ltd
R. Harris et al.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
Health to introduce a shortened course for university grad-
uates, which produced a generation of forward thinking
nurses including Margaret Scott-Wright, who went on to
become the first Professor of Nursing at Edinburgh Univer-
sity and the only Nursing Professor at the time in Europe.
In 1966, matrons disappeared from the NHS following a
report by the Committee on Senior Nurse Staffing Struc-
tures (The Salmon Report 1966). The report sought to
modernize nursing management to fit the changing land-
scape of the newly emerging District General Hospitals.
Whereas, in the past the matrons had had much of the day-
to-day control of their hospitals, their roles transformed
into departmental managers. Further changes resulted from
the introduction of ‘general management’ into the NHS in
the 1980s Department of Health (DH 2002). As part of the
modernisation of the NHS, ‘modern’ matrons returned to
acute NHS Trusts in 2002 (Gould 2008). These senior sis-
ters and charge nurses are required by the DH to provide
strong visible clinical leadership to improve the quality of
care and make the NHS more responsive to the needs of
patients and their families. To achieve this, ‘modern’ matrons
have key responsibilities (DH 2003) as outlined in Figure 1.
There was some flexibility in the way NHS trusts devel-
oped and implemented the ‘modern’ matron role. However,
a notable difference between ‘modern’ and traditional
matrons is that ‘modern’ matrons are accountable for a
group of wards or units, whereas the traditional matron
had oversight of the whole organization, a role more akin
to the director of nursing services or chief nurse of a health-
care organization.
Leadership in context
It was originally believed that leadership was a quality that
could be observed and measured by what leaders actually
did (McGregor 1960), considering leadership as an innate
quality of the individual (Stogdill 1974). Transactional the-
ories emphasize the relationship between the leader and the
followers (Burns 1978), whereas transformational theories
of leadership consider the goal of leadership as the ability
to transform people and organizations (Bass & Avollo
1994).
Before 1980, there was an absence of nursing leadership
research; even until the late 1980s, the literature is scarce
(Moiden 2002). In the early 1990s, theories of leadership in
nursing emphasized the personal qualities of the leader, the
effect of the leader on organizational functioning and cul-
ture, as well as the leader and group behaviour (Rafferty
1993). A well-used definition of nursing leadership at the
time emphasized leadership as a process of influence and
change:
the ability to identify a goal, come up with a strategy for achieving
that goal and inspire your team to join you putting that strategy in
action (Rafferty 1993, p. 3).
Theories also focused on the development of nurses and
nursing in the context of nursing (Antrobus & Kitson
1999). More recently, the importance of nursing leadership
programmes demonstrates that effective nurse leaders have a
positive effect on staff morale and patient outcomes (Swear-
ingen 2009) and the quality of patient care and patient satis-
faction (Tomey 2009). From trust board level to ward
management, the exercise of leadership from a position of
power and influence is critical to the development of nursing
practice and innovation and the creation of support in the
workplace (Hughes et al. 2006, Jumaa 2008).
Innovation and change
The literature on the spread and sustainability of innova-
tions in health care is too extensive to review in this paper
(Greenhalgh et al. 2004). However, McSherry and Douglas
(2011) provide a contemporary definition of Innovation in
Practice (IiP):
The encouragement of professionals to use their acquired knowl-
edge and skills to creatively generate and develop new ways of
working, drawing on technologies, systems, theories and associated
partners/stakeholders to further enhance and evaluate practice.
Innovation in practice is imperative to improve patient safety and
quality of care; IiP does not and will not occur in isolation requir-
ing investment, support and resource allocation from managers,
leaders and governments.
At all levels, leadership and innovation in nursing are
central to the development, delivery and maintenance of
high-quality care (DH 2008, Apekey et al. 2011, Ross
Key responsibilities of ‘modern’ matrons to provide clinicalleadership and improve quality of care are:
Leading by example
Making sure patients get quality care
Ensuring staffing is appropriate to patient needs
Empowering nurses to take on a wider range of clinical tasks
Improving hospital cleanliness
Ensuring patients nutritional needs are met
Improving wards for patients
Making sure patients are treated with respect
Preventing hospital acquired infections
Preventing problems for patients and relatives by buildingcloser relationships
•
•
•
•
•
•
•
•
•
•
Figure 1 Key responsibilities of ‘modern’ matrons (DH 2003).
© 2013 John Wiley & Sons Ltd 3
JAN: ORIGINAL RESEARCH Leadership and innovation in nursing
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
et al. 2011). It is widely assumed that clinical leaders have
the ability and capacity to champion innovation, although
there is little evidence to support this (Kitson et al. 2011).
However, certain attributes are associated with the combi-
nation of effective leadership and innovation, for example,
emotional intelligence is a factor that marks out individu-
als as leaders, innovators and effective managers (Cadman
& Brewer 2001, Akerjordet & Severinsson 2008). The
ability of leaders to create a working environment that
supports and encourages self-efficacy and teamwork are
also motivational forces that can inspire change and readi-
ness to adopt innovation (Pearlmutter 1998). However, the
team must share the desires and goals of the leader if an
innovation is to be successfully adopted (Litaker et al.
2008).
The study
Aims
Our preliminary aim was to explore the oral history tran-
scripts held in the Nurses’ Voices Archive of nurses from
1920–1980 at St George’s Hospital for their views and
experiences of being part of the nursing workforce and the
factors that influenced nursing practice development and
innovation. This aim was consolidated following early analysis
to explore nursing accounts of Matron Powell’s management
and leadership style and the impact of this on the implementa-
tion and sustainability of innovation in the workplace.
Design
The research design is secondary analysis of existing narra-
tive interviews (Heaton 2004) and was guided by the tenets
of naturalistic enquiry (Lincoln & Guba 1985), which seeks
to understand context-specific phenomena and as such suits
the aims of this historical analysis.
Sample
The participants for this analysis were purposively sampled
from a large archive entitled ‘Nurses Voices’ held at Kings-
ton University and St. George’s, University of London. This
extensive archive, accessible to scholars and researchers,
contains 1000 recorded face-to-face interviews with individ-
uals who trained or worked as nurses or midwives at St
George’s, Guys and St Thomas and St Bartholomew’s Hos-
pitals covering all aspects of the nursing experience. The
interviews were recorded and transcribed verbatim and the
full archive covers nearly a century of nursing 1920–2000.
Data collection
For practical reasons, this paper presents an analysis of the
St George’s archive of 132 nurse’s transcripts (131 female
and 1 male), who trained in the decades 1920–1980, con-
taining details of nurses experiences at St George’s Hospital
London from 1920–2000, which covers themes such as:
becoming a nurse, nurse education, uniforms, influential
nurses, war, disasters and epidemics and clinical practice
and innovation (McCubbin 2010).
Ethical considerations
The data retrieved from the archive were anonymized and
therefore there are no ethical issues.
Data analysis
The data were analysed using thematic analysis (Lincoln &
Guba 1985). To gain an initial understanding of the archive
and to identify any underlying themes, all transcripts were
read in full by an independent researcher who was not
involved in the data collection. The process of reading and
re-reading and analysis of the transcripts took over
6 months. Close reading and copious notes produced initial
data sets about the life and work of Matron Powell; it was
clear from the initial examination of the transcripts that her
role was a central and overarching influence on staff. Further
reading and coding produced smaller more meaningful sub-
categories (Miles & Huberman 1994, Ryan & Bernard 2000).
Themes in the data were generated inductively by grouping
together emergent codes in the data with similar meaning.
Rigour
All St George’s transcripts were included and so there was no
selection bias. Analysis was carefully conducted with detailed,
reflexive notes for discussion in the team to verify data coding
and interpretation. As data were anonymous and historical,
we could not ask participants to verify our analysis.
Findings
The analysis revealed two emergent themes: open communi-
cation and innovation and change.
Open communication
The ability to communicate at all levels is a key leadership
skill. Using both verbal and non-verbal communication
4 © 2013 John Wiley & Sons Ltd
R. Harris et al.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
Matron Powell communicated with patients and staff and
created a working culture were patients had access to
matron and staff felt valued regardless of seniority:
Muriel Powell came in to talk to us in block and of course we all
shot to our feet as one did and she said, ‘sit down we are all col-
leagues’ (Nurse at St George’s (N@SG) 1963–1967 & 1973–1975).
I do remember her as someone that always gave good advice; her
door was always open. As a ward sister I found that invaluable
(N@SG 1949–1953).
Matron Powell would also use non-verbal communica-
tion to offer encouragement:
I refer to her as Matron Powell, because, obviously she became
Dame after she left, she was a lovely lady. She was young. She was
always winking. She was always encouraging (N@SG 1957–1961).
Her managerial style was firm but fair and appeared to
foster a sense of confidence:
You know you wouldn’t call Muriel Powell a disciplinarian, she
was strict, but she was fair. So you didn’t feel you were under a
strict regime, which I think is quite important (N@SG 1947–1956).
I think if people are too frightened of what somebody is going to
say, then you’re not going to do as well as if they are more relaxed
(N@SG 1949–1952 & 1954–1955 & 1957–1960).
Despite the demands of her role, she valued and priori-
tized patients and spent time talking to them, showing sen-
sitivity to the context and not wanting to intrude:
Matron Powell seemed to have an awareness that patients were
reluctant to talk to her in the presence of the ward sister, so she
would arrive any time unannounced and she would spend time
talking to patients on her own (N@SG 1951–1963).
These visits were often prompted by the knowledge of a
particularly ill patient, but if not, she would use feedback
from patients to improve services.
The influence of open communication on the working
environment
Open and respectful working relationships based on good
communication in and across professions were also adopted
by the staff:
Drs and nurses would speak easily to one another, there was an air
of camaraderie between the medical staff and the nursing staff
(N@SG 1954–1969).
These positive working relationships informed the culture
at St Georges:
Matron Powell told me, what she would expect, she hoped the hos-
pital would have a general friendly. She felt it should be, not a
strict environment (N@SG 1949–1953).
It was essentially a friendly hospital. You know, friendliness
between staff and friendliness between patients was the norm,
which I think I felt when I read the prospectus. And I felt, well, I
could survive in a hospital like that (N@SG 1949–1952, & 1954,
1955,1957–1960).
It was a very friendly hospital. People would always stop and talk
to you. You always felt you could ask someone one if you were
not sure (N@SG 1946–1953).
Courtesy was reported as the norm at St George’s
(N@SG 1952–1956–1957–1958) as well as excellent nurs-
ing care and experience:
The nursing care was excellent. It was great to have nurses who had
the standards you wanted to see on the wards. The culture, if you
like, they [the nurses] were the culture carriers (N@SG 1967–1974).
Innovation and change
This theme, called ‘innovation and change’ reflects Muriel
Powell’s leading influence to improve standards of care. It
is unlikely that she would have used these terms, but would
have seen the reforms she introduced as a part of her voca-
tion in her role as matron (Gliddon & Powell 1952). We
acknowledge that the use of these terms is relatively recent
in health care; however, we consider that they are
appropriate and do reflect the descriptions of Muriel Pow-
ell’s impact on nursing; she was clearly recognized as a lea-
der, with a vision for change:
She was an exceptional matron. She was head of the London
Teaching Hospital Matrons Association. Matron Powell had vision.
She was a leader and she got things moving (N@SG 1957–1963,
1965–1968, 1970–1976, 1981–1984).
The ability of Matron Powell to implement innovation
and change was described by participants:
It was a totally different approach, people were seen as individuals
not as patients. They were never seen as ‘the appendix in bed 12′.
You had to remember people’s names and you weren’t allowed to
speak about people like that, which I think was quite new in nurs-
ing in those days (N@SG 1961–1964).
One example was her introduction of the patient’s day
based on a holistic model of care and desire to treat people
as individuals, rather than patients:
© 2013 John Wiley & Sons Ltd 5
JAN: ORIGINAL RESEARCH Leadership and innovation in nursing
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
I remember her [Matron Powell] saying that it was better for
granny to see her grandchildren on the ward than it was to give
her a pint of blood (N@SG 1949–1965).
It was so different. We didn’t wake patients up if they were asleep
first thing in the morning just to stick a thermometer in their
mouths (N@SG 1951–1963).
Matron Powell also had the support of her staff, which
may have helped them to adopt this new way of working
as they could also appreciate the rationale behind the
‘patients day’:
I was sympathetic to the patient’s day because I slept late when I
could. I didn’t want cups of tea in the morning and it really felt
brutal waking up some of these people with cups of tea (N@SG
1958–1970).
Matron Powell also maintained a ‘constant’ presence to
ensure the successful implementation of the patient’s day:
She lived in a flat that looked down on some of the wards and if
she saw lights on before 7 o’clock in the morning, she would be
down on that ward and asking why the night nurse had got the
lights on (N@SG 1957–1961 & 1972–1980).
Another area of innovation that Matron Powell was
instrumental in was improving nurse education:
At the end of our training it was realised that a lot of girls weren’t
getting a well rounded knowledge of nursing because they hadn’t
been on various wards or departments. So Matron Powell organ-
ised what was called the ‘observer corp’ and groups of 6, 8 or 10
were organised to go on the wards or departments, not to work,
but to observe. So we developed our observational skills and gained
a fair knowledge of what was going on. So when questions arose in
our final papers one at least had a general idea (N@SG 1947–1955).
Just before our final exams, we acquired a clinical teacher. A
fairly innovative idea, I think, of Miss Powell. And she would
come round and talk to us about our work and to give us an
opportunity to ask questions (N@SG 1951–1959, 1963–1968,
1978–1980).
Supporting others to make changes
Matron Powell also supported staff who shared her enthusi-
asm for innovation and change. A notable example was the
support matron Powell gave to one of her ward sisters to
trial a form of team nursing. This involved the pairing of
qualified nurses with less qualified assistants. Following a
successful trial, team nursing was implemented across the
hospital:
There was a remarkable woman on McAlmont Ward called Vivien
Jenkinson and […] there again, that was typical of Muriel Powell
knowing her people. Vivien Jenkinson […] was the one who did an
original piece of research which was published on ‘Patient Assign-
ment as different from Job Assignment’. And came to the conclu-
sion that it was not really viable to go down that road of patient
assignment and out of her work came the concept of ‘Team Nurs-
ing’ (N@SG 1951–1960).
Working environment
The introduction of team nursing above was described by
Dame Muriel Powell as a ‘great improvement for it enabled
a seriously ill patient to have a bedpan, bath, mouth care
and her dressing done at the same time, which was much
less exhausting; it was also more satisfying for staff to give
care in this way’ (Powell 1975).
Muriel Powell also introduced innovative changes to the
working patterns of women. Long before the value of older
workers in the nursing workforce had been acknowledged,
Matron Powell was instrumental in the recruitment and
retention of older and married women:
Muriel Powell did a lot of stuff that was regarded as very progres-
sive at the time, including taking older nurses on although it’s now
become mainstream (N@SG 1955–1959).
Muriel Powell was probably one of the foremost matrons in Lon-
don who actually allowed….or….enabled married women to con-
tinue to work (N@SG 1962–2000).
She took the trouble to encourage older women (N@SG 1958–
1971).
A further example of this was to persuade her ward sis-
ters to give nurses at least a weeks’ notice of their off duty:
‘I was alarmed to discover that they [nurses] still only knew
when they would be free on the morning of their off duty’
(Powell 1975).
There was a positive response to this innovation:
We could never plan our time off. We’d only have time to perhaps
sit in the park and then we were required back on the wards. Then
we had this new system; which was marvellous we could plan our
own time off (N@SG 1946–1959).
At St George’s, the ‘Patients Day’ and team nursing were
trialled and introduced in the fifties. With hindsight, both
can be considered the forerunners of patient centred care.
The introduction of the ‘observer corp’ gave student nurses
access to clinical observation, which was hitherto unavail-
able. Long before equality legislation Dame Muriel was
6 © 2013 John Wiley & Sons Ltd
R. Harris et al.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
actively promoting diversity in the workforce, through her
encouragement of older and married women.
The combination of enthusiastic leadership and co-opera-
tive staff produced a culture at St George’s that enabled
and supported innovation. Central to this culture was
Matron Powell’s ability to be:
a terrific agent for change. She used all her skill and ingenuity to
persuade other people that change was for the better (N@SG
1958–1970).
Discussion
This paper discusses the meaning of leadership as exempli-
fied by a significant personality and charismatic matron and
seeks to understand the present using an historical lens by
interrogating narrative interviews collected using an oral his-
tory method. This research has revealed that Dame Muriel
Powell clearly imposed her personal imprint and identity on
the role of matron in many different ways. She was passion-
ate about nursing and she had the ability to identify potential
to develop nurses of the highest quality who were capable of
delivering first class care. Not one to stick to rigid ward rou-
tines Dame Muriel was able to think beyond the ‘norm’ and
put the patient at the centre of care by re-structuring a ‘typi-
cal hospital day’ and develop new ways of working which
were progressive for her time. The two themes that emerged
as central in this examination of Muriel Powell’s leadership
were open communication and innovation and change and
these are also key roles ascribed to modern matrons in the
21st century by the Department of Health. She embodied the
characteristics of transformational leadership as defined by
Bass and Avollo (1994), particularly creativity and vision.
She led the hospital and her nursing teams proactively with
actions and activities in accordance to her strongly held
beliefs and values demonstrating features of ‘Congruent
Leadership’ as defined by Stanley (2008).
In terms of innovation and change, the combination of
enthusiastic leadership and co-operative staff which was
carefully fostered by her produced a culture at St George’s
that enabled and supported innovation. There is limited evi-
dence of any relationship between nursing leadership and
patient outcomes (Vance & Larson 2002), although there is
evidence that positive leadership is associated with an
increase in patient satisfaction (McNeese-Smith 1999,
Doran et al. 2004). Clearly, Matron Powell was a ‘terrific
agent for change’, described as ‘firm but fair’ and she was
described as having many of the strategies described as
essential to this role: having a progressive vision; enabling
support from staff by enabling them to appreciate the ratio-
nale behind a change; being a visible presence to support
adherence to change; encouraging other champions and
innovators in the working environment thus developing
ownership of the change culture. During the 1990s, various
innovative approaches were introduced to improve nursing
practice (e.g. Nursing Development Units) (Ross et al.
2011). An important role in these units was that of clinical
leadership and different models were adopted and evaluated.
What became clear was that the ability of nurse leaders to
deploy leadership strategies for change was constrained by
their position in the organizational hierarchy: those without
managerial responsibility had the capacity to develop a
vision for the future, but did not have the authority to make
this vision a reality without relying on the goodwill and co-
operation of senior managers. In contrast, those with day-
to-day managerial responsibility experienced difficulty
extracting themselves from administrative concerns to be
able to think in strategic terms and this was even more of a
problem for those leaders with managerial responsibilities
for the wider organization (Christian & Norman 1998).
Matron Powell was comparatively unencumbered by any of
this sort of external bureaucracy and clearly had the ‘free-
dom’ to make changes and the capacity to develop a vision
and thus create a first class nursing environment, where
patients received high quality care, staff were recognized
and respected and innovative ideas were implemented.
Communication emerged as a central theme from the
archive. The ability to communicate at all levels is a key
leadership skill (Rafferty 1993, McSherry & Douglas
2011). Matron Powell was able to effectively use both ver-
bal and non-verbal communication with patients and staff
and created a working culture where patients had access to
matron and staff felt valued regardless of seniority. She lis-
tened and was clearly sensitive to barriers to communica-
tion particularly for patients and willing to work around
these.
In addition to these characteristics, which other factors
enabled Matron Powell to fulfil her leadership role so effec-
tively and how are these comparable in today’s hospital
environments? First, unlike nurse leaders today, she had
overall responsibility and a vision of the whole hospital
environment. The changes to nursing management intro-
duced by the Salmon Report (1966) heralded a nursing
structure where prestige and remuneration increased with
distance from the bedside. This reduced the opportunity for
nurse managers to see a problem and deal with it. Larger
hospital environments and dispersed responsibilities of nurs-
ing leaders today reduce this further. Matron Powell, who
lived on-site, was a continual and visible presence through-
out the hospital, which is not the case for busy nurse lead-
© 2013 John Wiley & Sons Ltd 7
JAN: ORIGINAL RESEARCH Leadership and innovation in nursing
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
ers of today who have lives outside the hospital, have fami-
lies and other caring responsibilities and are continually
drawn away from the clinical environment. One recent ini-
tiative to provide strengthened and visible nurse leadership
at ward level is ‘Back to the Floor Friday’ (Jones & Grif-
fiths 2011). All nurses/midwives above Band 7 in the Trust
returned to clinical practice in uniforms on Fridays.
Although it was difficult to identify tangible evidence of
improvements, many positive themes and some staff bene-
fits emerged around learning together, professional net-
working, communication and championing change all of
which were reported to be beneficial to staff.
Time, or lack of it, is a big challenge in senior leadership
roles, but Matron Powell had the flexibility and capacity to
manage her time well and respondents felt that she always
had time for them which increased their sense of worth and
value. These characteristics contributed to what was
described as an ‘open and respectful working environment’
which pervaded. It was perceptive of one respondent to
describe the nurses in this environment as ‘culture carriers’.
Matron Powell was in post at St George’s for 22 years.
This is in contrast to the significantly high rate of executive
turnover in healthcare organizations worldwide today
(Jones et al. 2008). The current turnover is influenced by
factors such as age, gender, education and lack of career
enhancement opportunities and remuneration (Duffield
et al. 2011). However, the continual re-organizations of
roles and management structures in the UK also have an
inevitable impact on turnover in nurse leadership posts.
Some of the negative consequences of high turnover have
been identified as destabilizing effects on organizations and
staff (Cummings & Estabrooks 2003, Havens et al. 2008);
and significantly loss of an important advocate (Jones et al.
2009), which is particularly adverse for sustainment of
innovation. Through her long tenure, Matron Powell pro-
vided consistency in her role and was able to ensure
improvements were sustained over a long period of time.
Limitations
Although the analysis was able to exploit a rich and exten-
sive archive, we do not know why some ex St George’s
nurses volunteered to be interviewed and others did not.
Secondly, the archive is full of ‘fond memories’ and
although there are extensive references to hard work and
long hours, the archive contains little if anything negative
about Matron Powell or St George’s Hospital. Therefore,
those that agreed to be interviewed were likely to have
done so because they had positive things to say and as such,
the possibility of bias is acknowledged.
Conclusion
In the aftermath of the Francis (2013) Report, there is
renewed attention to the importance of the right leadership
to create a culture conducive to high-quality care. Muriel
Powell was successful as a nurse leader at a time when
patients were in hospital for longer, care was less special-
ized and technical and health care less political and target
driven. Therefore, the challenges she faced were different,
but not necessarily easier. While the context of health care
and the demands on leaders are different, there are key les-
sons to learn. The impact of seeing the nursing leader, visi-
ble to staff and patients and directly accessible, had a
pervasive influence on workplace culture, nurses’ morale
and care delivered to patients. Furthermore, she had an
overwhelming impact on nurses’ experience that generated
considerable loyalty and respect. The UK Chief Nursing
Officer and Lead Nurse for Public Health have recently
published their vision for Nursing, Midwifery and Care
Staff entitled ‘Compassion in Practice’ underpinned by six
fundamental values (the 6 C’s): care, compassion, compe-
tence, communication, courage and commitment (DH
2012). It can be seen from this analysis of the narratives of
the nurses who worked with her that her work epitomized
all of these values and inspired nurses to do the same. The
recent ‘Releasing Time to Care – the Productive WardTM’
initiative has focused on streamlining ward processes and
environment to enable nurses to increase the time they
spend providing direct care to patients, thus improving care
quality and safety (NHS Institute for Innovation &
Improvement 2011, Davis & Adams 2012). In the same
way that this has freed up nurses to nurse, we would argue
that there is a need to free up leaders to lead. This paper
provides an historical account of the benefits of this. Nurses
and nursing leaders today, as those from our heritage, can
be inspired by Dame Muriel Powell.
Acknowledgements
The Nurses Voices Archive was established as a result of the
work led by Kath Start (formerly Deputy Dean) in collabora-
tion with Carol McCubbin and St George’s Hospital League
of Nurses, funded by St George’s Hospital Charity and the
Faculty. The archive is held in the Faculty of Health, Social
Care and Education (Kingston University and St George’s,
University of London) http://www.healthcare.ac.uk/research/
groups/workforce-development/nurses-lives/st-georges/.
Dr Janette Bennett drew on the interview data in the
Nurses’ Voices archive, undertook the analysis and pre-
pared the first draft of this paper before her untimely death
8 © 2013 John Wiley & Sons Ltd
R. Harris et al.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
in 2012. As a nurse and social psychologist, Janette was
interested in identity and became fascinated with the Muriel
Powell story and her aura as a charismatic leader, as it was
recalled and told through the memories of these nurses. We
also acknowledge Sara Christian who contributed to earlier
drafts of this paper.
Funding
This research received no specific grant from any funding
agency in the public, commercial, or not-for-profit sectors.
Author contributions
All authors have agreed on the final version and meet at
least one of the following criteria [recommended by the IC-
MJE (http://www.icmje.org/ethical_1author.html)]:
• substantial contributions to conception and design,
acquisition of data, or analysis and interpretation of
data;
• drafting the article or revising it critically for important
intellectual content.
References
Akerjordet K. & Severinsson E. (2008) Emotionally intelligence
nurse leadership: a literature review study. Journal of Nursing
Management 16(5), 565–577.
Antrobus S. & Kitson A. (1999) Nursing leadership influencing and
shaping health policy and nursing practice. Journal of Advanced
Nursing 29(3), 746–753.
Apekey T.A., McSorley G., Tilling M. & Siriwardena A.N. (2011)
Room for improvement? Leadership, innovation, culture and
uptake of quality improvement methods in general practice.
Journal of Evaluation in Clinical Practice 17, 311–318.
Bass B.M. & Avollo B.J. (1994) Improving Organisational
Effectiveness through Transformational Leadership. Sage
Publications, Thousand Oaks, CA.
Burns J.M. (1978) Leadership. Harper & Row, New York.
Cadman C. & Brewer J. (2001) Emotional intelligence: a vital
prerequisite for recruitment in nursing. Journal of Nursing
Management 9(6), 321–324.
Christian S.L. & Norman I.J. (1998) Clinical leadership in nursing
development units. Journal of Advanced Nursing 27, 108–116.
Cummings G. & Estabrooks C. (2003) The effects of hospital
restructuring that included layoffs on individual nurses who
remained employed: a systematic review of impact. International
Journal of Sociology and Social Policy 8(9), 8–53.
Davis J. & Adams J. (2012) The ‘Releasing Time to Care – the
Productive Ward’ programme: participants’ perspectives. Journal
of Nursing Management 20, 354–360.
Department of Health (2002) Modern Matron in the NHS: A
Progress Report. Department of Health, London.
Department of Health (2003) Modern Matrons – Improving the
Patient Experience. Department of Health, London.
Department of Health (2008) High Quality Care for All. NHS
Next Stage Review Final Report. Department of Health, London.
Department of Health (2012) Compassion in Practice: Nursing,
Midwifery and Care Staff Our Vision and Strategy. Department
of Health, London.
Doran D., McCutcheon A.S., Evans M.G., MacMillan K.,
McGillis Hall L., Pringle D., Smith S. & Valente A. (2004)
Impact of the Manager’s Span of Control on Leadership and
Performance. Canadian Health Services Research Foundation,
Ottawa, ON.
Duffield C., Roche M., Blay N., Thoms D. & Stasa H. (2011) The
consequences of executive turnover. Journal of Research in
Nursing 16(6), 503–514.
Fealy G., Kelly J. & Watson R. (2013) Legitimacy in legacy: a
discussion paper of historical scholarship published in the
Journal of Advanced Nursing, 1976-2011. Journal of Advanced
Nursing 69(8), 1881–1894.
Francis R. (2013) Report of the Mid Staffordshire NHS
Foundation Trust Public Inquiry. The Stationery office, London.
Retrieved from http://www.midstaffspublicinquiry.com/report on
12 May 2013.
Gliddon P. & Powell M. (1952) Called to Serve. Hodder &
Stoughton, London.
Gould D. (2008) The matron’s role in acute National Health
Service Trusts. Journal of Nursing Management 16(7), 804–812.
Greenhalgh T., Robert G., Bate P., Kyriakidou O. & Macfarlane F.
(2004) How to spread good ideas. A systematic review of the
literature on diffusion, dissemination and sustainability of
innovations in health service delivery and organisation. Report
for the national Co-ordinating Centre for NHS Service Delivery
and Organisation R & D (NCCSDO), London.
Havens D.S., Thompson P.A. & Jones C.B. (2008) Chief nursing
officer turnover: chief nursing officers and healthcare recruiters tell
their stories. Journal of Nursing Administration 38(12), 516–525.
Heaton J. (2004) Reworking Qualitative Data. Sage, London.
Hughes F., Duke J., Bamford A. & Moss C. (2006) Enhancing
nursing leadership: through policy, politics and strategic
alliances. Nurse Leader 4(2), 24–27.
Jones K. & Griffiths L. (2011) Back to the floor Friday: evaluation
of the impact on the patient experience. Journal of Nursing
Management 19(2), 170–176.
Jones C.B., Havens D.S. & Thompson P.A. (2008) Chief nursing
officer retention and turnover: a crisis brewing? Results of a
national survey. Journal of Healthcare Management 53, 89–106.
Jones C.B., Havens D.S. & Thompson P.A. (2009) Chief nursing
officer turnover and the crisis brewing: views from the front line.
Journal of Nursing Administration 39, 285–291.
Jumaa M.O. (2008) The ‘F.E.E.L’ good factors in nursing
leadership at the board level through work-based learning.
Journal of Nursing Management 16, 992–999.
Kitson A., Silverston H., Wiechula R., Zeitz K., Marcoionni D. &
Page T. (2011) Clinical nursing leaders’, team members’ and
service managers’ experiences of implementing evidence at a
local level. Journal of Nursing Management 19(4), 542–555.
Levinson D.R. (2013) Skilled nursing facilities often fail to meet
care planning and discharge planning requirements. Department
© 2013 John Wiley & Sons Ltd 9
JAN: ORIGINAL RESEARCH Leadership and innovation in nursing
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
of Health and Human Services USA Office of Inspector General.
Retrieved from https://oig.hhs.gov/oei/reports/oei-02-09-00201.
pdf on 4 July 2013.
Lincoln Y.S. & Guba E.G. (1985) Naturalistic Inquiry. Sage
Publication, London.
Litaker D., Ruhe M. & Flocke S. (2008) Making sense of primary
care practices’ capacity for change. Journal of Laboratory and
Clinical Medicine 152(5), 245–253.
McCubbin C. (2010) Nurses’ Voice: Memories of Nursing at St
George’s Hospital London 1930–1990. Faculty of Health and
Social Care Sciences, Kingston University and St. George’s
University of London, London.
McGregor D. (1960) The Human Side of Enterprise. McGraw Hill,
New York.
McNeese-Smith D.K. (1999) A content analysis of staff nurse
descriptions of job satisfaction and dissatisfaction. Journal of
Advanced Nursing 29, 1332–1341.
McSherry R. & Douglas M. (2011) Innovation in nursing practice:
a means to tackling the global challenges facing nurses, midwives
and nurse leaders and managers in the future (Editorial). Journal
of Nursing Management 19, 165–169.
Miles M.B. & Huberman M. (1994) Qualitative Data Analysis: An
Expanded Sourcebook. Sage, Thousand Oaks, CA.
Ministry of Health and Scottish Home and Health Departments
(1966) Report of the Committee on Senior Nursing Staff
Structure (the Salmon Report). HMSO, London.2
Moiden M. (2002) Evolution of leadership in nursing. Nursing
Management 9(7), 20–25.
NHS Institute for Innovation and Improvement (2011) Rapid
Impact Assessment of The Productive Ward: Releasing time to
careTM. NHS Institute for Innovation and Improvement,
Coventry. Retrieved from http://www.institute.nhs.uk/images//
documents/Quality_and_value/productiveseries/Rapid%20Impact
%20Assessment%20full%20report%20FINAL.pdf on 12 May
2013.
O’Dowd A. (2008a) NHS nursing in the 1950s. Nursing Times 104
(1), 20–22.
O’Dowd A. (2008b) NHS nursing in the 1960s. Nursing Times
104(5), 18–20.
Pearlmutter S. (1998) Self-efficacy and organisational change
leadership. Administration in Social Work 22(3), 23–38.
Powell M. (1975) Patients are People: Nursing as a Career.
Educational Explorers, Reading.
Rafferty A.M. (1993) Leading Questions: A Discussion Paper on
the Issues of Nursing Leadership. King’s Fund Centre, London.
Ross F., Redfern S., Harris R. & Christian S. (2011) The impact of
nursing innovations in the context of governance and incentives.
Journal of Research in Nursing 16(3), 274–294.
Ryan G.W. & Bernard H.R. (2000) Data Management and
Analysis Methods. In Handbook of Qualitative Research, 2nd
edn (Denzin N. & Lincoln Y., eds), Sage Publications, Thousand
Oaks, CA, pp. 769–802.
Scott E. (2000) Muriel Powell Remembered. A Profile of her Life.
St George’s Nurses League, London.
Stanley D. (2008) Congruent leadership: values in action. Journal
of Nursing Management 16(5), 519–524.
Stogdill R. (1974) Handbook of Leadership, 1st edn. Free Press,
New York.
Swearingen S. (2009) A journey to leadership: designing nursing a
leadership development program. Journal of Continuing
Education in Nursing 40(3), 107–112.
Tomey A.M. (2009) Nursing leadership and management effects
working environment. Journal of Nursing Management 17(1),
15–25.
Vance C. & Larson E. (2002) Leadership research in business and
health care. Journal of Nursing Scholarship 32(2), 165–171.
The Journal of Advanced Nursing (JAN) is an international, peer-reviewed, scientific journal. JAN contributes to the advancement of
evidence-based nursing, midwifery and health care by disseminating high quality research and scholarship of contemporary relevance
and with potential to advance knowledge for practice, education, management or policy. JAN publishes research reviews, original
research reports and methodological and theoretical papers.
For further information, please visit JAN on the Wiley Online Library website: www.wileyonlinelibrary.com/journal/jan
Reasons to publish your work in JAN:
• High-impact forum: the world’s most cited nursing journal, with an Impact Factor of 1·527 – ranked 14/101 in the 2012 ISI Jour-
nal Citation Reports © (Nursing (Social Science)).
• Most read nursing journal in the world: over 3 million articles downloaded online per year and accessible in over 10,000 libraries
worldwide (including over 3,500 in developing countries with free or low cost access).
• Fast and easy online submission: online submission at http://mc.manuscriptcentral.com/jan.
• Positive publishing experience: rapid double-blind peer review with constructive feedback.
• Rapid online publication in five weeks: average time from final manuscript arriving in production to online publication.
• Online Open: the option to pay to make your article freely and openly accessible to non-subscribers upon publication on Wiley
Online Library, as well as the option to deposit the article in your own or your funding agency’s preferred archive (e.g. PubMed).
10 © 2013 John Wiley & Sons Ltd
R. Harris et al.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
Author Query Form
Journal: JANArticle: 12325
Dear Author,During the copy-editing of your paper, the following queries arose. Please respond to these by marking up yourproofs with the necessary changes/additions. Please write your answers on the query sheet if there is insufficientspace on the page proofs. Please write clearly and follow the conventions shown on the attached correctionssheet. If returning the proof by fax do not write too close to the paper’s edge. Please remember that illegiblemark-ups may delay publication.Many thanks for your assistance.
Query reference Query Remarks
1 AUTHOR: Please check all author forename and last name representation and
confirm that they are correct.
2 AUTHOR: Ministry of Health and Scottish Home and Health Departments
(1966) has not been cited in the text. Please indicate where it should be cited; or
delete from the Reference List.
USING e-ANNOTATION TOOLS FOR ELECTRONIC PROOF CORRECTION
Required software to e-Annotate PDFs: Adobe Acrobat Professional or Adobe Reader (version 8.0 or
above). (Note that this document uses screenshots from Adobe Reader X)
The latest version of Acrobat Reader can be downloaded for free at: http://get.adobe.com/reader/
Once you have Acrobat Reader open on your computer, click on the Comment tab at the right of the toolbar:
1. Replace (Ins) Tool Î for replacing text.
Strikes a line through text and opens up a text
box where replacement text can be entered.
How to use it
‚ Highlight a word or sentence.
‚ Click on the Replace (Ins) icon in the Annotations
section.
‚ Type the replacement text into the blue box that
appears.
This will open up a panel down the right side of the document. The majority of
tools you will use for annotating your proof will be in the Annotations section,
rkevwtgf"qrrqukvg0"YgÓxg"rkemgf"qwv"uqog"qh"vjgug"vqqnu"dgnqy<
2. Strikethrough (Del) Tool Î for deleting text.
Strikes a red line through text that is to be
deleted.
How to use it
‚ Highlight a word or sentence.
‚ Click on the Strikethrough (Del) icon in the
Annotations section.
3. Add note to text Tool Î for highlighting a section
to be changed to bold or italic.
Highlights text in yellow and opens up a text
box where comments can be entered.
How to use it
‚ Highlight the relevant section of text.
‚ Click on the Add note to text icon in the
Annotations section.
‚ Type instruction on what should be changed
regarding the text into the yellow box that
appears.
4. Add sticky note Tool Î for making notes at
specific points in the text.
Marks a point in the proof where a comment
needs to be highlighted.
How to use it
‚ Click on the Add sticky note icon in the
Annotations section.
‚ Click at the point in the proof where the comment
should be inserted.
‚ Type the comment into the yellow box that
appears.
USING e-ANNOTATION TOOLS FOR ELECTRONIC PROOF CORRECTION
For further information on how to annotate proofs, click on the Help menu to reveal a list of further options:
5. Attach File Tool Î for inserting large amounts of
text or replacement figures.
Inserts an icon linking to the attached file in the
appropriate pace in the text.
How to use it
‚ Click on the Attach File icon in the Annotations
section.
‚ Enkem"qp"vjg"rtqqh"vq"yjgtg"{qwÓf"nkmg"vjg"cvvcejgf"file to be linked.
‚ Select the file to be attached from your computer
or network.
‚ Select the colour and type of icon that will appear
in the proof. Click OK.
6. Add stamp Tool Î for approving a proof if no
corrections are required.
Inserts a selected stamp onto an appropriate
place in the proof.
How to use it
‚ Click on the Add stamp icon in the Annotations
section.
‚ Select the stamp you want to use. (The Approved
stamp is usually available directly in the menu that
appears).
‚ Enkem"qp"vjg"rtqqh"yjgtg"{qwÓf"nkmg"vjg"uvcor"vq"appear. (Where a proof is to be approved as it is,
this would normally be on the first page).
7. Drawing Markups Tools Î for drawing shapes, lines and freeform
annotations on proofs and commenting on these marks.
Allows shapes, lines and freeform annotations to be drawn on proofs and for
comment to be made on these marks..
How to use it
‚ Click on one of the shapes in the Drawing
Markups section.
‚ Click on the proof at the relevant point and
draw the selected shape with the cursor.
‚ To add a comment to the drawn shape,
move the cursor over the shape until an
arrowhead appears.
‚ Double click on the shape and type any
text in the red box that appears.