A scoping review of rebel nurse leadership: Descriptions, competences and stimulating/hindering factors.
J of Clinical Nursing May 6 2021
To (1) give an overview of rebel nurse leadership by summarising descriptions of positive deviance, tempered radicals and healthcare rebels; (2) examine the competences of nurse rebel leadership; and (3) describe factors that stimulate or hinder the development of rebel nurse leadership.
Research shows nurses have lower intention to leave their jobs when they can control their work practices, show leadership and provide the best care. However, organisational rules and regulations do not always fit the provision of good care, which challenges nurses to show leadership and deviate from the rules and regulations to benefit the patient. Three concepts describe this practice: positive deviance, healthcare rebels and tempered radicals.
Scoping review using the Joanna Briggs Institute methodology and PRISMA‐ScR checklist.
Papers describing positive deviance, healthcare rebels and tempered radicals in nursing were identified by searching Scopus, CINAHL, PubMed and PsycINFO. After data extraction, these three concepts were analysed to study the content of descriptions and definitions, competences and stimulating and hindering factors.
Of 2705 identified papers, 25 were included. The concept descriptions yielded three aspects: (1) positive deviance approach, (2) unconventional and non‐confirmative behaviour and (3) relevance of networks and relationships. The competences were the ability to: (1) collaborate in/outside the organisation, (2) gain and share expert (evidence‐based) knowledge, (3) critically reflect on working habits/problems in daily care and dare to challenge the status quo and (4) generate ideas to improve care. The factors that stimulate or hinder the development of rebel nurse leadership are as follows: (1) dialogue and reflection, (2) networking conditions and (3) the managers’ role.
Based on our analysis, we summarise the descriptions given of rebel nurse leadership, the mentioned competences and provide an overview of the factors that stimulate or hinder rebel nurse leadership.
Relevance to clinical practice
The descriptions produced in this review of rebel nurse leadership and the stimulating or hindering factors listed should help nurses and managers encourage rebel leadership.
What does this paper contribute to the wider global clinical community?
- Organisational rules and regulations do not always fit the provision of good care, which challenges nurses. When nurses show more leadership in daily practice it will influence and enhance the quality of care and help retain nurses.
- The understanding of positive deviants, tempered radicals and healthcare rebels, their competences and the factors that stimulate or hinder the development of rebel nurse leadership will help management and nurses to support and develop rebel nurse leadership in daily practice.
From the article
The increasing demand for nurses (Marć et al., 2019) and their high turnover (Duffield et al., 2014; Fasbender et al., 2019; Li et al., 2018) have resulted in a workforce shortage that has an adverse impact on healthcare quality (Aiken et al., 2018; Ball et al., 2014). Research shows that reasons for nurses to resign include the high workload, job stress and little control over their own professional practice (Aiken et al., 2002; Fasbender et al., 2019; Li et al., 2018). Several studies indicate that nurses have lower intentions to leave their profession if they can control their daily practice and show leadership (Blake et al., 2013; Ducharme et al., 2017; Li et al., 2018). Fully understanding the role of nurse leadership in daily practice is crucial, especially with the current challenge of retaining nurses.
There are many studies on nurse leadership in the literature. These studies often highlight nurse leadership from a leader–follower perspective and resonate with the transformational leadership paradigm (Hutchinson & Jackson, 2013). Transformational leadership focuses on the cultural aspects of an organisation and leaders establishing followers with their vision, norms and belief systems (Hutchinson & Jackson, 2013) that create meaning and motivation for the followers (Bass & Steidlmeier, 1999). Many transformational leadership studies in nursing focus on the hierarchical leader, a designated position of leadership of individuals (e.g. nurse manager and nurse executive) versus healthcare professionals (e.g. nurses) as followers (Reichenpfader et al., 2015; Sfantou et al., 2017; Wong et al., 2013). However, these papers direct ‘little attention […] towards understanding how leadership may be enabled in those not in formally designated leadership positions or how organisational processes can be changed to liberate follower's potential to lead’ (Jackson & Parry, 2011 in Hutchinson & Jackson, 2013, p. 14). Many nurses do not have a designated position of leadership, but any nurse can exhibit leadership in their practices. Clark observes (Clark, 2008, p. 30): ‘Some nurses may not think of themselves as leaders because they equate leadership with authority or with specific job titles rather than as a way of thinking or behaving’ in daily work at the frontline. To understand more about leadership in everyday practices, Leadership‐as‐practice (LAP) theory provides insights into the moral, emotional and relational aspects of leadership in daily working life (Raelin, 2011). Rather than envisioning leadership by its rational, objective and technical aspects (Carroll et al., 2008), LAP helps us understand how leadership is enacted by those not in designated positions. It shines light on how the context influences leadership and the dynamics within organisations that foster leadership. The lens of LAP might provide valuable new insights into nurse leadership in daily practice, how it can be supported and how it could influence the retainment of nurses.
Nurses want to provide the best care for their patients, but they work in organisations with rules and regulations that might not always fit their norms and beliefs on what the best care is. In terms of LAP theory, rules and regulations influence the moral, emotional and ultimately relational aspects of leadership in daily practice (Raelin, 2011). Wallenburg et al. (2019) found that nurses may find it challenging to comply with the organisation's rules and regulations and sometimes also feel that the professional guidelines hinder the provision of best quality care for the individual patient. Gabbay and Le May (2016) state that if professionals want to make a good clinical decision for their patients’ care the variability of the multifarious considerations becomes part of their clinical decisions. The authors stated that no theoretical, research‐based knowledge or clinical guideline could ever be expected to cover all these considerations (Gabbay & Le May, 2016). Therefore, nurses sometimes deviate from the professional norms and organisational rules and regulations to generate better outcomes for their patients or to improve processes on their wards. However, hierarchical leaders do not always permit deviation, which requires individual nurses to show leadership as they must balance between conformity and compliance in order to be a ‘good’ employee and deviation to benefit their patients and the organisation of their wards (Berwick et al., 2017). The literature also describes ‘bad rebelism’ and ‘wrong deviation’ (Bevan, 2010); deviating in your own interest and breaking the rules out of anger only undermines the quality of care (NHS, 2016, slide 66).
Several studies describe professionals showing leadership in daily practice as ‘positive deviance’. Gary defines positive deviance as ‘an intentional and honorable behavior that departs or differs from an established norm; contains elements of innovation, creativity, adaptability, or a combination thereof; and involves risk for the person deviating’ (Gary, 2013, p. 29). Bevan's description of deviating professionals in health care (Bevan, 2010) formed the basis of the online School for Health and Care Radicals, established in 2014, nowadays called the School for Change Agents. The purpose of the school was ‘to develop effective change agents, ultimately contributing to fast, large‐scale, sustainable improvement in health and social care, leading to better patient outcomes’ (Grifford et al., 2015). Bevan defines ‘healthcare rebels’ as ‘committed to the patient‐centred mission and values’ of their organisation and see ‘many possibilities for doing things in different ways’ (Bevan, 2013). The set‐up of the school was inspired by Meyerson's book explaining her research on tempered radicals, individuals who ‘navigate the often murky organisational waters to pursue their ideals while fitting in enough to succeed’ (Meyerson, 2008, p. 8). In addition, several other studies in health care describe professionals showing leadership in daily practice as ‘positive deviants’. The concepts of positive deviance, healthcare rebels and tempered radicals describe nurses who deviate creatively from formal rules and regulations, not in their own interests, but for better health care (quality). Wallenburg et al. (2019) observe that deviating healthcare professionals—nurses—tend to ‘stay under the radar’ of management to achieve their goal of improved patient care. To deviate and find another, better way demands experimentation, trying things out and evaluating the results (Clancy, 2010; Meyerson, 2008; Wallenburg et al., 2019). Given that positive deviants, healthcare rebels and tempered radicals ‘stay under the radar’, it is not surprising that these concepts are seldom mentioned in the nursing leadership literature. However, if rebel nurse leadership is better understood, it might be possible to study this more closely in nursing practice. Therefore, this scoping review provides an overview of perspectives on nurse rebel leadership based on the literature on positive deviance, healthcare rebels and tempered radicals.
Nurses’ leadership plays a crucial role in daily practice, especially given the current challenge of retaining nurses and maintaining healthcare quality. This scoping literature review aimed to provide an overview of rebel nurse leadership, culled from the literature on positive deviance, healthcare rebels and tempered radicals. Our review gives insights into nurse rebel leadership, describes the competences of rebel nurse leaders and explains the factors that stimulate or hinder the development of rebel nurse leadership.
After synthesising the descriptions and competences mentioned in the three concepts, we identified several common aspects. Rebel nurse leaders show unconventional nonconformist behaviour that varies or differs from norms, rules, codes of conduct, practices or strategies. They challenge the status quo with their ability to develop and use social networks (peers, other disciplines and management) in‐ and outside their organisation to obtain evidence‐based knowledge. They share information and gain the engagement of others to provide better outcomes for patients and organisations. As a result, these nurse leaders consistently outperform their peers using the same resources.
Important competences are the ability to: (1) collaborate and network with diverse professionals and management in‐ and outside the organisation, (2) obtain and share expert (evidence‐based) knowledge, (3) critically reflect on working habits, organisational logistics and problems in daily care and dare to challenge the status quo and (4) generate ideas to improve care. Factors supporting rebel nurse leadership are as follows: (1) formal and informal communication—dialogues and reflection—to reveal positive deviant behaviour, to support the exchange of normative points of view on the current situation and collectively find new solutions to improve quality, (2) networking in‐ and outside the organisation to share deviant activity and ideas that help to encourage others and (3) management's willingness to stimulate professional deviation.
7 RELEVANCE TO CLINICAL PRACTICE
This scoping review describes rebel nurse leaders, their competences, and provides an overview of factors that stimulate or hinder the development of rebel nurse leadership. This understanding will help management and nurses to support and develop rebel nurse leadership. More nurse leadership will influence and enhance the quality of care and help retain nurses.
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