Band 5 Nurses’ Leadership Development as a Current Care Priority in England: A Qualitative Study of Perceptions, Barriers, and Ways Forward

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Background
In England, there is at present a relatively heavy emphasis on nurses' development of leadership skills [1] to ensure the care nurses provide and delegate is person-centred and of a consistently high standard [1], and to act as a role model for others [1]. Te NHS Healthcare Leadership model [2] emphasises how all individuals in a healthcare organisation can develop their leadership skills, not only those with formal leadership roles. Current workforce policy, therefore, requires all nurses to develop leadership skills, irrespective of band or grade. A strong relationship has been found to be linked between nurses' leadership skills and patient outcomes [3], including that good nursing leadership supports the provision of high-quality care [1,2,4,5], improvements in quality of care provided [6], patient safety [7,8], patientcentred care [9], patient satisfaction [10], staf recruitment, retention and job satisfaction [11,12], efective change management [13], costs reduction [14,15], and fnancial performance [16].
Even newly qualifed nurses are expected to lead on a day-to-day basis; however, they often lack the confdence to lead [17]. Nurses who are qualifed for university degree level enter the NHS at band 5 and are expected to provide excellent professional, skilled, and efective person-centred, evidence-based nursing care [18]. At the current pay scale, band 5 nurses earn £27,055 to £32,934 [19]. As they gain further knowledge, skills, and experience, they may progress to higher bands within the nursing banding system [20].
Arguably, the current situation in England in which newly qualifed nurses often do not receive the training they require to develop their leadership skills early in their careers, risks leaving a crucial skills gap that may extend into the longer term, stymying important leadership development and losing a valuable opportunity to enable nurses to further improve the quality of their patient care [17].
Conversely, there are multiple benefts associated with proactively identifying and developing internal candidates, yet fewer than 7% of healthcare organisations have implemented formal leadership succession planning programmes [14].
A strong argument exists therefore for prioritising nurse leadership training, with potential benefts for individuals and organisations, with "the need for leadership at all levels of nursing. . . overwhelmingly evident" [21]. Despite this, clinical leadership training has been predominantly focused on managers and management-focused training [22], a situation which has historically excluded band 5 nurses from leadership training [23] with a negative impact on workforce efectiveness, efciency, and quality of care delivery [24]. Transitioning from band 5 to band 6 arguably demands high levels of leadership skills, and band 5 nurses may not possess which has led to calls for immediate action to prepare a new generation of nursing leaders [25]. Such calls take on greater urgency given high levels of attrition among experienced nurses in England, who are either leaving the profession or widely anticipated to through a combination of age (1 : 5 nurses in England are 56 years of age or over) and escalating work pressures [26].
Moreover, care service and quality demonstrate improvements where health professionals at all levels have access to appropriate leadership education [22]. Current leadership programmes tend to prepare nurses for leadership roles only after promotion [27], with scant opportunity to develop skills in advance. Tis may hamper leadership development at band 5 and impede the transition to higher levels within the service.

Leadership in Nursing
Despite current requirements for all nurses to develop leadership skills [1], there remains a lack of consensus regarding how "leadership" should be defned in nursing [28]. Te essence of leadership includes nurses' ability to infuence and direct patient care by demonstrating exemplary care [29]. However, leading care is not directly synonymous with leading other staf [30] although there may be much overlap between the two.
Additionally, there is a lack of consistency concerning the styles of leadership employed by senior staf that can be a pivotal role in inspiring band 5 nurses' own leadership development. Winston and Patterson [31] identifed in excess of 90 dimensions of leadership which demonstrates the complexity of leadership as a concept. Tese can be combined and contribute to leadership styles in highly variable ways that may range along a spectrum from autocratic to transformational [32,33].
While taxonomies detailing key attributes of leadership exist (e.g., NHS [2]), it is less clear how band 5 nurses themselves perceive leadership or opportunities to lead, how diferent perceptions emerge, how these may difer depending on diferent settings and circumstances, and which specifc contexts currently contribute to leadership development or impede it. Leadership and how it is defned and practiced is likely to vary according to diferent care settings, bands, and grades that calls for greater specifcity and a move away from using the term "leadership" too generically [34].
Although preceptorship programmes are highly valued by nurses [35], they are not a substitute for continuing leadership development [36] that is underpinned by active, structured support [37].
Tese issues have added gravitas given the signifcant attrition of nurse leaders in the UK within an ageing workforce [38] which necessitates the recruitment of younger and less experienced nurses to fll the gap. Tis is a situation further exacerbated by low stafng levels and high workloads during the pandemic [39] and subsequently that has led to less experienced staf having to take on signifcant levels of responsibility.
Tis study explored these issues and challenges by engaging with band 5 nurses across a diverse range of healthcare contexts, settings, and circumstances. Given the NMC's requirement for nurse leaders to manage and lead care [1] and RCN's [40] call to promote nurse leadership development to ensure high quality, safe, and compassionate health care, this represents a timely juncture to explore the issues and challenges surrounding band 5 nurses' leadership, alongside ways of overcoming them, and to use the insights gained to add to the current knowledge base.

Methods
Te research team consisted of three academic staf who contributed equally to data collection and subsequent analysis. Te lead researcher was an assistant professor of nursing with expertise in leadership and management. Te other team members were an associate professor of nursing and a senior research assistant, both with research expertise in workforce development. Te research team felt that this study's exploration of shared understandings within organisational, policy, and cultural contexts aligned well with Crotty's [41] view, "that all knowledge, and therefore all meaningful reality as such, is contingent upon human practices, being constructed in and out of an interaction between human beings and their world, and developed and transmitted within an essentially social context." Tis supported the rationale for adopting a qualitative methodology situated within a constructivist paradigm.

Sample.
To gain insights into band 5 nurses' experiences of leadership across a diverse range of contexts, the plan was to locate the study in NHS primary care, community care, secondary care, and care homes operated by private and voluntary sector providers across North East England. Participants were accessed via gatekeepers who were service managers working in these providers (matrons, GP practice managers, care home managers, and lead community nurses). Gatekeepers provided their band 5 nursing staf with study information explaining the purpose/aims of the study and what participation involved. Staf were given time to read information sheets which emphasised participation was voluntary and that deciding not to participate would not In total, 18 band 5 nurses responded to the invitation to participate. All were accepted as participants in the study, and all consented to participate. Te response rate was lower than predicted due to the outbreak of COVID-19. Tis impacted the availability of staf to participate, necessitating some scaling back of recruitment, particularly from primary care and voluntary sectors. Despite this, the remainder of the study protocol remained intact and recruitment possible from secondary care (n � 14), care homes (n � 3), and community nursing services (n � 1), refecting a diverse range of nursing roles, NHS trusts, and care-provider operators ( Table 1). As well as representing heterogeneity in terms of being drawn from diferent clinical settings, the sample was varied regarding age groups (20 to 69 years of age), sex, nursing experience from <1 year to >30 years, and country of birth.

Data Collection.
Data were collected via individual semistructured interviews. All members of the research team conducted data collection. Te frst three interviews were face-to-face. Subsequent interviews were conducted online or by telephone due to COVID-19. Interview questions were informed by the fndings of the literature review and explored participants' own experiences of leadership development and practice, and reasons underpinning them. Average length of interviews was 46 minutes, and none exceeded one hour. Tis aforded time to record participants' in-depth accounts of their experiences.

Data Analysis.
Interviews were audio-recorded and transcribed verbatim. Tematic analysis (TA) was used to analyse the data and selected for its profciency in organising, analysing, and reporting patterns (themes) within data in rich detail [42]. An inductive analytical approach was adopted, i.e., data-driven. Te six-phase guide to conducting TA, as outlined by Braun et al. [42], was employed: (i) Familiarisation with the data (ii) Generating initial codes (iii) Organisation of the initial codes into patterns to generate themes (iv) Reviewing themes (checking themes against raw data to ensure a good ft and reclassifcation of themes into levels) (v) Defning and naming themes (vi) Interpretation Trustworthiness was enhanced using three methods. Firstly, all transcripts were independently coded by all three members of the research team, and the codes were compared. Tis supported validation of codes, supporting valid theme development. Teme development was a collaborative process involving all three researchers meeting together to discuss themes. Secondly, attention was given to negative cases, which allowed for discussion of diferent perspectives and contradictions in the data. Analysis of negative cases helped to refne the interpretation of the data. Finally, refexive strategies were used to reduce the risk of researcher bias. Tis was particularly important as the research team had prior knowledge and expertise in leadership and management, and workforce development. Two refexive strategies were used: (i) "oppositional arrangement of perspectives" supports researchers to become aware of the range of perspectives at work within established frames of social norms [43] and (ii) "backgrounding" whereby "background" data (data that on frst analysis may seem less signifcant) are foregrounded. Te transformation from background to foreground prompts researchers to investigate whether any topics of potential signifcance that had not been expected were encompassed within the text [43]. Member checking by sending draft codes and themes to participants was attempted. However, none of the participants were able to respond, as they generally felt that time constraints due to COVID-19 made responding difcult.

Results
Findings from the thematic analysis revealed three key themes representing the staf's experiences of leadership: (i) defning leadership, (ii) opportunities for leadership, and (iii) promoting leadership development. Each of these and interview evidence supporting them will be presented in turn.

Teme 1: Defning Leadership.
Participants struggled to agree on a clear defnition of leadership in the context of nursing; in particular, there was some tension about whether nature/innate ability or nurture was most critical to leadership development. Tis respondent felt that leadership was contingent on experience; i.e., it was nurtured over time: However, the general consensus was that leadership relied on nature/innate qualities, rather than a set of qualities that could be nurtured: Tese comments are interesting for their emphasis on leadership as primarily innate and an inherited trait, rather than universal, and how this appears to run counter to recent directives calling for all nurses to fulfl the requirement to develop leadership skills which assume it is a universal quality.
Participants also associated leadership with a higher level of seniority, beyond their own band 5 status and entrenched within the organisational, hierarchical structure: Participants, therefore, associated leadership with seniority/delegating responsibility to others, requiring a sound knowledge of other staf's competencies.
Despite the apparent majority view that leadership relies on inherent qualities, other evidence appeared to contradict this; i.e., a number of participants felt in nursing it relied on nurture/experience as opposed to natural talent: P13: I don't think people take you seriously to do leadership when you're a little bit younger. . .
Moreover, this view seemed to present a bias as well as a barrier for younger staf who might aspire to lead: P6: I fnd it hard to lead someone who is older or been on the job longer.
Despite these tensions/contradictions, there was consensus among participants that as band 5 nurses they may not specialise in leading staf, but they nevertheless specialised in leading care and participants acknowledged this important distinction: While promotion beyond band 5 was perceived to increase opportunities to lead/manage others, it was also viewed by several participants as shifting away from leading patient care; something, they were opposed to: P5: I don't want to lose patient contact and still be a nurse. I wouldn't want to be a band 6 because of the loss of patient contact.
Despite some reservations, the majority of respondents felt band 6 ofered the best compromise between allowing nurses to continue to lead care while also leading staf. However, promotion to band 7 was perceived by many to denote the demarcation point at which directly leading patient care abruptly ended:

P2: Te idea of being a sister is great, but I don't want my day monopolised by doing rotas/stafng. I want patient contact.
Furthermore, participants perceived band 7 as a point of departure from close, collegiate working towards a more distal, managerial role: P11: I think we've got one Band 7 in the building. We rarely see her.

P11: I've never met a Matron.
While a range of perceptions, some contradictory, were uncovered regarding how band 5 nurses viewed leadership, greater consensus was found concerning leadership style. In general, participants' nurses preferred more democratic leadership styles, especially their perceived capacity to ofer motivation/inspiration/mutual respect: P5: Leadership is a person who you can always turn to who knows the answers but who will talk to you in a way that is encouraging. A notable fnding also was that transactional style was more likely to be evidenced in very acute care settings such as emergency departments, theatres, and critical care wards. Tis suggests that leadership style is not only determined by individual choice but also by context/setting which may be instrumental in facilitating (or impeding) certain styles. One explanation for the salience of transactional style found here in emergency departments/theatres/critical care wards may be that these settings require rapid, expert decision-making, and timely adherence to protocols that make good guidance/ efective knowledge exchange a priority.
Moreover, leadership style may not only be infuenced by context/setting but more specifcally still the unique circumstances currently unfolding within that context/setting. Tis means leadership style may be more fuid than fxed:

P7: [He is] a democratic leader, but he can be a transactional leader and a rational leader.
In summary, band 5 nurses' perceptions of leadership and how it is best defned revealed a range of interpretations that were sometimes contradictory. Leadership in the context of nursing appears to be nuanced, complex, and variable and infuenced by multiple factors, rather than representing a fxed/immutable concept that is easily pinned down.

Teme 2:
Opportunities to Lead. Discussing band 5 leadership, many participants indicated their experience of leading people as a hallmark of leadership (as distinct from leading patient care) was determined by opportunities to lead. Tis appeared very much contingent on work setting/ working arrangements/practical necessity, rather than strategic or planned professional development. For example, participants who worked in care homes highlighted that they were often the only registrant nurse on their unit and therefore automatically expected to lead in terms of stafng/ resources/resident care. Tis expectation fed into nurses' perception leadership was integral to this particular role: Opportunities for band 5 nurses to lead were especially prevalent where senior staf were unavailable and, of practical necessity, responsibility for leadership was delegated:

P3: You're leading the whole ward when your manager is not there.
Respondents working on wards in secondary care welcomed opportunities to take on a stronger leadership role, but some would like more frequent opportunities: By contrast, participants working in ITU settings indicated there were generally few opportunities for leadership. One respondent revealed that in their area of practice, band 5 staf is actively discouraged from leading: P6: I am. . .more encouraged to stay at the bedside and try to limit my job to. . .doing observations-not expressing leadership skills.
Care setting also limited opportunities to lead where participants worked in the community. Although band 5 nurses were assigned case-loads conferring much responsibility, they primarily operated as lone workers that restricted them to leading patient care:

P14: I am a leader of my own care for my own patients.
A key fnding in general was that although band 5 nurses had ample opportunity to lead patient care, opportunity to lead people was highly variable and contingent on context/ circumstances. Some participants were seldom ofered the opportunity to lead people, while others were comparatively overwhelmed with opportunities. Often, this meant an imbalance regarding opportunities to lead people, as highlighted by these participants working in theatres and EAU who often faced emergency situations: P7: . . .a band 6 as team leader. . .rang in sick so I was moved up as the team leader. . .It was quite a struggle, obviously. I said. . ."it's not my choice to be the team leader, I was put here and I'll play that role, but if something happens, it's my name they're going to. . .chase up." P14: We went on shift one night-it was me and another junior member of staf. . .we were left in charge of the patient services as well because they'd gone of sick and no one could cover. So, we were in charge of bed management in the hospital, as well as running the suite. . .I was nervous. . . While more experienced band 5 nurses may be very capable of taking on intensive leadership roles, there needs to be a choice, rather than an expectation of compliance. Such decisions should always place patient safety frst. Band 5 nurses made a clear distinction between leading care and leading people with opportunities to develop the latter being highly variable and contingent on individual context/ circumstances.

Teme 3: Promoting Leadership Development.
Responses indicated a paucity of formal development via bespoke training/development programmes. In lieu, all participants reported heavy reliance on informal development that could be limited to being self-directed/opportunistic, i.e., observing colleagues, rather than planned or more deliberately co-ordinated: However, that informal training can be efective is illustrated here: P14: I get the most out of the time I've shadowed "X" who is the band 6 because she is making all of these decisions. . .she's explaining how processes work, she'll go through anything with me and explain why she's made the decision. She's got all the qualities of a leader. . .
Where informal training seemed particularly efective was when senior staf demonstrated a transformational leadership style that inspired trust, motivation, and empowerment in band 5 nurses: P13: . . .if I work alongside the Band 7's they are good at developing us or empowering us to do some leadership assignment. Usually, this goes with the patient care itself, like managing the zone and. . .I can perceive a sense of empowerment. Tat they're trying to input encouragement for me.
While the opportunity to shadow/mirror good leadership and receive encouragement/opportunities to develop it may be vital, arguably band 5 leadership should also be encouraged through formal leadership training as an adjunct to this: Tese examples illustrate how band 5 nurses may often be motivated/dedicated to the formal development of leadership skills, in accordance with guidelines recommending this (e.g., [1]), but can face systemic bias that prevents them. Moreover, this systemic bias appears to persist even among band 5's employed in settings where good leadership is essential to their role: P7: . . .we're team leaders for night shifts, but we didn't get the formal training of what being a team leader is, what qualities you need to lead a team.
Even where an exception was found and one participant initially granted support for formal leadership training, the promised support was unforthcoming: P8: I'm doing the Nightingale course so I'm meant to have a 1: 1 mentor and to actually do some shadowing and things with them, but that hasn't happened. . .
Moreover, the Florence Nightingale Leadership Development Course represents one of only a handful of formal leadership courses currently available to band 5 nurses in England.
In summary, band 5 nurses valued good quality informal leadership training that included shadowing/mirroring. Tis could be facilitated by the senior staf's adoption of a transformational style [44]. However, informal training could be limited to being self-directed/opportunistic, rather than planned/more deliberately co-ordinated. Opportunities for formal training were limited/not fully supported.

Discussion
Tematic analysis of the data elicited several key fndings, and a robust attempt was made to ensure proportionality between the data and the analytical claims and conclusions presented in this discussion.
Consistent with previous fndings (e.g., [28,45]), this study found a lack of consensus regarding how band 5 nurses perceived "leadership" in the context of nursing. While one participant held the view that leadership is created by an amalgam of nature/nurture, others felt that strong leadership required a particular set of innate qualities closely intertwined with personality traits. Tis latter view runs counter to recent evidence that traditional trait or personality approaches are of little value when it comes to delivering leadership training (e.g., [16]). Contradictions were also found in this study; e.g., while many respondents perceived leadership to be an innate quality, they also felt entitlement to lead was based on nurture/experience, rather than innate abilities/talents. Tis also appeared to present a bias against younger staf leading or aspiring to lead. Tese comments are interesting for the way they appear to run counter to recent directives calling for all nurses to fulfl the requirement to develop leadership skills (e.g., [1]) that carry the assumption all nurses are capable of leading both care and people.
Leadership was most frequently associated with hierarchical stafng structures and "top down," from the management level to the staf nurse on the ward and particularly the managers and those who held band 7 and band 6 positions. Tis required the ability to delegate responsibility to others and sound knowledge of other staf's competencies. Notably, however, the majority of participants felt leadership was associated with higher seniority, beyond band 5, and therefore largely outside their domain. Tere was consensus that band 5 nurses had a leadership role in terms of leading patient care. Notably, though, leading care was perceived to be quite diferent and discrete from "leadership of other people." Participants perceived "leading care" to be as vital as "leading people," if not more so, but viewed them as mutually exclusive. A few band 5 nurses recognised that although they wielded less authority, they carried out a leadership role-albeit at a diferent, often lower hierarchical level. Taken together though, the fndings support Stanley's [22] contention that more work is needed to outline what clinical nurse leaders are, and how they can recognise themselves as leaders.
Te fndings further reveal that band 5 nurses strongly perceive they work within a fairly rigid hierarchy in which clear divisions exist between themselves as subordinates on one side and leaders/management on the other in which "leadership" was frequently perceived to be synonymous with "management," especially beyond band 6. As Stanley [46] emphasises, "leadership" and "management" are not interchangeable concepts and there is danger in using them indiscriminately to delineate roles within healthcare systems. Management is primarily concerned with assuming control and maintaining a clear division between workers/ patients [47], and this should not be confated with leadership in healthcare which should ideally involve a more closely bound relationship between staf [48] and also patients [24]. Adherence to older 20th-century management models that promote hierarchical ordering of staf in which leaders and "subordinates" work in separate spheres have come under criticism for being outmoded/inefective [49], particularly where they continue to be applied within the NHS [9].
A related fnding was band 5 nurses' perceptions that promotion automatically signals a shift towards management and a concomitant move away from nurses' principal vocation to provide the patient care in close collaboration with colleagues. Such perceptions potentially presented serious barriers to seeking promotion or fulflling aspirations towards leadership. Tese perceptions appeared to be reinforced when senior staf adopted more autocratic leadership styles consistent with more rigid/hierarchical ways of working, and the more arcane management models discussed earlier.
Greater consensus was found regarding band 5 nurses' perceptions of what constituted optimal leadership style where high value was placed on senior staf's adoption of more democratic styles. Regarding this, the transformational style of leadership was valued highly, especially where it was 8 Journal of Nursing Management manifest in senior staf's adoption of an approachable, motivating and reassuring stance that presented a good role model to follow and inspired trust [44]. As Gopee and Galloway [50] note, efective leaders tend to focus on infuencing staf's behaviours and especially motivating, inspiring and energising individuals. It is not only how band 5 nurses perceive/defne leadership that may be important but also the example/infuence set, refected in senior staf's leadership style. By contrast, autocratic leadership styles were perceived negatively. Of note, this study found evidence that senior staf who promoted knowledge exchange in an approachable and collaborative way were more likely to be found in very acute care settings such as emergency departments, theatres, and critical care wards. Tis perhaps refects the need in such settings for rapid, expert decision-making, ensuring the team closely adheres to set protocols in a timely manner. Tis fnding underscores the importance not only of leadership style but also context/setting in providing ideal environments for certain styles to fourish. Participants working on wards in secondary care similarly reported opportunities to take charge of their ward and lead staf and patient care. Nevertheless, there needs to be a balance. Some band 5 nurses expressed concerns they sometimes felt overwhelmed with opportunities to lead and out of their depth. Arguably, there is a requirement for training in leadership in advance that should accompany opportunities to lead.
Meanwhile, band 5 nurses who worked in care homes were often the only registrant nurse on their unit and automatically expected to lead in terms of stafng, resources, and resident care. Tis expectation-reinforced nurses' perception leadership was integral to their role but not necessarily supported by specifc leadership training.
By contrast, participants working in ITU settings indicated that, in general, there were limited opportunities for leadership with one participant reporting active resistance to this by senior staf. Similarly, band 5 nurses working in community settings rarely encountered opportunities to lead due to their role as lone workers.
Evidence was found for participants' motivation to acquire leadership skills. However, while this could be encouraged where senior staf adopted more democratic leadership styles (e.g., transactional or transformational styles), opportunities for leadership development were frequently found to be contingent on conducive care contexts/ settings which were only available to some band 5 nurses. Moreover, leadership development trended to be limited to being self-directed and opportunistic, rather than planned and deliberately co-ordinated.
Tis study highlights how both these factors make access to informal leadership development by band 5 nurses highly variable and not always equitable. Tis inequity was likely to be exacerbated where there was a lack of support for band 5 nurses' formal leadership training, which this study also uncovered. Tis is a situation also made problematic by the paucity of training programmes currently available in England.
One way to restore equity/increase opportunities for leadership for all nurses would be the creation of nationally available, formally validated leadership development programmes dedicated to promoting leadership of people as distinct from leading care and bespoke/available to all band 5 nurses who wanted it, irrespective of age. Programmes should ideally focus on developing clinical leadership skills and potential, as distinct from managerial skills training and complement rather than detract from leading good patient care. Ideally also, training should be resourced and overseen by an external governing body to ensure that it combines formal training supported by mentors with ample opportunities for practice-based training alongside informal shadowing/mirroring of good practice as an important adjunct rather than a replacement to this.

Limitations.
Tis was a relatively small-scale crosssectional study involving 18 participants from North East England. Te response rate was lower than planned due to the outbreak of COVID-19 which impacted on the availability of primary care and voluntary sector staf. Further research is needed in this area, including consultation with larger samples from other regions and a wider range of clinical settings to establish how band 5 leadership training could be better designed, resourced and implemented, and externally governed and validated.

Conclusions
Tis study explored band 5 nurses' perceptions of leadership across a diverse range of diferent healthcare contexts/settings in England. Tis revealed a number of defciencies and inconsistencies regarding how leadership is defned, characterised, and promoted. Ways of improving quality and provision are discussed. Given high rates of senior staf attrition in England and recent guidelines promoting nurse leadership development at all levels as a prerequisite to high quality, safe, and compassionate health care, there is a burgeoning need for renewed discussion of band 5 nurses' leadership development.

Data Availability
Te data supporting the current study are available from the corresponding author upon request.