A qualitative descriptive study of effective leadership and leadership development strategies used by nurse leaders in European island countries

Abstract

Aim

Nurse leaders influence workplace culture; however, little is known about ethnic cultural influences on nurse leader development. This research aims to identify personal strategies promoting effective leadership by nurse leaders from European small island countries.

Design

Descriptive qualitative study.

Methods

In 2017, nineteen semi‐structured interviews with nurse leaders from England, Greece, Republic of Ireland and Malta explored leadership journeys, strategies employed to support their growth and development, and how cultural identity played a role. Transcripts were analysed using reflexive thematic analysis.

Results

Four main themes and 12 subthemes captured the strategies and approaches of the nurse leaders: (1) Influences, (2) Communication, (3) Process and (4) Relationships. These findings reflect and validate the five transformational leadership practices of the Exemplary Leadership Model. While cultural island identity was discussed, there was a shared cultural identity within the role of “nurse leader” that spanned all islands.

Patient or Public Contributions

Nineteen nurse leaders contributed to this study.

1. INTRODUCTION AND BACKGROUND

In the ever‐changing health care environment, it is imperative that nurse leaders are prepared and equipped to face the various challenges that come with guiding change (Porter‐O’Grady & Malloch, 2019). Studies demonstrate that effective nurse leaders can positively influence nurse satisfaction, nurse retention and patient outcomes (Hughes, 2019), for example in a review of the literature, quality leadership emerged as the most important element for a healthy work environment (Shirey, 2017). There is growing recognition that leadership in health care is a practice‐based activity grounded in the local cultural and organizational context (Edmonstone, 2018). According to Brown (2018), is it important for leaders to have conversations about cultural norms and differences because different cultural messages and expectations can corrode trust and psychological safety. Several papers address nurse leadership influence on the organizational culture (Yodang & Nuridah, 2020), but few have considered or compared if there is an ethnic cultural influence on the nurse leader development and leadership strategies.

In European nursing history, nursing organizations, nursing concepts and nursing practices developed mutually in transnational exchanges between multiple European countries over the last 200 years (Kreutzer, 2019); however, according to the World Health Organization (WHO), in Europe 20 years ago, there were widely differing roles and conditions related to nursing between European countries (Salvage & Heijnen, 1997). Subsequently, the WHO placed an emphasis on measuring outcomes of nursing interventions across countries in Europe (Salvage & Heijnen, 1997). The Nurse Forecasting Human Resources Planning in Nursing project investigated the effects of nursing workforce dynamics such as number of nurse staff, skill‐mix and working environment on nurse job satisfaction, intention‐to‐leave, patient satisfaction and patient outcome in European countries (Rafferty et al., 2019). A follow‐up project provided an overview of the key structural and organizational factors to inform the dynamics of the nursing workforce in 14 European countries (Rafferty et al., 2019). While this research found important themes related to policy issues, quality of care, workforce planning, education and training and regulation and migration, the study did not explore nurse leadership, leaving a gap about the influence and role of nursing leadership on the wider nursing profession (Rafferty et al., 2019).

Just as there are differing roles and conditions among nursing in different European countries, (Salvage & Heijnen, 1997), nurse leadership development is dependent on the cultural context of a country. The cultural context of leadership, defined as the shared meaning, norms, values and expectations of how leadership is exercised, strongly influences leadership behaviours and development (Eti‐Tofinga et al., 2017). Island countries may have historic influences from other nations such as colonialism and contemporary influences such as economic trade (Billot, 2005); however, island countries remain culturally distinct due to the persistence of local indigenous culture and geographic separation from other nations (Eti‐Tofinga et al., 2017). Island countries can share cultural similarities, such as distinguishing insiders and outsiders which helps islanders gain a sense of self‐identity, safety and security in an uncertain world (Billot, 2005). Overall, these small‐island cultural values and island context influences the ways in which leadership is framed, constrained and facilitated (Billot, 2005). Nurse leadership development in small‐island culture is not well studied, and research on nurse leadership development from large countries, for example in the United States and within Europe may not be appropriate in small island contexts.

The purpose of the present study was to address a gap in knowledge regarding nurse leadership with consideration of cultural nuances and influences, specifically within the context of four European island countries: Malta (M), the Republic of Ireland (I), Greece (G) and England (E). Our goal was to understand the personal strategies that nurse leaders employ to promote effective leadership, if they varied by island culture, and how we may learn from them. These islands were identified as they are broadly comparable in terms of size, funding of health care systems and nursing practices, meaning that cultural influences may be easier to identify.

2. METHODS

2.1. Design

This was an exploratory descriptive qualitative study. The local Institutional Review Board granted ethical approval (IRB00131727). This study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines (Tong et al., 2007).

2.2. Data collection

A sampling strategy of purposive and snowball sampling was used with the rational that this approach enabled identification of individuals who could provide contextual meaning, specifically nurses with experience of the “defined social processes” of accomplished academic, clinical, and administrative nurse leadership in Malta, the Republic of Ireland, England and Greece (Luborsky & Rubinstein, 1995). These countries were chosen because of significant cultural differences and similarities in island population size. Leaders residing in the respective European countries identified and emailed introductions between potential participants and study team.

VH, an experienced, doctoral prepared, qualitative researcher and academic faculty, developed the interview topic guide, confirming contextual understanding of phrasing in each country with independent nurse representatives (see Appendix 1). Interview topics rather than specific questions and prompts are provided in Appendix 1 as specific questions were adapted for language and cultural nuance. VH conducted semi‐structured interviews in‐person, over the phone (lasting approximately 1 hr) or via written response based on the preference of the participant. Due to funding constraints in the study, we were unable to access verbal translators. Therefore, the option of written communication meant that free online translation services could be used to support data collection, with back‐and‐forth probing, with those who were less comfortable communicating verbally in English. Emailed or written responses instead of telephone or face‐to‐face interviews were chosen in the case of participants who were less comfortable with spoken English, or in cases where there were scheduling challenges. Prior to the telephone or face‐to‐face interviews, participants received written information about the study, time to ask any questions, and informed they could interrupt or stop the interview at any stage without question. Participants provided both oral and written consent to participate in the face‐to‐face interviews. The participant for the telephone interview, the email returned response and written responses provided oral consent. The written responses contained no personal identification information.

2.3. Analysis

VH transcribed the interviews and RW and CL (doctoral‐trained nurses with expertise in qualitative research methods) undertook an independent inductive analysis using reflexive thematic analysis (Braun & Clarke, 2006, 2021a, 2021b) supported by Atlas.ti software. We selected reflexive thematic analysis due to the onus on the researcher to consider the impact of personal, functional and disciplinary reflexivity on the process (Braun & Clarke, 2021b). This was fundamental given that we were considering leadership experiences from a range of cultural nuances but within one profession. In the first phase of analysis, RW and CL individually reviewing the raw interview data to identify key words and phrases and summarize the broad meaning identified in the data pertaining to participant’s histories and reflections on their leadership journey. They met to discuss their progress and interpretation of the data and review their early observations. In phase two, RW and CL performed individual, systematic data coding, meeting to discuss their progress, reflect on personal interpretations and develop a coding schema. For example, both researchers noted that across all interviews, participants shared challenges to their development, learning, intended practice changes and leadership journeys. In phase three, RW and CL compiled the codes into potential themes, using the coding schema to identify relationships, patterns and meanings between the codes. Building on the earlier example, the challenges identified across the interviews were now classified as barriers, as all demonstrated specific mechanisms that had prevented or delayed either their own leadership growth or the growth and change they wanted to implement as leaders. In drawing out this early understanding of a potential theme, it was noted “small island culture” influenced the ways that barriers might occur, but there was considerable overlap between the island countries and the experiences of being a nurse. Therefore, the potential theme “barriers” reflected a shared experience across the nurse leaders in locations of limited size, resource and opportunity, rather than highlighting barriers that stemmed from unique (island) culture‐influenced encounters. In phase four, through discussion and reflection of the data, RW and CL reviewed the themes against the coded extracts from phase one, building a thematic map (sometimes called a coding tree, see Appendix 2) to capture the story of the data against the research question(Braun & Clarke, 2021b), as discussion and checking of potential themes helped demonstrate where broad, overarching themes encapsulated a series of subthemes. Braun and Clarke (2021b) discuss this flexible approach to blending activities across the six phases, as analysis can become recursive within the reflexive approach. In practice, RW and CL observed that codes lay within 12 subthemes that sat within four overarching themes. Some particularly rich codes were used to inform more than one subtheme and theme, for example one participant discussed challenges to their progress that came from resentment or indifference of their colleagues. This code was placed within the subtheme “barriers” which itself sat within the overarching theme of “influences”, but it also spoke to the subtheme of “connections” and the theme “relationships”. Finally, in phase five, to verify their findings, RW and CL met with VH for peer review of their processes, specifically to determine the credibility of their analysis within the wider context of nurse leadership. The process included discussion of discrepancies and refining of the subthemes and overarching themes. This process also ensure that data (Walker, 2012)themes were identified pertaining to the leadership experiences and strategies of the participants (Walker, 2012). In phase 6, Finally, RW, CL, JT and CP(two nurse researchers, trained in qualitative methods) performed a final review of Braun & Clarke (2021a), or additional themes, or subthemes, and reflected on the 20 question‐tool for evaluating thematic analysis (Braun & Clarke, 2021a).

3. RESULTS

A total of 19 European leaders in senior government, academic, administrative and clinical leadership positions consented to participate in the study (Table 1). Table 1 is limited to participant ID code, island country and years in leadership to protect the anonymity of the participants. Five participants were from England, four from Greece, four from the Republic of Ireland, and six were from Malta. Eighty‐four per cent were female (N = 16), and the mean age was 49 (range 32–60). The mean number of years in a nursing leadership role was 17 (range 3–38, one data point not given). Fourteen interviews were completed in‐person, one via telephone, and four via written communication.

TABLE 1.

European Island participant demographics

Participant	Island country	Years in leadership
EP 1	England	33 years
EP 2	England	8 years
EP 3	England	18 years
EP 4	England	7 years
EP 5	England	17 years
GP 1	Greece	8 years
GP 2	Greece	8 years
GP 3	Greece	No Response
GP 4	Greece	38 years
IP 1	Republic of Ireland	16 years
IP 2	Republic of Ireland	15 years
IP 3	Republic of Ireland	20 years
IP 4	Republic of Ireland	30 years
MP 1	Malta	3 years
MP 2	Malta	16 years
MP 3	Malta	30 years
MP 4	Malta	8 years
MP 5	Malta	8 years
MP 6	Malta	21 years

Through the processes of data analysis, we found that there was considerable overlap in the experiences of leadership journeys across the different islands. Although some cultural nuances were expressed (“In my culture, it is necessary to be a diplomat and less dynamic.” GP2), in general the limitations and opportunities experienced across the participants were closely aligned and connected to working in the environment of a small island:

[It’s] still about who you know in Ireland; the connections are your inroad. IP2

Sameness is part of Maltese culture. Groups stick together. Others follow and do the same…[with a ] very rigid structure…team playing, collaboration, get buy in. MP5

Due to this strong overlap and relationship between growth as a leader in the context of a small island, the thematic findings took shape around four identified four overarching themes: Influences, Communication, Process and Relationships (see Appendix 2). Nested within each theme were between two to four subthemes that further expanded and exemplified attributes and behaviours salient to the nursing leadership experiences provided (Appendix 2). Each theme included contributions from multiple participants representing each of the islands included in this study. Participant contribution is designated following the quote in parentheses with the Island (E = England, I=Ireland, M = Malta and G = Greece) and participant number, that is EP1 indicates English Participant number 1. Appendix 2 presents an extract from our coding tree, capturing the overlap in experiences between participants. Quotations have been edited for grammar.

3.1. Theme 1: Influences

The first theme identified was that of Influences. Influences referred to forces impacting professional or leadership development. Subthemes embedded within Influences were Values, Self‐Schema, Entry to Leadership and Barriers. Values were a force impacting development in that they were the core concepts that define and give meaning to role. One participant from England defined that values a leader should demonstrate are “a willingness to listen, tolerance, a belief in self, resilience and confidence to just enact justice and fairness” (EP5). Another Irish participant stated that developing leaders should “be brave; be bold; trust instincts; be true to self; connect and collaborate; don’t be afraid to take calculated risk” (IP2).

Like values, self‐schema was found to be an influence of development because it refers to a dynamic mental model of the individual’s professional self. A leader from Greece stated “There are no specific factors that can influence my leadership style because I have self‐confidence. I feel strong and sure about myself and I love my job” (GP4). An English participant reflecting on their experience, recommended for new leaders to “be true to yourselves, gain confidence and competence in your own self leadership and be mindful of the moral and ethical decision‐making and unintended consequences of what might happen as a result of your decision‐making” (EP5). These perceptions of self were described as shaping leadership style and work.

Entry into leadership was another influencing force in leadership and professional development. This subtheme refers to the point at which individuals began developing leadership skills or role. Initiation of development was either internally or externally motivated. Internal motivation included “Felt stifled in job and needed to take on more responsibility” (IP1). “Part of my individual make‐up. Leaders are born and have certain personal attributes. Because I wanted to make a difference and I was capable. I could influence…” (IP2). “I wanted to look at nursing in more depth than clinical practice work would allow” (EP3). External drivers were stated as “Nurse leader (officer) told about courses and motivated me” (MP6).

Unlike the previous influences, barriers were seen as impeding forces to adaption and adoption. Multiple participants from each island spoke to barriers, with a striking subtheme of intra‐professional struggle. One Maltese leader listed barriers as “Doing the right thing but getting yelled at. Know [sic] how to help patients but do not have the resources” (MP6). Another leader spoke of “lack of support by other nurses…” (IP2). Another leader further described this type of barrier as “Envy from other senior people.” (IP3). Two Greek leaders noted barriers to leadership development were erected by “the jealousy of the upper management” (GP2) and the “Indifference of colleagues and amateur behavior of all parties” (GP3). Finally, an English leader stated that “I have worked in a dysfunctional organization group that was very punitive. I had to work in my role to try to soften the environment and make the environment more rational” (EP1). All of these influences, whether positive or negative were felt to be impactful on growth and development as a leader.

3.2. Theme 2: Communication

The theme “Communication” referred to the interpersonal transmission of information and contained three subthemes: verbalization, advice and improvement. The thread of communication shaped leadership growth and development and was universally experienced among the participants. Communication was manifest through verbalizations. Verbalizations referred to receiving and transmitting information with purpose and clarity. For example: “Listen well; communication is key; keep talking; establish what you want; when you know what you want then can negotiate better” (IP1). Advice was another type of communication that supported leadership growth. Advice referred to transmission of lessons learned provided to assist another’s growth and development. Advice that shaped these leaders included: “Collegiality is important. Be accessible” (EP2). “Be hard‐working, fair and strong in order to handle all the tasks and as far as they can to help people” (GP1). Finally, “have [sic] patience and time management” (MP5). Notably, across the islands, the advice given was about management of self versus management of processes.

Along the lines of advice was the communication subtheme of improvement. Improvement referred to messaging that aimed at reinforcing growth. All leaders recognized that their growth was a continual journey throughout their careers. They spoke of how advice pushed them to use even challenging encounters to reinforce growth and personal development. One powerful reflection on improvement included “Learned that had to get enemies to give me advice ‐ how to deal with obstructers” (MP2).

3.3. Theme 3: Process

The final two primary themes, “Process” and “Relationships,” operationally focused on specifics in how to become a leader. These are in contrast with the previous themes of communication and influences, which spoke to stimuli that impact leadership development. Process referred to the method or means of leadership development, experienced by multiple participants across the geographic sample. Subthemes of Process were Change (institutional role or work adaptation to new expectations or methods) and Informal v. Formal (methods of acquiring role and expertise). The process of change included “Political awareness was very helpful in understanding how a process works and how decisions are made” (EP1). Another change strategy was “Be strategic on how you align with the organization. You need to add value. Developed a strategic plan with buy‐in of the big deans” (EP4) and “Take shame away and focus on change” (MP6). Additionally, “Need an insider and outsider ability to critic and make changes; be a troublemaker in a way that you are invited back for a solution” (IP4).

Along with Change, “Informal versus. Formal processes” were instrumental to leadership development. These processes referred to methods of acquiring expertise. “A Masters in Business Administration [sic] helped early in career on projects. [My] Main learning occurred at the grass roots level” (IP3). “[It’s] Still about who you know in Ireland; the connections are your inroad; learning strategies … to understand; important to do your homework first” (IP1). One Greek leader noted that growth occurred from “broad range of experiences” (GP4) while an English counterpart noted “The real work happens outside of the meeting. Nothing useful happens in the meeting” (EP3).

3.4. Theme 4: Relationships

The final theme, “Relationships” (associations impact leadership development) was universally expressed as transformational. The associated three subthemes were Mentorship (guidance given from a place of experiential knowing), Role Models (leaders to be emulated) and Connections (interpersonal skills and relationships that must be navigated to be successful). Exemplars of Mentorship that fostered leadership skill and capacity were “Working with the chief nurse prepared for leadership roles; mentoring from leader with opportunity to flex; represent office but also present own work; taught how to mentor others; have a defined career structure: clinical pathway, management path, education path” (IP2). Also, a mentor should “Have to be knowledgeable (experienced). Have courage, professional and not let others push them down – no [sic] professional jealousy. Admit mistakes” (MP3). These mentors worked directly with the emerging leaders.

Role Models were seen as a distinct entity, that of a different leader to be emulated: “Role models both good and bad enabled me to see who I would want to be like” (EP3). “Experiential learning; nurtured and developed by influential and progressive leaders. A young manager/director of nursing who went on to be the human rights leader; she was a great role model.” (IP2). “Role models helped me. Modules of leadership ‐ training days ‐ conflict resolution” (MP1) As such, role models were seen as important sustainers of leadership growth and development. The final relationship articulated was one of Connections. That ability to “build bridges” was seen as very important to successful leadership. “In my culture, it is necessary to be a diplomat and less dynamic” (GP2). The ability to build connections needed “a combined hard and soft side; need straight speaking (direct) with political acumen; know how to make a pitch to the group without aggression or undermining individuals; need to be a vision maker” (IP4).

4. DISCUSSION

In our exploration of the personal strategies employed by nurse leaders to promote effective leadership and leadership development, we identified four main themes, Influences, Communication, Process and Relationship and 12 subthemes. The themes and subthemes were derived from an inductive analytical approach undertaken primarily by two nurse researchers experienced in qualitative methods, but less familiar with the theories and history of international nursing leadership outside of their respective countries (CL is North American, RW is English), and then latterly confirmed by two further nurse researchers, also trained in qualitative methods. However, the transparency of qualitative research allows us to acknowledge the preconceptions of the research, and in this study, we highlight the expertise of VH in nursing leadership (Hughes, 2017a, 2017b; Hughes et al., 2019, 2020) Her observations and recognition of gaps in the literature led to the development of this study, and she anticipated seeing cultural differences impacting the types of strategies utilized by nurse leaders within island countries. As the study team approached the analysis, the decision was made that authors RW and CL would independently conduct the analysis. The purpose was to reduce the potential for “leading” the findings based on the preconceived expectations and expertise of VH who had already carried out the data collection activities. To this end, as described previously, VH role in analysis was to review the findings at a later stage of the analytic process as a means of bracketing any potentially biasing perspectives (Tufford & Newman, 2012). We used an inductive approach, purposely avoiding using an underpinning theoretical or conceptual framework to guide the data analysis as stated and identified four main themes with 12 subthemes.

Interestingly, as stated, cultural and ethnically driven strategies were occasionally mentioned by participants, but not with the emphasis anticipated by VH initially. Rather, on reflection of the collected findings of the analysis, VH instead identified a clear connection between our findings and the Exemplary Leadership model, discussed below (Kouzes & Posner, 2017) (Figure 1). Herein, patterns were more reflective of the culture of nursing and the identity of being a nurse, rather than the identity of being from a specific island and its prevailing ethnicity and culture.

FIGURE 1.

Study themes and subthemes with representative quotes

The participants in the study had the vision and ability to lead change into reality. As stated, the attributes and behaviours of the accomplished nurse leaders that emerged during the thematic analysis fit well with transformational leadership, specifically the work of Kouzes and Posner (2011) in the Exemplary Leadership model. The theory provides an interesting framing for the study findings, speaking to the present focus in nursing, and giving an unexpected finding of transformational leadership operationalized within nursing leadership practice in four European island countries. We have created a visual representation using a crosswalk approach, to depict the nesting of our findings within the Five Practices of Exemplary Leadership (Kouzes & Posner, 2011) (Figure 1).

The idea of transformational leadership has evolved over time. Bass (1985) presented a formal theory of transformational leadership building upon the earlier work of Burns’s (1978). Kouzes and Posner built upon some of the transformational concepts to help refine understanding resulting in the development of the Exemplary Leadership Model (Abu‐Tineh et al., 2009). Transformational nursing leadership has been widely studies internationally (Hughes, 2019) and has demonstrated a significant positive relationship with both patient care outcomes and nursing. Specific benefits have been noted in improvements in patient satisfaction, patient mortality, healthcare utilization and patient safety (Hughes, 2019). Further, transformational nurse leadership was associated with enhanced nurse retention, decreased workplace civility and increased nurse intent to stay (Hughes, 2019). As shown in Appendix 2 and Figure 1, the themes and subthemes from this study contain applicable strategies for nurses seeking to develop as effective leaders.

As part of the demographic data collected, the participants shared their successes across their careers. Though the interviews focused more broadly on the strategies and approaches taken in leadership, it is important to acknowledge the magnitude of the accomplishments the leaders achieved. The nurse leaders challenging the status quo with accomplishments that range from excellent to extraordinary. Some of the nurse leaders focused on creating healthy work environments that resulted in high nurse retention rates. Others focused on improving patient outcomes via leading national nursing research, driving national policy changes and implementing national structural empowerment through the creation of new nursing leadership positions. Still other nurses obtained positions within the national government to influence drastic changes in nursing curriculum and advanced practice nurses' scope of practice. In addition, the study participants strengthened nurses to learn how to think on their own and celebrated the victories by letting others share the credit for successes. Demonstrating faith in the ability of others and developing trust was a key part of leadership success. The findings support the claim made by Kouzes and Posner (2011) (Kouzes & Posner, 2011) that successful leaders demonstrate Exemplary Leadership Practices across different cultural contexts.

Nurse leaders in this European study identified barriers to leadership development such as jealousy, envy by senior people, working in nursing silos, not knowing how to play politics, lack of support, lack of preparation for the role and lack of resources. A literature review by Hughes (2019) discovered similar nurse leadership barriers wherein barriers to effective nurse leadership fit into four subthemes: nurse leadership development, nurse enacting leadership roles, nurse leader advancement and nurses serving on boards (Figure 2).

FIGURE 2.

Barriers to effective nurse leadership

Hughes (2019) identified lack of support as one of the key barriers to the nurse enacting the leadership role and conflicting priorities and time management (aspects of work/life balance) as barriers to nurse leadership advancement. Similarly, Kalaitzi et al. (2019) identified a lack of support and work/life balance as barriers to women’s leadership in Greek and Maltese healthcare settings during a qualitative analysis of interviews with 36 academic, clinical and administrative healthcare leaders. The top barriers identified in Greece and Malta to women’s leadership in health care were work/life balance, lack of family support, gender gap, gender bias and a lack of social support (Kalaitzi et al., 2019). Additional healthcare leadership barriers identified less frequently for Malta and Greece included a lack of leadership skills, lack of mentoring and networking, lack of confidence and lack of flexible working environment (Kalaitzi et al., 2019). A lack of perceived support, opportunities to gain financial or board‐level experience, attend leadership training or have mentorship often due to workload distribution were barriers to preparing director of nursing leaders in England (Cabral et al., 2019). Similarly, nurse leaders in Malta and the Republic of Ireland identified a lack of leadership preparation, limited opportunities and heavy workloads as barriers to nurse leadership development (Hughes et al., 2019, 2020). The lack of nurses serving on organizational boards in Ireland resulted in a lack of representation of nurse interests and nurse authority (Fealy et al., 2011).

5. LIMITATIONS AND IMPLICATIONS

One limitation of the sample is the participants represent those who have been successful in their careers in terms of gaining leadership roles. As such, the perspectives on what equates to effective leadership and leadership development may not be shared by those not in positions of power. Therefore, while we present our findings as potential strategies to support future leaders, they must be understood within the nuanced perspective they represent.

Second, while the research was conducted across several islands with different cultures, Malta, Greece and Ireland all experienced colonization by the UK, and the influence of the British nursing model is evident globally. As such, some of the similarities may stem from this aspect. While the influence of the British arose in some of the interviews, it was not discussed enough to inform the analysis, though it does represent an opportunity for future research. The similarities in experiences may be found in “smaller” locations, for example those with few opportunities for promotion and advancement. As such, future research could explore leadership journeys in rural communities of continents, for example the United States, Africa and mainland Europe.

6. CONCLUSION

The strategies used by the European nurse leaders to overcome barriers to advancement, role enactment and visibility on policymaking can be used by clinical nurses. European nurse leaders described intrapersonal struggles, reflection on values and self‐awareness as coping mechanisms to overcome barriers and to contribute to personal growth and professional development. The use of communication strategies, supportive relationships and interactive processes enabled the European nurse leaders from the four island countries to achieve career advancement and make meaningful contributions to advance healthcare policies and practices. Perhaps it is not just the strategies that the successful nurse leaders used to overcome barriers, but rather the resilience that developed in response to the individual struggles that set them apart from less effective leaders. Some of the characteristics of resilient health care professionals include good support networks, reflective ability, empathy, emotional intelligence, self‐awareness, sense of humour, social confidence in communication and work–life balance (Grant & Kinman, 2014). Several European Nurse Leaders described the importance of the above attributes during the interviews. Somehow, these nurse leaders were able to reflect on their experiences, adjust their behaviours and communication strategies and establish valuable connections to influence the current and future of the nursing profession and healthcare delivery.

For transformational healthcare changes to occur, we need strong nurse leaders, from the bedside to the boardroom, using effective strategies to influence decision‐making and healthcare practices throughout the continuum of care. The European nurse leaders demonstrated that effective nurse leadership made a significant difference in transforming health care within Europe. Building upon the leadership lessons and coping strategies of accomplished nurses can help prepare junior nurses to meet the challenges of the rapidly changing healthcare environment.

CONFLICT OF INTEREST

The authors have no relationship, financial or other conflicts of interest to declare.

APPENDIX 1. Interview Topics

Topic 1: Decisions for pursuing leadership roles

Topic 2: Barriers in leadership journey

Topic 3: Facilitators to leadership journey

Topic 4: Relationship of culture to leadership style, decisions and experiences

Topic 5: Essential leadership skills (generally and culturally)

Topic 6: Examples from experiences

APPENDIX 2. Supplemental Data: Extract from Coding Tree

THEME 1: INFLUENCES
Theme Description: Forces impacting professional/leadership development
Subtheme	Thematic Description	Representative Quotations
Values	Core Concepts that define and give meaning to role	“A willingness to listen, tolerance, a belief in self, resilience and confidence to just enact justice and fairness borne out of my experiences…” (EP5) “Someone should be objective, fair, decisive, and patient. I don't know if these skills are similar in other cultures.” (GP4) “Be brave; be bold; trust instincts; be true to self; connect and collaborate; don't be afraid to take calculated risk; In Ireland more of a staff association (union); so nurses need to have their support or initiative will fail.” (IP2) “Learned leadership position through girls only club (girl guides). Naturally speak out and can easily control a group. Driven because cannot stand for things to not be done correctly.” (MP2)
Self‐Schema	Dynamic mental model of one's professional self	“I wanted to be challenged or have a stretch. Partly because the opportunities were available. Others were moving into leadership roles and so I moved with them. I combined leadership with academic work. I also wanted to influence evidence‐based practice.” (EP1) “There are no specific factors that can influence my leadership style because I have self‐confidence. I feel strong and sure about myself and I love my job.” (GP4) “Start off as you need to be; be the person that you want to be; solve problems as they come; bounce back from the problem and ask for solutions so that people think on their own; do not try to tip toe around people; have to draw a line; no longer the friend but the leader.” (IP3) “Watching two nurses who were good leaders that influenced. Nurse faculty instilled such a sense of pride and wants to get better and stronger and pushing for professional issues. Importance caring and empathy for patients.” (MP4)
Barriers	Impeding forces to adaptation or adoption of leadership role and efforts as a leader	“…no preparation. I learned on the job, I had a top management job…I was financially illiterate. Politics made it hard to resolve financial issues. I had to learn how to play hard ball.” (EP4) “Indifference of colleagues and amateur behavior of all parties.” (GP3) “Envy from other senior people. [I] grasped every opportunity that came way and did not experience any problem to access; Had to prove myself and work with others. Created barriers for self; leadership nursing focus and puts into silos for executive positions.” (IP3) “When does not listen to intuition then regret it. Doing the right thing but getting yelled at. Know how to help patients but do not have the resources. What have to continue to press to get solution when know right.” (MP6)
Entry ton Leadership	Point at which individuals began developing leadership skills or role	“Many years of experience in the different medical departments and my studies made me able for the position.” (GP4) “Part of my individual make‐up. Leaders are born and have certain personal attributes. Because I wanted to make a difference and I was capable. I could influence….centered on care for patience and utilizing and providing care for patient.” (IP2) “I wanted to look at nursing in more depth than clinical practice work would allow. With education I was able to look at more depth rather than the clinical focus which was more traditional and looked to how nursing had always done it.” (EP3) “Nurse leader (officer) told about courses and motivated me. First‐line management and basic management through university of Malta; shadowed nurse officers.” (MP6)

THEME 2: COMMUNICATION
Theme Description: Interpersonal transmission of information
Subtheme	Thematic Description	Representative Quotations
Verbalization	Receiving and transmitting information clearly	“In my new role, I cannot tell anyone what to do. I have to have the enthusiasm and encourage their confidence and convince them.” (EP1) “Listen well; communication is key; keep talking; establish what you want; when you know what you want then can negotiate better. Decrease in experienced nurses; junior nurses not as assertive and lack same level of expertise, judgement, and assertiveness. It is not about you; do not take it personally; stay patient focused and don't down play your influence as a nurse.” (IP1) “Small so talk to person in charge, only needed permission to develop something. You only have to convince the organization so the project can happen very quickly.” (MP2)
Advice	Transmission of lessons learned, provided to assist another's growth and development	“Collegiality is important. Be accessible. Good communication. In other cultures if you are seen as a senior then you may not need to be as collegial.” (EP2) “To be hard‐working, fair and strong in order to handle all the tasks and as far as they can to help people.” (GP1) “Make sure that you are talking to the right person; chased consultants who had no power; learned to follow‐up with an email on what you understand and a timeline.” (IP1) “To be available and to appear available. Student perception, approachable and available. Patience and time management.” (MP5)
Improvement	Reinforcing one's growth	“Learned to listen more; tried to get a handle on what did management want; discovered that needed to be part of the team…” (IP1) “I learned that I had to get enemies to give me advice ‐ how to deal with obstructers.” (MP2) “Giving feedback on things that are not going well.” (MP5)

THEME 3: PROCESS
Theme Description: Methods/means of leadership development
Subtheme	Thematic Description	Representative Quotations
Change	Institutional role or work adaptation to new expectations or methods	“Doing all three leadership roles was very interesting because it gave me a wider perspective. Political awareness was very helpful in understanding how a process works and how decisions are made. I would have stayed in jobs less time. I should have moved into different positions sooner.”(EP1) “Need an insider and outsider ability to critic and make changes; be a trouble maker in a way that you are invited back for a solution; importance of authenticity, honesty, and respect.” (IP4) “Taking criticism – it is small work environment – you need to ‘criticize’ alone to ensure you do not embarrass people…do not get over the embarrassment. You want to take shame away and focus on change.” (MP6)
Informal v. Formal	Methods of acquiring leadership role and expertise	“In big staff meetings we would not discuss any issues. We just meet to meet the requirement. The real work happens outside of the meeting. Nothing useful happens in the meeting. There is a hierarchical structure where decisions are made based on position.” (EP3) “I became more patient and I learned how to listen my colleagues and talk with them.” Good listener and inspire respect from others to be fair…broad range of experiences.” (GP4) “Learned styles from previous managers; identified styles that fit and that I didn't desire; MBA helped early in career on projects. Main learning occurred at the grass roots level.” (IP3) “Young so had to prove myself. Participatory leadership style. Population in Malta is small. Not prepared clinical for new unit (emotional intelligence).” (MP3)

THEME 4: RELATIONSHIPS
Theme Description: Associations impacting leadership development
Subtheme	Thematic Description	Representative Quotations
Mentorship	Guidance from a place of experiential knowing	“Ability to see other people's point of views, for example, with local interest groups. It is important to communicate well but at different issues. Academic trust has a different style. It is important to have academic support.” (EP1) “Working with the chief nurse prepared for leadership roles; mentoring from leader with opportunity to flex; represent office but also present own work; taught how to mentor others; have a defined career structure: clinical pathway, management path, education path” (IP2) “Have to be knowledgeable (experienced). Have courage, professional and not let others push them down ‐ professional jealousy. Admit mistakes.” (MP3)
Role Models	Leaders to emulate	“Role models both good and bad enabled me to see who I would want to be like. In my culture there is a lack of directness so people often do not say what they think. Do not tackle poor performance. People simply do not ask the poor performers to do anything anymore. Never tell staff that they are good or bad. No reward or punishment for performance. Simply do not ask people to do things if they are in disfavor. The system is more voluntary focused on tasks. You can choose to not volunteer and do less work. Balance with family carries enough weight to justify poor work performance.” (EP3) “My staff respect my decisions, recognize my fob and at the same time understand how fair I am.” Really good staff retention.” (GP4) “Experiential learning; nurtured and developed by influential and progressive leaders. A young manager/director of nursing who went on to be the human right leader; she was a great role model.”(IP2) “Clinical role have to more and more like a role model. Lead by example ‐ have to understand how to implement change to improve practice” (MP6)
Connections	Interpersonal skills and relationships that must be navigated in order to be successful	“In my culture, it is necessary to be a diplomat and less dynamic.” (GP2) “Good reputation needed for opportunities; personality style; need to have a combined hard and soft side; need straight speaking (direct) with political acumen; know how to make a pitch to the group without aggression or undermining individuals; need to be a vision maker.” (IP4) “Resistance from faculty colleagues. Being the new person and could not understand why older staff had not already made changes. Learned to choose participants for projects carefully.” (MP2)

Hughes, V. , Wright, R. , Taylor, J. , Petchler, C. , & Ling, C. (2023). A qualitative descriptive study of effective leadership and leadership development strategies used by nurse leaders in European island countries. Nursing Open, 10, 1071–1082. 10.1002/nop2.1374

DATA AVAILABILITY STATEMENT

Research data are not shared.