Nursing Leadership: Issue Brief

Key takeaways

• Nursing leadership is critical to healthcare and exists at every level, from bedside to boardroom.
• Ingrained gender ideologies and structural hierarchies limit nursing leadership, and addressing this requires political engagement, a unified voice, and continued advocacy.
• Nurses can drive health system transformation by leveraging the full breadth and depth of their knowledge, skills and expertise.

Background

The call to advance nursing leadership has been growing over the past decade. The World Health Organization recently named leadership as one of four strategic directions and policy priorities for 2021 to 2025. Areas of particular focus include increasing the number of nurses in senior health positions, strengthening nursing input into policy, and investing in leadership skills development for nurses. Nationally, the Canadian Nurses Association (CNA) not only echoes these global directions but states boldly that “nurses can be and must be leaders”. Now more than ever, British Columbians and indeed all Canadians need engaged, courageous nurses active in diverse leadership practices. Gone are the days of limiting our vision of nursing leadership to clinical team leadership alone. The state of health care and the pressing need for change is a clarion call for nurses to expand what constitutes nursing leadership, the role of nurses in health care system leadership, and the ways in which nursing as a profession and a discipline can lead health care system transformation in a time of increasing demand and complexity. 

Evidence  

Defining nursing leadership 

The Canadian Nurses Association 2018 Position Statement on Nursing Leadership notes that “nursing leadership is about critical thinking, action, and advocacy”. Nursing leadership is not limited to those holding formal leadership roles. It happens across every domain of nursing and in every nursing role. 

• Nurses who work in direct care consistently mentor practice excellence, lead patient care through sound clinical judgment, engage in complex problem solving and innovation, and work relationally with patients and families as partners in care. 
• Nurse educators incorporate leadership skills and capacities into the nursing curricula across designations and educational levels, cultivating the future and advancing nurses the ability to enact leadership in practice. 
• Nurse researchers generate evidence for leadership practices in nursing and lead the development of the nursing discipline in new directions. 
• Nurse administrators lead interdisciplinary care teams, developing philosophies of care, directing workflows, implementing systems change, and enacting strategies to retain and recognize care team members. 
• Nurse lobbyists and organizers advance the nursing workforce, fight for safe work environments, and lead contract development, workforce policy, and labour relations across a multitude of contexts, roles, and organizations. 
• Nurse activists and advocates lead social justice movements and bring social and policy issues to public attention from a nursing perspective as part of driving toward a more just and equitable world. There is no domain of the health care system where nurses cannot lead. Indeed, nurse leaders belong wherever health and social policy decisions are made. 

Nursing knowledge for leadership 

It is important to recognize that nursing is not alone in our ability to integrate clinical skills, insight, and judgment into leadership practices. For example, our physician colleagues also bring clinical training and experience to leadership roles. Nurses cannot, therefore, claim that we have a unique right to leadership because of our connection to patient care. It is also inaccurate and remiss to lay claim to leadership because of nursing’s historical association with caring. Every person who works in health care shows up every day because they care. Nurses are not angels or heroes who alone carry the burden of a caring heart. What nurses do have is a unique body of disciplinary knowledge developed over centuries of practice, research, education, and leadership. It is to this unique nursing knowledge that nursing leaders must be encouraged to go to in the context of decision making, understanding that leadership rooted in nursing knowledge is powerful, valuable, and sorely needed. 

Addressing structural barriers to nursing leadership 

Where nurses are not welcome or have historically been shut out, nursing leaders must not only advocate for nursing participation but also demonstrate the value of nursing knowledge, practice, and skills at the leadership table. It is not enough to simply occupy a seat at the table. Nurse leaders must be educated, prepared, and skilled at demonstrating in real time and in complex political environments an integrated nursing leadership practice grounded in nursing knowledge. 

Where legislation shapes participation and engagement in leadership opportunities, nurses individually and collectively can advocate for legislative reform to address the inequity of representation. For example, the Province of British Columbia has invested $50 million over five years to increase physician engagement, demonstrating an exemplary and meaningful commitment to the critical need to include physicians in policy for health and health systems. When coupled with legislation that requires each health authority to enable a Health Authority Medical Advisory Committee with direct advisory access to the executive and Board levels, this kind of intentional inclusion ensures physician leadership presence across all levels of the health care system. This is an excellent example of how representation can be built into our health care landscape and provides other professional groups, notably nursing, the opportunity to name the kinds of structural changes needed to ensure other health care professions are similarly intentionally built into leadership tables. Nursing leadership includes naming these kinds of structural opportunities and engaging in coordinated, aligned advocacy for systems level change. Professional nursing associations can and must play a unifying role in coordinating such advocacy and working in policy and political arenas to lobby for representation and structural change. 

Leading unity in nursing knowledge and practice

Nursing knowledge shapes and defines the practice of nursing. However, in contemporary practice contexts, nursing is often aligned to medical definitions of care where nurses practice under the umbrella of medical specialties. For example, it is common for nurses to identify as renal nurses, oncology nurses, or trauma nurses. This extends to nursing’s leadership organizations as well, where professional associations no longer represent unified voices of nursing advancing nursing practice as uniquely defined by nursing knowledge, but rather nursing has become a single player in a sea of specialty nursing associations that advance the practices and knowledges unique to each medical specialty. These knowledge and practice divisions within nursing are further exacerbated by the complex structure of health care delivery. In British Columbia, for example, the health care infrastructure involves five regional health authorities, the Provincial Health Services Authority, the First Nations Health Authorities, and a multitude of private health care businesses. From rural and remote to urban, acute to community, preventative to trauma, the context for finding that unified nursing leadership voice is increasingly complex and challenging. However, nursing leadership rooted in nursing knowledge through a unified professional association such as NNPBC creates a line beneath this complexity, mentoring for others what nursing-informed approaches look like and how nurse-led care delivery can improve the health of citizens.

The impact of gender on nursing leadership

In addition to disciplinary bias in legislation and health system structures, the gendered nature of nursing continues to impact the scope and possibility of nursing leadership. Globally, nurses are the largest workforce in health care and in Canada, 95% of the nursing workforce is female. However, despite the significant majority of women in nursing, nursing leadership positions are disproportionately occupied by men who are nurses, particularly at senior leadership levels. This gender disparity is somewhat more balanced in many other countries for reasons that remain obscure. The World Health Organization has gone so far as to call the gendered state of nursing leadership a “glass elevator for men in nursing”, not merely a glass ceiling for women. Coupled with the broader gender bias against women in leadership that is socially pervasive in Canada, the internal gender bias within the nursing profession poses a significant attitudinal barrier that must be meaningfully addressed before nursing can expand into health system leadership in the ways in which nursing is being called upon to lead.

Preparing nurse leaders

The shared vision for the future of health care is a patient-centred system where citizens in need of care receive it in a seamless manner across a multitude of transitions, services, regions, and providers. This requires nurses to be active in collaborative leadership, working across disciplinary boundaries to enable transdisciplinary care in increasingly complex care environments. By virtue of advanced training in relational practice and the human focus on the person within a wider metaparadigm of knowledge, nurses are well positioned to enact leadership practices rooted in relationships. This is well aligned with contemporary calls for transformative and trauma-informed leadership where empathy and the ability to connect relationally are highly desirable leadership skills. Indeed, post secondary institutions and nurse educators play a critical role in building leadership competencies into the curricula and the conceptualizations of professional identity that shape the thinking of nursing students during their learning journeys. To prepare nurses to lead successfully in the complexity of health care and social policy, education must also include the development of skills in politics, strategy, public administration, human resource management, and fiscal stewardship.

Future orientations for nursing leadership

Growing capacity for nursing leadership is a key priority for NNPBC, nurses in British Columbia, across Canada, and around the world. This includes advocating for an expanded availability of leadership roles for nurses, explicitly naming and making visible how nursing knowledge serves as the foundation for nurses practicing in leadership roles and ensuring that nurses leading in health care have the authority and resources to meaningfully shape health services at every level. It also includes a willingness to end intraprofessional divisiveness around what constitutes “real” nursing and who gets to speak for nurses. Nursing must be united with a strong collective voice, moving beyond designation or position in a hierarchy to foster nursing leadership at every level and in every role.

We must extend our vision for what nursing leadership looks like beyond bargaining for higher compensation (although important) or a sole focus on increasing nursing workforce numbers as a panacea for all health care system challenges. The view for nursing leadership must also include policy creation, system reform, political leadership, program and service stewardship as well as workforce optimization, financial management, and the institutional products that shape care such as electronic health records, processes, workflows, care delivery models, and staffing decisions. Nursing must move from a conventional image of nurse leaders as managers of other nurses to nurses as leaders across the health care system and beyond. Nurses can and must signal loudly and with a united voice that nurses do not simply administer the day to day functions of a care team; we shape health care and lead change from bedside to boardroom.

Key considerations

Individual nurses

• Reflect on the ways in which nursing knowledge informs your nursing practice and consider how other knowledges intersect with our disciplinary foundation.
• In enacting a leadership practice, consider what the unique contribution of nursing is to the domain of leadership you work within. What do you as a nurse bring to the table that no one else could bring?
• Lead as a nurse. Name yourself as a nurse when introducing yourself. Share with your colleagues, teams, and leaders how nursing informs the work you do. Make nursing visible in your practice.
• Create opportunities in your teams and organizations for leadership growth and learning. These can be formal leadership training opportunities, informal mentorship, learning circles, or reflective practices.
• Build collaborative relationships with other leaders as equals, acknowledging their unique disciplinary contributions while remaining rooted in your own.

Professional associations

• Develop a nursing leadership competency framework to support nurses in conceptualizing, enacting, and communicating leadership from a nursing foundation.
• Design and deliver an integrated pan-Canadian leadership program that establishes a shared base of knowledge and practice for nurse leaders in Canada.
• Build leadership content, training, and professional development into regional association member offerings to contextualize shared national approaches within each provincial context.
• Mentor nursing leadership in public by being active politically, in advising governments and health care organizations as respected leaders on the health system and demonstrating meaningfully the value of nursing leadership beyond nursing issues alone.
• Work collaboratively with nursing unions, other health care provider associations including physician leadership groups, governments, public servants, media, and post-secondary partners to build shared strategies for action to improve health care service, policy, and delivery.
• Build shared policy and advocacy platforms, promote the nursing profession, and lobby actively for nursing participation as equal, valued members of the health leadership team.

Health care organizations

• Ensure every executive health care leadership team has a designated nurse leader with authority and resources to take meaningful action
• Surface and remove the historical barriers that limit which health care professions can hold leadership offices. For example, consider nurse leaders for all executive roles, not just Chief Nursing roles. Consider a nurse for Chief Health Officer, Chief Financial Officer, and CEO.
• Recognize that a focus on nursing staff and nursing practice is a necessary focus, given that nurses comprise the majority of health care workers in our health system. Develop infrastructure to provide explicit support for nursing practice and knowledge development, and to optimize the contribution of nurses to systems improvement and transformation.
• Create formal mentorship programs for nurses including new graduate mentorship, leadership development, and executive coaching. Help nurses see the opportunities for growth as leaders in your organization by encouraging and valuing the unique contribution of nursing knowledge to the health care system.

Post secondary partners

• Extend the focus of nursing leadership in curriculums for LPNs, RNs, RPNs, and NPs from managing other nurses to broad spectrum leadership competencies in health care.
• Examine the ways in which curriculum around task-based elements of nursing practice may limit and constrain nurses from assuming leadership in not only the practice setting but beyond.
• Foster the formation of a professional identity for nurses that includes leadership as a driving force in nursing work.
• Prepare graduates in all four nursing designations for the complexities of the contemporary practice environment, including instilling vision, problem solving, conflict management, and relational skills in emerging nurses.

Governments

• Implement Chief Nursing Officer positions at senior levels of government in every province and territory as well as nationally. Ensure these roles are well-resourced and have the authority to meaningfully shape health policy.
• Recruit nurses onto advisory panels, committees, boards, and commissions to meaningfully inform health policy and governance.
• Consider who is being asked to speak for nurses and how legislative frameworks and regulatory structures shape who speaks for health care.
• Seek out reliable nursing advisory bodies such as professional associations to support public servants and elected representatives in making sound decisions for the health of British Columbians.
• Incorporate nurses into senior leadership positions in policy portfolios that impact health, including social determinants of health such as housing, children and families, finance, education and advanced education, environment, labour, mental health and addictions, and poverty reduction.
• Create and communicate opportunities for emerging nurse leaders to have line-of-sight to nursing leadership roles across provincial/territorial and national contexts to ensure effective retention strategies and meaningful career opportunities commensurate with nursing’s centrality to health care.

Key messages

• Nursing leadership is central to the success of publicly funded health care in Canada.
• Nursing leadership happens at every level, in every position. From bedside to boardroom, nurses lead.
• Leadership extends beyond leadership for nursing or of nurses. Nursing is a disciplinary foundation upon which a leadership practice rests and adds value to any domain of leadership within health care, including roles from which nurses have traditionally been excluded.
• Systemic oppressions associated with gender role ideologies tangibly impact the opportunities for nurses to lead in health. Such barriers are both intraprofessional and external, resulting in real barriers to nursing leadership advancement that are resistant to change without ongoing attention and advocacy. Shifting entrenched oppressions that limit nursing leadership requires unity of advocacy across nurses and nursing organizations.
• As a profession, nursing must dispel the myth that “real” nurses are bedside nurses. All nurses are real nurses and nurse leaders practice nursing when they are rooted in nursing knowledge and advancing nursing’s disciplinary commitments to health, environment, populations, policy, and justice.
• Leadership in health care is enabled by structures and histories that privilege the voices, practices, knowledges, and expertise of some disciplines over others. Realizing nursing leadership requires advocacy in legislative and regulatory change as well as skillful engagement politically and in health policy making landscapes.
• Nurses are educated experts in relational practice and, as leaders, are well positioned to engage in the kind of collaborative leadership practices that are recognized as essential for health care transformation.
• Nurses in British Columbia and beyond must be united in our call for expanded opportunities for nurses to lead, resolving internal professional divisiveness to achieve this shared goal.
• Nurses do not merely lead other nurses or lead for nursing; nurses can and must lead everywhere health decisions are being made.

NNPBC wishes to thank Angela Wignall RN, BSN, BA, MA for her work in developing this document.

Should you have any questions or comments about this Issues Summary please direct them to info@nnpbc.com.

Further reading and resources

• CIHI: Canada’s health care providers, 2015-2019¹
• Canadian Nurses Association (CNA). (2009). Position statement: Nursing leadership.²
• Forging a Strong Nursing Future: Insights from the Canadian Context³
• WHO: Global strategic directions for nursing and midwifery 2021-2025⁴
• The role of education in developing leadership in nurses⁵
• Collaborative leadership part 1: The nurse leader’s role within interprofessional teams⁶
• Collaborative leadership part 2: The role of the nurse leader in interprofessional team-based practice – shifting from task to collaborative patient/family-focused care⁷
• Editorial: Connecting nursing leadership and patient outcomes⁸
• State of the world’s nursing: Investing in education, jobs and leadership⁹

References 

1. Canadian Institute for Health Information. Canada’s Health Care Providers, 2015 to 2019. Published online 2020. Accessed February 20, 2026. https://www.cihi.ca/sites/default/files/document/canada-health-care-providers-2015-2019-meth-notes-en.pdf
2. Canadian Nurses Association. Position Statement – Nursing Leadership. Published online 2009:1-8. Accessed March 10, 2026. https://hl-prod-ca-oc-download.s3-ca-central-1.amazonaws.com/CNA/2f975e7e-4a40-45ca-863c-5ebf0a138d5e/UploadedImages/documents/Nursing_Leadership_position_statement.pdf
3. Duncan S, Rodney PA, Thorne S. Forging a strong nursing future: insights from the Canadian context. Journal of Research in Nursing. 2014;19:621-633. doi:10.1177/1744987114559063
4. World Health Organization. Global strategic directions for nursing and midwifery: 2021-2025. Published online 2021. Accessed February 20, 2026. https://iris.who.int/server/api/core/bitstreams/11723bae-3fd4-46f0-a4ea-9dc8fd153667/content
5. Marcellus L, Duncan S, MacKinnon K, et al. The Role of Education in Developing Leadership in Nurses. Nurs Leadersh. 2018;31(4):26-35. doi:10.12927/CJNL.2019.25758
6. Orchard CA, Sonibare O, Morse A, Collins J, Al-Hamad A. Collaborative Leadership, Part 1: The Nurse Leader’s Role within Interprofessional Teams. Nurs Leadersh. 2017;30(2):14-25. doi:10.12927/CJNL.2017.25258
7. Orchard CA, Sonibare O, Morse A, Collins J, Al-Hamad A. Collaborative Leadership, Part 2: The Role of the Nurse Leader in Interprofessional Team-Based Practice – Shifting from Task- to Collaborative Patient-/Family-Focused Care. Nurs Leadersh. 2017;30(2):26-38. doi:10.12927/CJNL.2017.25257
8. Wong CA. Connecting nursing leadership and patient outcomes: state of the science. J Nurs Manag. 2015;23(3):275-278. doi:10.1111/JONM.12307
9. World Health Organization, International Council of Nurses, Nursing Now. State of the world’s nursing: Investing in education, jobs and leadership. Published online 2020. Accessed February 20, 2026. https://iris.who.int/server/api/core/bitstreams/5d564226-7418-4c10-9fb3-08d7e09626ec/content