The core of care: Dame Donna Kinnair on bravery in leadership and the nursing workforce

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  • Posted:Friday 30 August 2019

A podcast about big ideas in health and care. We talk with experts from The King’s Fund and beyond about the NHS, social care, and all things health policy and leadership. New episodes monthly.

 

How can we address the nursing workforce crisis? Dame Donna Kinnair, Chief Executive and General Secretary of the Royal College of Nursing, sits down with Helen McKenna to talk about nursing, workforce pressures and her leadership journey.

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Key:

HM: Helen McKenna

DK: Dame Donna Kinnair

HM:

Hello, and welcome to the King’s Fund podcast where we talk about the big issues and ideas in health and care.

I’m Helen McKenna. I’m a Senior Fellow here at the Fund and I’m your host for this episode. Today, we’re sitting down with just one guest, something that those of you who are regular listeners will know we do from time-to-time on the podcast. The idea behind this is to hear from senior leaders in health and care about their leadership journey and their views on the big challenges currently facing the sector. So, I’m honoured to be joined today by Dame Donna Kinnair who is Chief Executive and General Secretary of the Royal College of Nursing.

Donna, welcome to The King’s Fund podcast.

DK: Thank you.
HM:As an introduction, can you tell us a little bit more about who you are and what you do?
DK:

So, as Donna I’m a nurse and I actually have been a nurse for 35 years. I actually now have held many leadership positions, but now I actually run the Royal College of Nursing, and that is both a trade union and a professional Royal College. So, it deals with issues around professional practice and nursing policy, but it also deals with matters that look after employment issues and the impact on some nurses and the wider healthcare family of the system issues.

HM:Great. We’ll be talking a little bit about your career journey and workforce issues and also your views on leadership later in the episode, but first, to start us off, you’ve worked in nursing for many years, but let’s go all the way back to when you were a child, what did you want to be when you were older?
DK:

So, as a very young child I wanted to be a nurse because my father spent quite a bit of time as a chronic asthmatic in hospital, so that’s when the idea to be a nurse, I suppose, it looked good, they had a really beautiful uniform and they seemed to be always doing things to my father, and they were sort of, it felt a bit sometimes like they were in charge. So, I think as a young girl, I probably wanted to be a nurse.

HM:And do you think that was about wanting to be in charge? Or was it about the uniform?
DK:I think it was more about the uniform. It just looked very glamorous, but it felt as though they were doing things well with my father, so the care that he was receiving. And I probably was very young at this time, so they were quite impressionable, and equally I remember thinking that a doctor was a nurse because it was a female. So, you can see how long ago that was. So, I think it was a natural thing for me to think, that if I wanted to work in the health service, I would be a nurse.
HM:So, you said when you were very young, did you switch as you got older or did something else happen?
DK:

Yes, I changed. I think during school years, I went to a grammar school and so as I was doing my A Levels, I remember thinking about being a nurse and I was doing maths and English and Physics, so it wasn’t things that you would do and then automatically go into nursing. So, it was quite interesting that the advice I got was ‘oh no, you’re going off to university.’

I actually, there were two things that happened. I think, also at the time I was about 15 when my brother died and it made me think about whether I wanted to be around death, so actually that was a decision, I think, that helped me not to be a nurse straightaway. So, I didn’t actually feel that I was going to have the skills or the qualities to be a nurse after having experienced that myself. So, I actually did go off to university.

HM:

I’m sorry to hear about your brother and I guess having been around death so young, then that impacting on what you thought you wanted to do.

But you came back to it later on?

DK:

Yes. It was something that was there. I left uni having done Maths and I suppose I always thought about nursing and I got married very quickly after, I got married to somebody I went to school with, so it was quite important for me to have a job that I could always do.  So, it was teaching or it was nursing, but I ended up going into management training for Marks & Spencer.

So, it was while I was at Marks & Spencer, and pregnant, that I actually ended up speaking to an occupational health nurse who had said to me, she was just treating me or making sure that my ankles weren’t swollen because it was a standing role, I said to her ‘oh, do you know what I always wanted to be a nurse’ and she just looked at me and she said ‘well, you still can. You’re still young, what’s your problem?’ So, actually that set me thinking about whether I would be able to do it, what I would do with a child? I was a very young mother, so it was what would I do with a child if I was on my own ever in the future? So, that tells you I’m a bit of a planner.

HM:Yes, thinking through all eventualities.
DK:All eventualities. So, that made me sort of be curious about it and I applied while I was pregnant.
HM:Wow. And left the Marks & Spencer graduate scheme? Wow. All prompted by this occupational health nurse who asked you a question? 
DK:

Yes.

HM:Wow.  And the NHS got you ever after. So, you’ve told us about how it all started and obviously you’re currently the Head of the Royal College of Nursing. Can you tell us a bit about what happened in between, in terms of some of the roles that you took after you started as a nurse?
DK:

Yes. So, nursing was an ideal career for me because you have a lot of variety of nursing.  So, at the time I trained, I spent some time looking after children, obviously I was a mother so it suited me as well working with other people’s children. I spent time working in theatres and recovery.

Around the time that I trained, a lot of the nursing was about HIV and AIDS so I spent, as a staff nurse, time working with victims of HIV and AIDS and actually that was probably some of the toughest nursing because, from a student nurse I started in that era where actually when you looked at a patient, we didn’t really know what was wrong with them.  We didn’t know how contagious this condition was and very early in my career I didn’t know where it was going to go to. It was very scary at the time, starting nursing at a time when you were faced with something that people had no idea, they just knew it impacted on the immune system. And I remember my very first care, we used to get dressed up in gowns and almost like spaceman suits to deliver care.

HM:To patients with...?
DK:

To patients. And I guess, as a nurse, what you were very conscious of was the fact that people expect you to touch them when they are sick and that’s often what we do when we’re consoling another individual, or you’re delivering care. So, touch is very important. And actually, for me, fundamentally it was difficult, one of the most difficult things was actually you weren’t really touching patients and that really impacts on the way you communicate with patients.

And, to be honest, you recognise that when people are that ill they are very vulnerable and your role as a nurse is often to offer that support and to not really react, but to hold their pain really. And some of that is the way in which you communicate, the way in which you speak, the way in which you touch patients, the way in which you deliver care, and the way in which you respect that individual. And I think that was really difficult to do when you were masked up and gowned up.

So, I think for me, I think we nursed in some of the most difficult times until we saw that we didn’t have to do that anymore and actually we could strip off the gowns and actually deliver care the way in which we were trained to do.

HM:And so that’s fascinating just in terms of how it seems like in that experience you were getting to the core of some of what care and nursing is made up of?
DK:

Yes, I think this reflects back to your own experience really, because being, one of the things I said to you earlier is that I’d had a bereavement at 14, so I knew when I became a nurse that sometimes it was about being with people and not saying silly things. So, you can’t solve that problem for anybody, it happens, but actually just being present and actually just being in the moment with somebody is important.

 So, for me, I think all of those things were life experiences that contribute to your nursing and that, I think, is what came to bear in that time period for me.

HM:Okay. So, I wanted to ask, so you served as a nurse assessor to the Victoria Climbie enquiry back in early 2000s. 

DK:

2001.
HM:Yes, which, I mean I remember it being in the media and it being a very awful case, I just wanted to ask what was it like being part of that and what did you learn from that experience?
DK:

Yes, it was a total sort of, I was going to say accident being part of that, because I had decided in my head before I joined that, that I would not do, I was going to step out of child protection because I’d been in it a long time, and I always feel that actually once you’ve seen things and you’re seeing them again and again, it probably is time for you to leave it for somebody else to take up the baton.

So, I actually decided and I remember when Victoria Climbie’s death flashed up on the TV, I was on the phone to my sister in America and I said oh, there’s been another child death, how glad I am that I’m leaving child protection. Little did I know that I was going to be called to be an assessor on the Climbie Enquiry. And I did think very long and hard about doing that role because it is a painful role and particularly as my daughter was the same age as Victoria. So, there was always, for me, a daily reminder of the life that could have been because my very youngest child was the same age.

So, I think it gave me a perspective in terms of my role on that was to make sure that we actually did learn the lessons from that as a system and that we weren’t saying it was the usual communications issues or the usual things that we said about child protection. So, for me it was very painful and I will always remember it as a time in my life when I think maybe I should have thought a little harder because it was a year of constant seeing things and hearing things, that actually you wouldn’t really wish to be hearing on a daily basis.  

But I think on reflection, I remember when I’d finished the Enquiry and I was talking to my Chief Exec at the time and I did say to him, on reflection I think we had done the best we could do in terms of turning every stone, making sure that we’d looked at the system issues, not so much the individual issues because I was very conscious that the media spent a lot of time looking at individuals, but actually it was our job to make sure that we were looking at the system issues as well. And I think one of the reflections I have about that Enquiry is it did look at the system issues, it didn’t just blame individuals, because it recognised that they were operating in a system and that decisions wasn’t at the individual practitioner level.

HM:Yes, absolutely. And I think we often try to run to blaming individuals as these kinds of bad apples
DK:

It’s easier because you can shift that one individual rather than sort the system out.

HM:

So, you’ll be familiar with the fact that the NHS is currently struggling with a workforce crisis and I think figures are suggesting that it’s particularly bad in nursing where there’s a shortage of over 40,000 nurses, if I’m correct.

I wanted to start by asking you about what you’re hearing from your members about the impact of those shortages on those working in the profession right now?

DK:

So, I think for every nurse, the importance of being able to give good nursing care is a priority and I think what I’m hearing from members is that they’re often not able to do this. So, often you’re juggling aren’t you and you’re prioritising and that means that somebody isn’t getting their drugs, somebody isn’t getting washed, somebody isn’t getting the help that they need, and hospitals are a pretty dangerous environment particularly if you’re an elderly patient with Alzheimer’s you actually do need the care that nurses can give just to keep you safe really.

Now, what happens is when there’s not enough of you, you’re not able to deliver that care. And if that constantly happens, day after day, what also happens is people think well actually if I’m not winning, I might as well opt out. So for the first time we’re seeing more people leave the profession than ever before and that’s problematic to me because that starts a crisis, because it then means have we reached that tipping point where people are finding the job just too difficult to do? So, if your patients are constantly saying ‘nurse, can you do this?’ and you can’t get to do it, or if you’re crowded in A&E and there’s nowhere to put someone, it eventually can lower your morale so that actually you think maybe it’s easier to work in Aldi.

HM:Yes. One of the concerns that we highlighted in some of the work we’ve done at The King’s Fund is around this idea of potentially we’re creating a vicious cycle where you haven’t got enough staff, you’ve got loads of shortages, you haven’t got enough staff there in the first place and then the burden that’s put on the staff that are actually there, where conditions have just become, the pressure becomes too much and people start, we’re seeing that in sick leave, we’re seeing that in bullying and harassment rates in the NHS Staff Survey, and then increasingly people starting to leave. How do you get out of that cycle?
DK:

So, I think it’s important that, well you’re not going to get out of that cycle immediately and I don’t think the nursing profession would expect us to. But I think a priority for the profession and a priority for us as the College, is that safe staffing is important. We cannot no longer, I think as a profession, tolerate our leaders and others saying how wonderful everything is when actually we know when we’re boots on the ground that it’s almost impossible for us to deliver safe quality of care.

And so, I think the vision that I have is the College really does lead the way in tackling the issues that are affecting its members. When we talk to our members, when we survey our members, they say the biggest issue for them is safe staffing, and I think that’s what we have to tackle. And whether that’s in policy terms, whether it’s the way in which we fund the education of nurses, whether it’s the pay for nurses that means that if you’re going to, we’ve got a shortage in the profession now, so what are we going to give to attract them?
All of those issues; the education, nurses traditionally had a contract with the NHS but we weren’t well paid but we were very well educated, whether that was on the ground or whether we did courses and paid for them ourselves, but we were learning. Actually, if you’re so busy that you’re not able to learn or debrief from some of the events that you see, you may just reach a tipping point where nobody wants to do the job anymore. And so, it’s important for me, as the leader of the Royal College, to put the voices of the nurses that I represent out there and actually make sure that those policy makers are taking account of the issues.

And it’s not just the issues for nurses because we deliver care, so it’s the issues for patients because at the end of the day if the nurse can’t deliver good care, your patient isn’t going to get good care. We’re not going to deliver the good outcomes. And we know how important the role of a nurse is in the improved outcomes to patients.

HM:And, I mean you talk about safe staffing, I see that as the policy objective, just briefly what are the policy levers or mechanisms that you’re calling for from the Royal College of Nursing for the government and national bodies to do, to ensure there are enough nurses?
DK:So, I think there’s got to be an increase in the domestic supply of nurses. So, it’s not good enough when you’re in a crisis to leave it to the free market because actually you’ve done a change, you’ve created a change by removing of -
HM:Just like the bursary?
DK:

Yes. The way in which we funded education and now we’ve seen a drop-off. We’re not really seeing growth, so no matter how they dress it up, we know that we’re not really seeing growth. So, actually I think it’s incumbent on the government to do something about that in the first instance. So, whatever that looks like, whether it’s targeted funding for education, I think they can’t have missed a trick for actually if you’ve taken away something and the outcome is worse, you might need to just put it back. So, the first call is that we’ve got to increase the domestic supply of nurses.

I think at the moment we have, and successive governments have relied on overseas recruitment by only training fewer nurses in our country, and part of that is making it appealing to do the job of a nurse. The one worry that I have is the more we highlight some of the issues, the more off-putting it can become. So, actually we want to talk about the benefits to nursing. I’ve had the most fabulous career and have nursed many, many patients, but equally it does need investment. And so, we’re calling for the Government to acknowledge that they need to grow safe staffing numbers, but also invest in nursing education.

HM:There’s a lot going on right now. We’ve got a new Prime Minister in post, who’s made various announcements about the NHS, so capital funding, there’s the workforce crisis, there’s Brexit; potentially it looks like we’re set to leave the EU at the end of October, that could change.  But given all of that, what is on the top of your list of asks to government?
DK:

So, whether or not we leave the EU on 31st October, we still need to address the issues of our people, our healthcare, our education, that still needs to be addressed. So, I think whatever happens, we will still have to come back and look after the health of our nation. And so, for me, it’s just ensuring that those things don’t get lost in the melee of Brexit, and I recognise that Brexit will have huge implications on health, trade deals with have huge implications on health, but I think it’s important that the things that we’ve asked government for doesn’t get lost in that melee. So, we still need to increase our supply of nurses, we still need to invest in their education because that is what impacts on patient outcomes.

HM:Absolutely. I want to ask you a bit about your experiences as a leader and hopefully be able to share some of your insights. What or who has shaped your approach to leadership over the years?
DK:

I think as a child, I used to read a lot of autobiographies about people’s lives. I used to love reading the things that people did so Ghandi, Nelson, real learning from some of those issues, even Barack Obama, you can just always read in an autobiography with so happens?  What made them choose that path?

But I remember as a student nurse, I used to work on a haematology ward, and I had a really forward-thinking Oncology nurse that was leading that department and the good thing about her was she was always calm. It was always a patient’s issue, it wasn’t her issue, she always remaining calm and being able to hold that patient and whatever happened for them, whether it was good news or bad news, she always there, present.
And I think, for me, it was a lot of learning from that individual, her name was Adrienne, that she was an absolutely superb nurse, but what I remember most about her is that nursing was quite hard in those days, because I talked to you about HIV, we also had the crisis with haematology patients and whether they were getting their drugs from, their blood transfusions, from America, so all of those issues were going on when I was training.

But when Adrienne would come on, she would always be respectful of what you had done and she’d always say oh great, Donna’s been on. And that, to me, would mean that she had faith in the work I had done during that night or during that day, and it was appreciative.

So, for me, one of the biggest things that I’ve always learnt is that there’s respect for people and respect for persons really, but also being really appreciative of people doing and saying thank you really, or noticing that they’ve done something. So, I think that was a person for me that actually was always present when you were speaking to her, she wasn’t elsewhere, she was present with patients and she always took the time to notice you.

HM:You’ve held a variety of very senior leadership roles, what do you think are the qualities that make a good leader?
DK:

So, I think, for me, there is that respect for other people. You can’t lead unless you have a follower and if you haven’t got a follower, then you’re not a leader. So, for me, it’s something about how you share that leadership because you’re not always the one person that has all the knowledge. So, for me, it’s about taking on board other people’s opinions, making sure that they can input into what you’re trying to achieve. So, while I might want to get somewhere, it may not be definite. It maybe that I can flex it so that I can accommodate the wants of a wider group of people.

    So, I think that’s really, really important that actually recognising that you can’t be a leader without followers. You can’t have a conversation with yourself, you’ve got to have a conversation with others in terms of the direction that you’re going in.

    The other bit for me is being quite brave. So, I think it’s always been important in my career to make sure that I own the decisions that I need to take. So, if I think back at some of the really, really difficult times of being a Director in Southwark around the gangs, having a patient shoot a nurse dead, some of it was taking those brave decisions about whether you’re going to carry on caring in that situation and put other people at risk, or whether you’re going to take that decision to remove it.

And the other thing that I think that governs this is being able to speak true to power.  It doesn’t have to be rudely but you do have to speak it. So, there is no point in joining the masses that are saying everything is good if you can clearly see it’s not good.

And I think those are the important things is that people stop listening to you if they don’t believe that you’re going to deal with the real issues.  I think it’s important to respect their views and to make sure that you bring them along with them and hear them, but also when you’ve got to take a decision, take it.

HM:Okay. And I love the point about bravery and I guess I was just thinking as you were speaking about in your current role, undoubtedly, you’re speaking truth to power on a regular basis and I just wondered if it’s, as somebody much more junior in their career, when I speak truth to power I get quite a physical feeling, it’s like a whole body; flutters in your stomach, I just wondered if it gets any easier?
DK:

A little bit, I guess, because there comes a point in your career when it doesn’t matter, you’re going to do the right thing anyway. I guess that earlier in your career you’re really worried about what’s career-limiting, so I think it gets easier and you get to a stage in your life where you think actually, I will need to say this. So, I think it becomes easier as you get more senior in your career.

But I don’t think that ever goes away. You are often on your own because if you’re going to speak true to power you’re going to go against the herd mentality sometimes, and that is never easy because you might be in a room full of people and you can see that everybody is nodding at something and you can’t even see that something that they’re nodding at; you know that that’s not a factual real.  And sometimes you just have to call it out.

And it doesn’t get easier in that way because it still means that you’re taking a brave act, it doesn’t mean that I don’t have butterflies in my stomach, I’ve just learnt as a nurse to calm them, because actually that’s what you do in every single situation. 

HM:And they're there a lot.
DK:Yeah. So, every single situation you’ll always have those butterflies, but I’ve just learnt to make sure that they’re not visible. 
HM:Okay. I’m interested in learning from failure, so I just wondered if you can think of a time, a particular time when you failed as a leader or in your career and what you’ve learnt from it?
DK:

So, I think for yes, there will be many times that I’ve had to go back and learn from things that haven’t gone quite right, whether that’s trying to change a department or do turnaround in terms of delivering services.

I think, for me, one of the earlier times in my career probably was how I got into child protection really, was I can be quite articulate and I can argue a point quite well and I remember as a young nurse arguing for a child and it’s mother to stay together, and actually for us to put services in. And won the argument, except for that weekend, that child was locked in the house alone.  

And so, actually when you are faced with being articulate and arguing well for something and actually the outcome on that child was hugely negative. He didn’t die, but actually it was a suffering for that individual, it was quite interesting because my mentor at the time, I remember him saying to him, being articulate and being able to argue well doesn’t mean you get all the points. It’s important for you to actually observe well.

And it also taught me that you don’t know everything, you don’t know what you think you know sometimes. So, it’s important to recognise that. You can only judge something on what you can see and that’s not always right.

HM:So, that it still allows room for different possibilities and questions?
DK:Yes. And I think it’s something, when you’ve had an issue like that, it’s not a mistake that you make too readily. You are more cautious, rightly or wrongly, but I think you do learn, you do reflect where your voice is in delivering something.
HM:And if you could go back to the start of your career and give yourself just one piece of advice, what would it be?
DK:I think, for me, it’s about finding joy in everything you do. I think my 20-year-old self sought to do that. I don’t think it’s the advice I gave myself then, but if I was now, I’d say actually that’s been the most important thing in my career is actually if you can’t find joy in it, you shouldn’t be doing it. And so, making yourself and others happy about what you’re doing.
HM:Great. Well, thank you so much for joining us today, Donna. It’s been a real privilege to have you on the podcast.
DK:Thank you.
HM:

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