Leadership Experiences of Modern Matrons in an Acute NHS Trust

To explore and understand the leadership experiences of modern
matrons, within an acute NHS Trust
NIGEL LAWRENCE R S C N B S C ( H O N S ) , M S C 1 and JANET RICHARDSON B S C ( H O N S ) , P H D , C P S Y C H O L , R N , D N , P G C E 2
1
Lead Nurse for Children and Safeguarding, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK and
2
Professor of Health Service Research (Honorary Consultant in Public Health–NHS Plymouth), Faculty of Health,
Education and Society, Plymouth University, Plymouth, UK
Background
Following public consultation, the National Health
Service (NHS) Plan (Department of Health (DoH)
2000) identified the need to appoint modern matrons to
provide an authoritative, visible and accessible clinical
figure to lead wards and departments; the intention of
the role was to improve quality of care, the patient
experience and to help restore public confidence in
healthcare. The matron role was re-introduced to
address nursesÕ apparent powerlessness when faced with
clinical concerns. Three main responsibilities of the role
Correspondence
Nigel Lawrence
Directorate Offices
Centre for WomenÕs Health
RD and E NHS Foundation Trust
Exeter EX2 5DW
UK
E-mail: [e-mail]
L A W R E N C E N . & R I C H A R D S O N J . (2012) Journal of Nursing Management
To explore and understand the leadership experiences of modern matrons,
within an acute NHS Trust
Aim The aim of this study was to explore and understand the leadership
experiences of modern matrons.
Background Modern matrons were re-introduced to the National Health Service
in 2002, and effective leadership has been identified as being essential for the role to
be successful. However, there is minimal evidence of how modern matrons
experience effective leadership.
Methods The study used a descriptive generic qualitative methodology; one-to-one
semi-structured interviews were conducted with nine matrons. This was
subjected to an inductive thematic analysis.
Results Three themes were found to influence modern matronÕs leadership
experiences: leadership behaviours, negative influences and leadership investment.
They did not follow one leadership style but adapted this to their situation.
Various factors appeared to restrict their leadership effectiveness.
Conclusions The findings suggest that exposure to a range of leadership styles
should be included in preparation and CPD for the modern matron role and a more
consistent job description and job purpose should be developed.
Implications for nursing management Leadership styles such as transformational
leadership alone do not meet the complex demands of nursing leaders, and
therefore there is a requirement for greater flexibility in leadership development for
all health care professionals.
Keywords: credibility, investment, leadership style, transformational leadership
Accepted for publication: 3 April 2012
Journal of Nursing Management, 2012
DOI: 10.1111/j.1365-2834.2012.01432.x
ª 2012 Blackwell Publishing Ltd 1

were proposed by the Department of Health (DoH
2001). These were: (1) to provide leadership to clinical
staff to secure and assure the highest standards of
clinical care, (2) ensure the availability of appropriate
administrative support services in their ward groups, (3)
to provide a visible, accessible and authoritative pres-
ence in ward settings to whom patients and their fam-
ilies can turn for assistance, advice and support.
The modern matron role was further defined in 2002
by the introduction of the 10 key responsibilities (DoH
2002). However, on introducing the role, individual
Trusts were given the opportunity to define the matronÕs
role according to their local needs. Consequently, there
has been variation in how the role is provided between
and even within Trusts (Gould 2008). Since 2002,
modern matron numbers have increased rapidly, and by
2008 there were 5538 modern matrons on NHS wards
(Mooney 2008). The role has evolved and become
increasingly complex as new targets and challenges
have been introduced. In particular, there has been an
increasing emphasis on the modern matronÕs role in
response to environmental cleanliness and infection
control (DoH 2004a,b, Shuttleworth 2004, Gould
2008).
Evaluation of role
Several small qualitative studies have evaluated the
matron role. Some studies suggest the role is successful
in demonstrating that through effective leadership,
matrons are enabling the improvement of patient care,
for example in areas of infection control (Kemp &
Morris 2003, Hill & Hadfield 2005, Keeley et al. 2005,
Dealey et al. 2007, Gould 2008, Smith 2008a,b).
However, the matronsÕ ability to promote high stan-
dards of cleanliness and infection control may be being
compromised due to limitations of domestic services
(Gould 2008).
Agnew (2005) asserts that matrons have replaced
nursing directors as the visible public face of nursing. In
contrast, Barbour and Dodd (2007) suggest that the role
is different to other senior nursing and management
roles because it ensures continuous direct contact be-
tween patients and middle managers. This might ex-
plain why any power and authority the matrons have is
negotiated, and located in the credibility of the indi-
vidual, rather than the authority of the matron role
(Keeley et al. 2005).
The largest and most comprehensive study of the
modern matron initiative was carried out by Read et al.
(2004). This mixed-methods study found that modern
matrons given the appropriate support, and with a
focused clinical role have great potential for improving
patient care. However, in many cases organizational
support was limited and the modern matrons had to
rely on their own leadership qualities to achieve their
goals.
Although a policy document from the Royal College
of Midwives (2002) supports the concept of the modern
matron, no studies were found that evaluated the role in
midwifery.
Organizational and personal factors
The majority of published studies suggest that the
implementation of the role has been successful. How-
ever, several studies have identified factors that appear
to reduce the effectiveness of the role. These issues in-
clude unrealistic organizational expectations, increasing
administrative tasks and the absence of budgetary
control (Gould 2008, Koteyko & Nerlich 2008). This
results in competing operational and clinical aspects of
the role, which has led to a hybrid management role
that has potential for tension and conflict (Savage &
Scott 2004, Dealey et al. 2007). These factors have re-
duced the matronsÕ visibility, and therefore lower their
organizational authority and credibility (Read et al.
2004, Koteyko & Nerlich 2008). Furthermore, many
matrons report feeling under-prepared for the role,
being unaware of their own development needs, and
having a deficit in business management skills (Read
et al. 2004, Gould 2008, Koteyko & Nerlich 2008).
Leadership and the modern matron
Previous studies appear to suggest that leadership is a
major factor in influencing the matronsÕ effectiveness
(Cole 2002, Barbour & Dodd 2007, Dealey et al. 2007,
Smith 2008b). When highlighting the importance of
effective leadership, many studies advocate a transfor-
mational leadership style for matrons (Hill & Hadfield
2005, Keeley et al. 2005, Scott et al. 2005, Dealey et al.
2007, Clark 2008, Koteyko & Nerlich 2008). However,
attributes and actions associated with transformational
leadership may not be adequate or broad enough to
meet the demands of senior nursing roles within the
NHS (McIntosh & Tolson 2008).
Several studies, (Scott et al. 2005, Barbour & Dodd
2007, Gould 2008, Smith 2008b) reported that the
modern matrons demonstrated leadership ÔqualitiesÕ and
ÔresponsibilitiesÕ, but provide little evidence regarding
how these attributes were demonstrated. Read et al.
(2004) implied that the matrons within their study had
to rely on their own leadership qualities to achieve their
N. Lawrence and J. Richardson
ª 2012 Blackwell Publishing Ltd
2 Journal of Nursing Management

goals, particularly through using interpersonal and
communication skills. Smith (2008b) identified several
factors that clearly reduced the matronsÕ leadership
capabilities, such as role conflict, a lack of role clarity,
role overload, competing priorities and blurred
boundaries with other roles.
Whilst studies have attempted to evaluate the leader-
ship role of modern matrons, there is limited literature
regarding the leadership experience of nurses in this role.
The study
Aims
The aim of this study was to explore and understand the
leadership experiences of modern matrons within an
acute NHS Trust, and explore from their perception the
organizational and personal factors that influence their
leadership experiences.
Methods
A descriptive generic qualitative methodology approach
(Cohen & Crabtree 2008) was used to explore and
understand the leadership experiences of modern ma-
trons. Semi-structured interviews were used for data
collection. Interviews were conducted away from the
participantÕs work area, were audio-recorded and
transcribed verbatim for analysis. The interview guide
was based on issues arising from the literature and
prompts to encourage participants to talk about their
leadership experiences. Two pilot interviews were
carried out to test the interview guide and revisions
made accordingly (Table 1).
Study participants
Participants were modern matrons in one acute NHS
Trust. All modern matrons within the Trust were given
an information leaflet and invited to participate. The
lead researcher (NL) attended several modern matron
meetings to introduce the study and invite participation.
There are 20 matrons in the Trust and the intention was
to interview up to nine modern matrons or until data
saturation was achieved (this included one senior mid-
wife). There were no male senior matrons in post at the
time of the selection process. This provided a cross-
section of modern matrons from all specialties across
one NHS Trust, with various levels of experience within
the role, and with whom the interviewer (NL) had no
professional or personal relationship.
Data analysis
To provide a clear systematic approach, data were
analysed using the thematic analysis process described
by Braun and Clarke (2006). Thematic analysis was
selected because of its flexibility, due to its theoretical
freedom that allows it the ability to be applied across a
range of theoretical and epistemological approaches.
This theoretical freedom offered the opportunity to
produce a rich and detailed, yet complex analysis of
data (Braun & Clarke 2006). Transcripts were read and
re-read to gain familiarity with the data and to generate
initial themes.
To assist the identification of initial codes a visual
thematic map was created to provide a visual repre-
sentation of this early process (Braun & Clarke 2006).
Two transcripts were analysed by a second researcher
(JR) and following conferring on themes a coding
strategy was then agreed to apply to all the transcripts
(Green et al. 2007).
The individual participants were given serial numbers
(SM 1–SM 9), and all the lines in the transcripts were
numbered. This provided the opportunity to cross-ref-
erence, and allowed easier identification of important
sections within the data to return to during the iterative
analytical process (Hardy & Bryman 2004, Denscombe
2007).
Following this process the themes were returned to
the participants in the form of a thematic diagram for
them to confirm or deny the accuracy of the analysis
(Guba & Lincoln 1989). This form of member-checking
offered the participants the opportunity to comment on
the themes, and the seven who responded, were all
positive and agreed with the themes.
Rigour was also maintained through reflexivity by
keeping a research journal to promote a transparent and
visible process throughout the study (Cooper & Endacott
2007). All theoretical, methodological and analytical
decisions taken were recorded, allowing key entries and
Table 1
Interview question guide for modern matrons
Previous experience
Preparation for matron role
Specific responsibilities of current role
The 10 key roles for matrons
Understanding of leadership
Previous leadership experience and training
Leadership experience within current role
Examples of effective leadership
Personal factors that influence their leadership experiences
Organisational factors that influence their leadership experiences
Support required to develop leadership performance
What next for individual matron?
Anything further they would like to add?
Leadership experiences of modern matrons
ª 2012 Blackwell Publishing Ltd
Journal of Nursing Management 3