Decision-making

Various reasons were offered by the interviewees for making a transition to leadership. Some related to the interviewees from an individualistic perspective; for example, several participants mentioned the need for new challenges:

“I felt I was making changes in the university, but it wasn’t making a big enough

splash… So I started to get itchy feet about six years in, I – I looked at managers,

and I could see very positive attributes in managers – in leaders, in midwifery. I

knew who I wanted to be like, I just wasn’t sure how I was going to get there” –

Lesley, matron.

Interestingly, Lesley went on to successfully apply for a head of midwifery post between the two interviews, and was about to take up the HoM role when I interviewed her for the second time. Already, she was considering the future, and further challenges:

“I’m already thinking about that [moving on from HoM]. It’s really bizarre. I’m

already talking about [laughing] – it sounds bizarre. I haven’t even started! I’m

already talking about what I’m going to do next”.

Heather, meanwhile, saw the need for challenges in quite different terms, which related to her self-perception:

“I do like to challenge myself all the time. And I think this fear of failure drives me

really hard, because I have to be the best I can be, all the time”.

Susan described the need for challenges in relation to her move from a HoM role to her current position as LSA MO:

“It’s difficult, that one, to actually say what it is that makes you know – but I had – I

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Alongside the need for challenges, the majority of the interviewees mentioned a sense of inner drive and motivation, again emphasising the place of agency in their career decision- making:

“I do sometimes think to myself, how did I get to this point and why am I doing this,

when I qualified as a midwife and I should be on the floor just – I should be working

as a midwife. But it would never have been enough for me, to have just done that,

so I needed – I needed to do something on top of my midwifery training” – Caroline,

PDM.

Alongside these individualistic reasons for moving to leadership, interviewees’ career decisions also showed strong evidence of interplay with the wider organisational structures. For example, the desire to influence change was mentioned by most of the interviewees:

“And I do believe as well, that it’s far better to be in there, actively involved,

throwing your ideas in the pot, rather than sit back and be told, ‘This is how you do

it’. That’s not my style. I would rather be in there, contributing and developing

things” – Deborah, matron.

“I said, ‘Oh’, I said, ‘we need to stop all this closed glottis pushing and cheerleader

stuff’. And I was talking through about what I’d read, and again about

management of OP [foetal position] as well – ‘Oh, that’s it then, you’re going to

push our forceps rate up!’ And I thought, ‘How can I change practice if I am

working with that? Maybe what I need to do is go into education and try it from

the bottom’” – Natalie, LME.

Natalie’s sense of not wanting to accept the status quo, and of questioning the way things were done, was echoed by several other interviewees:

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“It’s this wanting to improve things, and looking for other ways of doing it, not just

thinking, well, it’s got to be that way. Why has it got to be that way? And why do

we have to do it?” – Deborah, matron.

“I came out of management to go back into clinical practice, but then I moved out

of clinical practice into management because I felt that there were things that were

being done that actually I felt should be done in a different way. And it was either,

then, shut up or actually get in there and get it sorted” – Susan, LSA MO.

While self-motivation was central to the interviewees’ leadership journeys, encouragement from others also played a significant part. Pauline spoke of the influence of her supervisor of midwives and her line manager in making the decision to apply for a HoM secondment:

“[She] said, ‘Well, what – you know, it’s good development for you just to be

exposed to the interview process’… She said, ‘It will be good exposure for you, just

to go into the - into a HoM interview to see what it’s all about’. And so – so I

spoke to my ex-head of midwifery, who I – who I’ve kept links with, and she said,

‘What have you got to lose?’ She said, ‘It would be good exposure for you’, so I

went for it”.

Deborah was able to reflect with hindsight on the influential role played by a former manager:

“I bumped into a previous manager of mine… And she said to me, ‘So, what are you

doing nowadays?’ I said, ‘I’m doing your old job!’ She said, ‘I always knew you

would’. So you know, it’s about having somebody there. And she did – you know,

even though she was a devil at times, she did actually see potential in me, and

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On the subject of encouragement from others, there was one dissenting voice among the interviewees. Caroline felt she had not had the encouragement from others to develop a career path:

“When I was qualified as a midwife, that’s what I was doing. I wasn’t really looking

there, at that time, or wasn’t being informed at that time, that there were several

pathways I could develop. I could develop into this, into that – and maybe rightly or

wrongly, you’re not told”.

All the interviewees spoke about finding the right level at which they could effect change and influence service delivery. This realisation came at various points in their career journeys. For example, Deborah was already a senior matron, and completed a strategic leadership development programme:

“So after I’d done the RCM’s leadership programme, I came back sort of fired up,

thinking, ‘I need to do something now, I need to go somewhere’. But at the time,

there wasn’t the opportunity for a head of midwifery post locally, and there wasn’t

much in the region either, and unfortunately due to family constraints, I can’t look

at the bigger picture. So I bided my time”.

At the time of the first interview, Lesley had been in the matron role for several months, having returned to the NHS from a university lecturer position where, as described earlier, she had realised she could not effect the kind of change she wanted to:

“I became an NLS instructor, and an ALSO advisory faculty instructor, so I was doing

a lot of networking, meeting with people nationally and internationally through

those forums, and thinking, ‘I need to back and, you know, make changes’”.

By the time of the second interview, Lesley had become frustrated at matron level, and had successfully applied for a HoM position in a different trust:

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“I guess I want my own service, I want to be responsible for the decisions I make.

It’s a bit frustrating, sometimes, delaying things because you have to escalate it

up… There’s due process to go through, and I just find that a little bit frustrating. I

could be completely wrong, but I feel I’m ready for it [the HoM role]”.

While Pauline found this ability to make a difference at matron level, rather than Lesley’s HoM role, she described it in similar terms:

“[I get] more satisfaction now, because I’m in a position where I can make a

difference – more of a difference than you can as a band 7. The band 7, you can

only go so far, and then you have to, you know, pass that information up – up the

ladder, if you like, for them to actually take note and decide whether they want to

do something about it or not. I’m now in a position where I can make that decision,

whether, you know, it is a good thing to move forward, whether it’s something that

we need to be taking note of and making changes, and listening to the women”.

Endogenous and exogenous factors are clearly evident in decision-making. Interviewees were able to identify that they often wanted ‘more’ from midwifery, and they showed an awareness that change can only be effected at senior levels of a management, strategic or academic hierarchy. Alongside an emphasis on their sense of inner motivation and drive, interviewees generally described a good deal of encouragement from others in the decision-making process, usually from individuals above them in the organisational hierarchy, who seemed to encourage them to consider things from a position of ‘Why not me?’ when contemplating a move into leadership and management.