Background: Nursing leadership suffers from a myriad of challenges that originate from the socio-political backdrop of the country. Lack of government support and resource constraints deny good leadership practice due to high patient turnover and few healthcare personnel.
Methods: A qualitative approach was utilized, involving semi-structured interviews with 15 nursing leaders from public sector tertiary care hospitals, Swat. The participants included a range of leadership positions to capture diverse perspectives.
Results: The study identified several major challenges. Resource limitations, primarily due to inadequate government funding, resulted in frequent shortages of essential supplies, equipment, and staff, particularly in rural facilities. Staffing shortages further compounded the issue, leading to excessive workloads and burnout among existing staff. The lack of formal leadership and management training was another critical issue, with many leaders promoted without adequate preparation. Socio-cultural barriers, especially gender biases, undermined the authority of female nursing leaders, reflecting broader societal attitudes. Additionally, the bureaucratic nature of the healthcare system created slow decision-making processes and administrative hurdles. Political interference in decision-making disrupted patient care and undermined leadership authority.
Conclusion: The findings highlight the need for comprehensive reforms to address these challenges. Improving resource allocation, enhancing leadership training programs, and reducing bureaucratic inefficiencies are essential for strengthening nursing leadership. Additionally, addressing socio-cultural barriers and minimizing political interference will contribute to more effective healthcare delivery. Implementing these changes is crucial for enhancing the overall quality of care and supporting nursing leaders in their roles.

Nursing leadership, Healthcare challenges, Public sector, Qualitative study, Socio-cultural barriers.

Nursing leadership suffers from a myriad of challenges that originate from the socio-political backdrop of the country. Lack of government support and resource constraints deny good leadership practice due to high patient turnover and few health personnel.[1] More so, the availability of health care depends on the type of region; urban or rural, meaning that leaders are under more pressure in the rural areas, which lack the resources to provide quality care.[2]  Low wages, poor remuneration, and other working conditions, such as high staff turnover, also have an impact on leadership and staff satisfaction.[3]

Socio-cultural factors, including conventional gender roles, reduce the power of female nursing leaders, making their leadership challenging.[4] This bureaucratic structure of Pakistan’s healthcare system poses another challenge, as slow decision-making hinders the required change processes.[5] Finally, a lack of sufficient vocational research and operational utilization of the findings hampers nursing leaders in creating and choosing improved methods.[6]

Unpredictable economic status and political systems in Pakistan result in a lack of a stable environment in which to deliver health care services, and planning for the future makes it very hard for leaders in the nursing field.[7] Also, the psychological and emotional status of the nursing leaders is often neglected while they work under pressure, they undergo stress, and there is a lack of encouragement and support from other leaders, which makes them experience burnout, and hence their effectiveness decreases.[8] Staffing issues also worsen these problems because, as the population’s healthcare requirements grow, so does the shortage of trained professionals available for positions.[9] In other words, what exercises the nursing leaders includes a large number of clients, inadequate staffing, and increased work and stress. It distorts staffing and talent acquisition, which requires the implementation of measures encouraging talent while ensuring the quality of patient care.[10]

This qualitative study explored challenges in nursing leadership within public sector tertiary care hospitals in Swat, Pakistan, using an exploratory and descriptive design. 15 participants included diverse leadership roles: 4 nursing supervisors, 4 head nurses, 4 ward in-charges, 2 clinical nurse superintendents, and 1 nursing superintendent. Purposeful sampling ensured representation from various organizational levels and sections. Insights were gathered to understand experiences and perceptions in their contextual settings.

Interview procedure: Semi-structured interviews were used to elicit richer details about the participants’ experiences. The interviews were semi-structured because the interviewers had specific questions they were to ask, but the interviewees could respond in their own way, and the interviewers could also ask follow-up questions.

Duration: On average, each interview took 45 to 60 minutes.

Setting: The interviews were conducted individually to maintain anonymity and confidentiality.

Data analysis: A thematic approach was used to analyse the data. The six steps of Braun and Clark were followed. After transcription, the data was read and reread to generate the main idea of fully understanding the audio-recorded material that had been gathered. The codes were then converted to the appropriate mode, their similarities and duplicates were removed, and new categories were created. Themes were produced based on categories, and participant quotes were used to confirm them.

Demographic finding: Of the 15 nurses with a mean age of 40 ± 1. 95 years, and all are from the public sector hospitals. And having different years of experience between >10-20 years. The roles were 4 (26. 6%) nursing supervisors, 4 (26. 6%) head nurses, 4 (26. 6%) nursing ward in-charges, 2 (13. 3%) clinical nurse superintendents and 1 nursing superintendent. They had academic qualifications which varied from PhD (2), master’s degree health related (4) followed by BSc Nursing (4), diploma in teaching & admin (4) and diploma in nursing (1).

Themes of the study: Following themes developed as study outcomes, including resource limitations, staffing shortages, educational gaps in leadership training, socio-cultural barriers, gender dynamics, bureaucratic hurdles, and political interference in decision-making.

Resource limitations: The participants described a lack of resources in healthcare organizations, particularly in the public system, as a major challenge to leadership in nursing. Lack of diapers, warmers, pumps, sterilizers, syringes, and other medical supplies and equipment, coupled with inadequate staffing due to low government budgets, made the process of rendering patient care difficult. Health facilities in the rural areas were the most affected; they could not even access the most basic needs like water and electricity, let alone provide quality care.

Participant quote: “We sometimes lack simple things like basic medications or even basic equipment to handle patients with, and it’s frustrating because as leaders we are expected to come up with solutions, but how can you come up with solutions when you don’t have what it takes?” (Nurse manager)

Staff shortages: Lack of staffing was cited as a major concern by the nursing leaders. Growth of the patients’ need for healthcare services and the shortage of nurses results in a heavy workload and exhaustion of the current staff. Consequently, nursing leaders had to dedicate most of their efforts to the attraction and retention of new nurses, thereby not having sufficient time and effort to devote to leadership and other strategic initiatives.

Participant quote: “We can never have enough nurses. There are so many patients, and the workload is high. Many nurses quit the profession midway”, I am spending time hiring and training new staff – it is an unending exercise – instead of mapping out and implementing change strategies (Nursing supervisor).

Educational gaps in leadership training: Nursing leaders identified the absence of formal leadership education as a substantial challenge, noting that most nurses were promoted to leadership positions without preparing them for their new role responsibilities. This contributed to inefficiencies in staff management and failure to accomplish organizational goals and objectives. Participants expressed the need for standardized, formalized managerial-leadership preparation initiatives since.

Participant quote: “When I was promoted to this leadership role, I had no formal training in management. I had to learn everything on the job, which isn’t always effective. Leadership requires specific skills that we aren’t taught in nursing school (Head nurse).”

Socio-cultural barriers and gender dynamics: Nursing leaders, including women, reported the challenges arising from the socio-cultural environment in Pakistan. Their leadership was always challenged by male employees, which was compounded by traditional cultures’ gender stereotypes and prejudices. Female participants expressed that their decisions were not always followed and respected, especially in health organizations that are dominated by male admins. They always had to remind everyone above them ‘‘I am the leader here.’’ Organizational culture was also a demerit that affected their leadership, since the following cultural barriers impacted the leadership negatively.

Participant quote: “Male subordinates do not accept a woman in a leadership position,’ they don’t see that nursing leadership is a role which should be with a woman; it is a challenge to fight every day (Female nurse supervisor).”

Bureaucratic hurdles: The bureaucratic and centralized structure of healthcare was considered a problem by the nursing leaders of Pakistan; the slow decision-making process could lead to an important improvement in patient care. When it comes to the implementation of new strategies, they experienced an issue of bureaucracy. They struggled with multiple layers of administration, which posed a challenge to their ability to respond to any challenge as and when it arose. Moreover, leaders across the setting indicated their voices were decentralized to higher administrative levels, implying that they had little power to bring change.

Participant quote: “The bureaucracy in our healthcare system is extensive. One needs to wait for several months before getting approval for matters that are as basic as recruiting new employees or buying equipment. It really hampers the agility of decision making in organizations (Nursing supervisor).”

Political interference in decision-making: Political influence was another challenge highlighted by nursing leaders, especially in the public sector, when making decisions concerning the institutions. Leaders at different levels of the health care system were interfering with decisions such as staffing, allocation of resources, and development of strategies for patient care, and they were also eroding the authority of nursing leaders. These interferences, initiated by political agenda and not health requirement, led to many setbacks, reduction of morale, and confusion among staff, hence putting a substantial challenge to the leadership in delivering constant quality care.

Participant quote: ” Often times, I have made a decision based on the needs of our hospital, but then a politician steps in and changes it (Nursing superintendent).”

The aim of the current qualitative study was to explore the challenges being faced by nursing leaders in the public sector tertiary care hospitals of Pakistan. This study identifies several endemic issues that lead to leadership inefficiencies and subsequently affect the quality-of-service delivery, particularly in the health sector.

The study revealed that due to shortcomings in government funding, the ailing nursing sector is beset with serious resource constraints, especially in those areas considered rural. It is therefore a major challenge to care for the patients due to the shortage of supplies, equipment, and staff, which has become a major source of frustration to the nursing leaders. These issues tally with research that indicates that a lack of resources affects the ability to deliver healthcare and the effectiveness of leaders in the facility.[11]

Shortage of staff re-emerged as a challenge, and while demand was high, the number of nurses was also inadequate to accommodate; therefore, the workload, stress levels, and fatigue resulted from this challenge. This pressurizes nursing leaders to emphasize the processes of recruitment and training instead of the positive changes. The high turnover rates and the patient load have a negative effect on care continuity and stability; research from different countries reveals that staffing shortages can lead to increased stress and job dissatisfaction among employees.[12]

To the researchers’ surprise, the study indicated a worrying lack of training and development for the nursing leaders in terms of leadership and management exposure, especially with most of the nursing leaders being promoted to such positions without adequate orientation, this acted as a major hindrance to efficiency in managing team and deploying strategies as required. This led to the need for standard leadership development programs, as what they had in place was not enough and very disordered. Such as getting feedback from the participants’ views.[13] Second, socio-cultural factors and gender issues acted as an impediment to change owing to resistance from male dominants centered on the female leaders. These problems relate to more extensive cultural norms shaping women’s appointments to leadership positions and demonstrate that the gender paradox persists with regard to the advancements of female employees in their
careers.[14]

Bureaucracy was identified as an issue as Pakistani Nursing leaders encountered slow decision-making processes, administrative barriers that have altered Patient care enhancement. Complex bureaucratic structures acted as barriers to timely decision making and implementation of required changes.[15] Moreover, political interferences in the decision-making process were highly damaging to patient care as political officials overruled staffing and resource decisions for shortages and delays. This shows why politics should be taken out of healthcare management to let decisions flow from what patients need and medical research shows.[16]

The findings highlight the need for comprehensive reforms to address these challenges. Improving resource allocation, enhancing leadership training programs, and reducing bureaucratic inefficiencies are essential for strengthening nursing leadership. Additionally, addressing socio-cultural barriers and minimizing political interference will contribute to more effective healthcare delivery. Implementing these changes is crucial for enhancing the overall quality of care and supporting nursing leaders in their roles. Allocate sufficient resources and provide formal leadership training to strengthen nursing leadership. Address socio-cultural barriers and streamline bureaucratic processes to enhance decision-making. Minimize political interference to ensure healthcare decisions prioritize patient needs.

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Corresponding Author:   
Shah Hussain
Department of Nursing
Zalan College of Nursing Swat, Pakistan
Email: shahpicu@gmail.com

Co-Authors:
Sardar Ali
Department of Nursing
Khyber Medical University Peshawar, Pakistan

Muhammad Anwar
Department of Nursing
Medtach College of Nursing Dir, Pakistan

Nisar Khan
Department of Nursing
United College of Nursing, Swat, Pakistan

Kainat
Department of Nursing
Zalan College of Nursing Swat, Pakistan

All authors contributed to the conceptualization, investigation, and data curation by acquiring and critically reviewing the selected articles. They were collectively involved in the writing – original draft preparation, and writing – review & editing to refine the manuscript. Additionally, all authors participated in the supervision of the work, ensuring accuracy and completeness. The final manuscript was approved by all named authors for submission to the journal.

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https://doi.org/10.63096/medtigo30623124

Hussain S, Sardar A, Muhammad A, Nisar K, Kainat. Challenges Faced by Nursing Leadership and Nursing Leaders in the Public Sector Swat: A Qualitative Study. medtigo J Med. 2025;3(1):e30623124. doi:10.63096/medtigo30623124 Crossref