Tissue viability nurses (TVNs) play a pivotal role in preventing avoidable harm, improving patient outcomes and reducing unwarranted variation in care. Historically, the role has been conceptualised primarily as one of advanced clinical expertise, centred on wound management, pressure ulcer prevention, education and audit. However, the context in which tissue viability services now operate has shifted significantly.

Organisational mergers, service reconfiguration and the continued maturation of integrated care systems have expanded the scope and complexity of specialist nursing roles. TVNs are increasingly required to align services across multiple sites, influence practice beyond organisational boundaries and contribute to strategic decision-making. Yet leadership capability is not always explicitly recognised or developed as a core requirement of the role.

This article argues that leadership capability is no longer an adjunct to tissue viability nursing practice, but a fundamental component of contemporary specialist practice. Drawing on leadership and systems theory and informed by practice-based experience of service integration during organisational merger, it explores why leadership development must now be considered essential for specialist nursing sustainability and influence.

Tissue viability nursing within an evolving NHS landscape

The NHS is characterised by complexity, interdependence and scale. Trust mergers and cross-system collaboration demand service alignment across diverse professional, cultural, and organisational contexts. For tissue viability services, this frequently involves harmonising clinical pathways, documentation, formularies, governance structures and education programmes.

While the technical work of standardisation is significant, the adaptive challenge is greater. Aligning services requires navigating professional identity, addressing variation in established practice and managing uncertainty among staff. TVNs are uniquely positioned within organisations: highly visible, clinically credible and connected to multidisciplinary teams across care settings. This visibility confers influence, but without leadership capability, this influence risks remaining reactive rather than strategic.

Therefore, the contemporary TVN must operate not only as a clinical expert, but also as a system leader.

The perceived plateau in specialist nursing

Alongside structural change, another narrative is increasingly evident within specialist nursing: the experience of professional stagnation. Many experienced TVNs describe reaching a plateau. Their clinical expertise is highly developed, yet opportunities for progression appear limited. Leadership roles may feel distant from their professional identity or be perceived as requiring a departure from clinical practice.

This sense of being ‘stuck’ is not indicative of limited ambition or capability. Rather, it reflects how specialist roles have traditionally been conceptualised. Clinical mastery has been prioritised; leadership capability has often been implicit, informal or self-taught.

In a transforming NHS, this conceptualisation is no longer sufficient. Without explicit development of leadership capability, specialist nurses risk remaining positioned as technical advisors rather than strategic contributors. The profession must reconsider whether leadership is an optional enhancement, or a core dimension of specialist practice.

Leadership, self-awareness and reflexivity

Leadership literature consistently identifies self-awareness and reflexivity as foundational capabilities for effective leadership in complex systems (Goleman, 2013; NHS Leadership Academy, 2013). During periods of organisational change, leaders’ emotional responses, assumptions and biases can significantly influence team dynamics and perceptions of change.
Within tissue viability services, leadership authority often derives from professional credibility rather than hierarchical power. This makes reflexivity particularly important. How a TVN responds to scrutiny, comparison between legacy services, or perceived challenge can either strengthen psychological safety or reinforce defensiveness and division.

Practice-based experience during a recent large-scale organisational merger demonstrated that technical expertise alone was insufficient to support service alignment. The more complex work involved facilitating dialogue between teams with different histories, addressing unspoken anxieties and tolerating ambiguity while new structures emerged. Structured leadership development, including participation in the Rosalind Franklin Programme, delivered by the NHS Leadership Academy, provided space to critically examine leadership behaviours, emotional responses, and assumptions about authority. This process reinforced that self-awareness is not a peripheral leadership attribute, but a prerequisite for influencing within complex systems.

Leading change: From communication to co-production

Traditional change management approaches within healthcare have emphasised communication, clarity, and implementation. Frameworks such as Kotter’s and Lewin’s models provide helpful structure. However, evidence increasingly suggests that sustainable change depends on meaningful inclusion and shared ownership (Cameron and Green, 2019).

Within tissue viability service integration, approaches that prioritise coproduction, joint service mapping, cross-site shadowing, collaborative audit review and shared education development can mitigate the ‘them and us’ dynamic that frequently accompanies mergers. These approaches enable variation to be surfaced constructively and allow staff to contribute to the design of unified systems.

Leadership in this context becomes less about directing change and more about enabling it. Inclusive leadership behaviours, rather than linear implementation alone, determine whether procedural alignment translates into cultural cohesion.

Systems leadership and complexity

Healthcare organisations function as complex adaptive systems in which outcomes emerge from relationships and interactions rather than predictable cause-and-effect processes (Senge et al, 2015; Greenhalgh and Papoutsi, 2018). Mechanistic leadership approaches that prioritise control and rapid standardisation may offer short-term reassurance but are insufficient to address deeper systemic challenges.

For tissue viability services operating across organisational boundaries, systems leadership is increasingly relevant. Aligning protocols may be technically straightforward; navigating professional identity, legacy loyalties and competing operational pressures is not. Leaders must be able to see the wider system, foster generative dialogue and support collective sense-making.

This represents a significant shift in the conceptualisation of the TVN role: from clinical expert problem-solver to system-level enabler. Such a shift requires intentional development of systems thinking and relational leadership capability.

Resilience and the emotional labour of specialist leadership

Prolonged organisational change carries emotional cost. Change fatigue, uncertainty and competing demands affect both teams and leaders. For TVNs, who often combine clinical accountability with service leadership responsibilities, the emotional labour can be considerable.

Resilience in this context is less an individual trait and more of a relational process. Leadership behaviours that promote autonomy, psychological safety, clarity of purpose and shared meaning strengthen collective resilience. Conversely, overly prescriptive or control-focused approaches may inadvertently amplify stress.

Sustaining specialist services therefore requires attention not only to operational alignment, but to the wellbeing and relational dynamics of those delivering care. Leadership development that addresses compassionate leadership, boundary-setting and self-regulation is essential for long-term effectiveness.

Implications for tissue viability nursing

The evolving NHS landscape has significant implications for the profession:

• Leadership capability should be explicitly recognised as a core component of the TVN role, alongside clinical expertise
• Structured leadership development should extend beyond operational management to include systems thinking, reflexivity and relational leadership
• Organisations should invest intentionally in specialist nurse leadership development to enable effective service integration and system-wide improvement
• Professional bodies and national networks should articulate leadership expectations within specialist competency frameworks.

Without this shift, specialist nurses risk remaining positioned at the margins of strategic decision-making, despite their system-wide influence and expertise.

Conclusion

TVNs are increasingly required to operate as leaders within complex and evolving healthcare systems. Leadership capability is no longer optional. It is fundamental to the sustainability, influence and progression of the specialism.

If specialist nurses are positioned solely as clinical experts, they will experience system change as something imposed upon them. If, however, leadership capability is embraced as a core professional responsibility, TVNs can actively shape service redesign, influence organisational strategy and extend their impact beyond individual patient encounters.

The question is not whether TVNs are capable of leading at system level, they demonstrably are. The question is whether leadership development will be recognised, supported and prioritised as essential to the future of the profession.

In a transforming NHS, the effectiveness of tissue viability services will depend not only on clinical excellence, but on the leadership capability of those who lead them.