Bureaucratic Caring in Action: Chief Nursing Officers' Leadership in Healthcare

To explore how chief nursing officers perceive and enact their leadership within bureaucratic healthcare systems, with a particular focus on patient safety, strategic responsibilities and the advancement of nursing care quality.

A qualitative study design was used. Semistructured interviews were conducted between October 2023 and May 2024 with nine female Chief Nursing Officers, representing diverse regional healthcare settings across Sweden. The interviews were analysed using reflexive thematic analysis, which was informed by the theory of bureaucratic caring to support interpretation.

Chief nursing officers described navigating hierarchical and bureaucratic systems while promoting person-centred care and professional governance. Their work involved balancing strategic mandates with ethical imperatives, advocating for workforce development and fostering a culture of proactive safety. The analysis generated four interrelated themes: (1) grappling with complexity and power structures; (2) guided by ethics, compassion and purpose; (3) empowering the nursing workforce to provide improved care; and (4) shaping quality care through innovation, evidence and technology.

Chief Nursing Officers can act as key agents of transformation at the intersection of structure and care. Their leadership extends beyond administrative functions to encompass strategic influence, ethical advocacy and system-level improvement. The findings underscore the need to further formalise and institutionalise the role, ensuring it is equipped with the mandate and structures required to lead across organisational levels. Strengthening such roles calls for leadership models that foster collaboration, support shared governance and enable flatter organisational hierarchies-structures designed to enhance participation, distribute decision-making and promote professional autonomy.

This study followed reporting standards for qualitative research by adhering to the EQUATOR Network guidelines and using the COREQ checklist.

Only health care staff participated in this study.

This study highlights the strategic, ethical and relational dimensions of chief nursing officers' leadership and its impact on patient safety, quality improvement and workforce development. The findings demonstrate that they can play a pivotal role in embedding ethical perspectives into healthcare leadership-bridging professional nursing values with structural and strategic priorities. This underscores the importance of enabling nurses to shape care systems in ways that promote safety, professional governance and person-centredness.