Recognizing and defining clinical nurse leaders

[Pages:5]Recognizing and defining clinical nurse leaders

David Stanley

Abstract

This article addresses the issue of clinical leadership and how it is defined. The concepts and definitions of clinical leadership are considered as well as the results of new research that suggests that clinical leaders can be seen as experts in their field, and because they are approachable and are effective communicators, are empowered to act as a role model, motivating others by matching their values and beliefs about nursing and care to their practice. This is supported by a new leadership theory, congruent leadership, proposed as the most appropriate leadership theory to support an understanding of clinical leadership. Congruent leaders (clinical nurse leaders) are followed because there is a match between the leader's values and beliefs and their actions.

Key words: Leadership n Models and theories n Nursing: role

Mullally (2001) suggested that effective nursing leadership is central to the success of the `NHS Plan' (Department of Health (DH), 2000). Therefore, if nurses are to make a profound contribution and support the Government's change agenda with, `a new breed of clinical leaders' (DH, 1999 p52), then understanding clinical leadership should be central to the goals of the nursing profession. Gaining an understanding of clinical leadership is also pivotal in recognizing who the clinical leaders are and to further explore the values associated with bedside, clinical care. The term `clinical leadership', although recognizable in nursing and allied health literature, has rarely been the subject of detailed study. This article addresses the questions: `what is clinical leadership?' and `how is clinical leadership defined?'

What is clinical leadership? There is a plethora of literature that addresses the topic of nursing leadership, although only a small portion specifically considers clinical nurse leadership. Of the papers that do, Christian and Norman (1998) and Cook (2001a, 2001b) investigate clinical leadership characteristics. Firth (2002) explores the balance between the clinical and managerial roles of ward leaders, concluding that ward managers experience

conflict between the managerial and clinical aspects of their role. Cosens et al (2000) identify ward `opinion leaders' and McCormack and Garbett (2003) consider the characteristics and skills of `practice developers,' who they describe as being like clinical nurse leaders.

Others have considered the concept of clinical leadership, with significant contributions from Peach (1995) and Lett (2002) (both from an Australian perspective), and the American authors, Dean-Baar (1998), McCormack and Hopkins (1995), and Rocchiccioli and Tilbury (1998), have added to the discourse. Berwick (1994) and Wyatt (1995), writing from a medical perspective and Schneider (1999), writing from a pharmacological stance, have also contributed. Malby (1998) makes the point, highlighted by Lett (2002) that although the term clinical leadership is used in a number of contexts there is little agreement on the definition.

This lack of agreement is compounded by the literature appearing to offer three distinct ways in which the term clinical leadership is presented. Firstly, it is used in terms of describing clinical leadership programmes or evaluations of clinical leadership programmes (Scott, 1987; Wright, 1996, Hambridge, 1997; McKeown and Thompson, 1999; Read, 1999; Cunningham and Kitson, 2000a, 2000b; Cooper, 2003; Faugier, 2003; Faugier and Woolnough, 2003). The programmes described are often used to train or develop nurses with leadership potential or nurses in leadership positions.They occupy considerable volumes of the literature available about clinical leadership and, while they are useful as guides to the benefit of the programmes, they commonly shed little light on the concept of clinical leadership itself.

Secondly, the literature is used to describe the work of managers who work in the clinical setting (Christian and Norman, 1998; Dean-Baar, 1998; Malby, 1998; McCormack and Garbett, 2003) and thirdly to describe the work of clinicians who practice at an expert level and who have or hold leadership positions (Harper, 1995; McCormack and Hopkins 1995, Cook, 2001a, 2001b; Lett, 2002). Because the literature is unclear on the concept of clinical leadership, defining a clinical leader or clinical leadership would be a sensible place to start.

A definition: clinical leader/leadership Harper (1995, p81) defined a clinical leader as:

David Stanley is Senior Lecturer in Nursing, University of Worcester Accepted for publication: December 2005

`...one who possesses clinical expertise in a specialty practice area and who uses interpersonal skills to enable nurses and other healthcare providers to deliver quality patient care.'

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Rocchiccioli and Tilbury (1998) also site excellence in clinical practice as an element of their perspective, but add that it also involves an environment where staff are empowered and where there is a vision for the future. Cook and Holt (2000) capture all these perspectives and declare that clinical leadership requires leadership skills for team building, confidence and respect of others, as well as vision and empowerment.They add that clinical leaders must also be good communicators. Lett's (2002, p20) definition is within these parameters, indicating that `clinical leaders provide vision to their followers and empower others', adding that a clinical leader is an `expert nurse who leads their followers to better health and health care.'

Cook (2001b p39) also brings the definition back to a nursing or clinical focus, declaring that a clinical leader is:

`...a nurse directly involved in providing clinical care that continuously improves care through influencing others.'

This implies that clinical leaders do not need to be in a management or senior position and points to leadership derived from the strength of the leaders' opinion.

Berwick (1994) and Schneider (1999) understand clinical leadership to be about being the experts in the field and that leadership should develop as leaders use their expertise and knowledge to drive reform and change. These definitions point to there being a number of key elements in the recognition of clinical leaders: n Clinical expert (Berwick, 1994; Harper, 1995; Rocchiccioli

and Tilbury, 1998; Schneider, 1999; Lett, 2002) n Effective communication or interpersonal skills (Harper,

1995; Cook and Holt, 2000; Cook, 2001b) n Empowerment, respect for others, team-building

(Rocchiccioli and Tilbury, 1998; Cook and Holt, 2000; Lett, 2002) n Drive change, make care better, provide quality care (Berwick, 1994; Harper, 1995; Schneider, 1999; Lett, 2002; Cook, 2001b) n Vision (Rocchiccioli and Tilbury, 1998; Cook and Holt, 2000; Cook, 2001b: Lett, 2002) However, a qualitative research study undertaken by the author between 2001 and 2004 that set out to explore the qualities and characteristics of clinical leaders and who the clinical leaders are, offers a new perspective on the concept and definition of clinical leadership.

the aid of a computer-assisted qualitative data analysis software (CAQDAS) programme, in this case NVivo 2.0 (Richards, 1999). Figure 1 outlines the research design summary.

Findings The research findings are extensive, but in relation to the concept of clinical leadership the following summary points can be offered.When identifying clinical leaders, participants in the phase 2 (n=42) and 3 (n=8) interviews indicated that they could be recognized because they demonstrated: n Clinical competence: this related to being both clinically

skilled, competent and credible in a specific clinical area n Clinical knowledge: this was linked to clinical competence

and being a clinical expert. This was also extended into knowing how teams worked, how individuals worked and knowledge of relationships

Figure 1. Research design summary

1. Literature review: In parallel with all other parts of the study

Focused on: Leadership, Clinical leadership, Empowerment, Oppression, Power, Organization, Culture, Nursing leadership, Ward leadership, Change, Authority

2a). Ethical approval and trust permission:

Questionnaire consent form and development of introduction letter

2b). Ethical and trust approval for phases 2 and 3

Further approval sought following the procedural changes to the study

3. Pilot Study: Questionnaire On a paediatric unit within the same acute NHS Trust 30 sent; 13 returned (43.3%) (Stanley, 2004)

4. Phase 1: Questionnaire Appropriate, qualified nurses identified from personnel list. Sent to qualified nurses in direct patient care areas, within one large acute NHS Trust. Aim to explore clinical leadership issues, the qualities and characteristics of clinical leaders and who the clinical leaders are. 830 sent; 188 returned (22.6%)

5. Phase 2: Focused interview In-depth interviews with a random selection of staff from different grades on four different clinical areas. Aim to explore issues related to clinical leadership and who the clinical leaders are in each area (42 interviews in total)

Aim and method The aim of the study was to identify who the clinical leaders are and critically analyse the experience of being a clinical leader. The two principle methods used to generate the data were a questionnaire and two sets of interviews. Both approaches were preceded by an extensive literature review and wide consultation with peers, the Local Research Ethics Committee and relevant NHS Trust managers. The principle research methodology was qualitative and a grounded theory approach (Glaser and Strauss, 1967; Chenitz and Swanson, 1986; Glaser, 1992; Strauss and Corbin, 1998) was used in establishing the direction of the research and analysis of the data. Data were analysed with

Connected indirectly or influenced Lead to

7. Results and discussion: Literature and the results from each of the three phases used to illuminate and analyse the issues of clinical nurse leadership and the experience of being a clinical nurse leader

6. Phase 3: Clinical leader interviews In-depth interviews with two clinical nurse leaders who received the most nominations from their colleagues, from each of the four different clinical areas. Aim to gather data about their experience of being clinical nurse leaders (eight interviews in total)

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n Effective communicator: this implied having listening skills, being able to explain things at the right level for staff and patients to understand and being able to influence and lead by virtue of their opinion

n Decision-maker: participants suggested that decisionmaking, not just in relation to clinical issues, but with regard to a whole host of issues, was central to clinical leadership

n Empowerment/motivator: participants looked to clinical leaders because of their enthusiasm and belief in what they were doing. Clinical leaders were identified because they were themselves empowered and could inspire others

n Openness/approachable: every participant, in keeping with the questionnaire findings, identified `approachability' as a recognizable characteristic of clinical leaders. Ineffective clinical leaders were described as `controlling' or dictatorial.

n Role model: clinical leaders were described as having their values on show and other nurses indicated that it was their ability to nurse or to care effectively that helped them stand out as clinical leaders

n Visible: participants overwhelmingly indicated that to be a role model, approachable, an effective communicator and clinically competent, the clinical leader needed to be visible. Present in the clinical environment, not in an office, not `hide bound' as one participant put it.

Discussion The significance of these findings might not at first be evident, with many of the attributes from the definitions above being represented in the characteristics and qualities identified in this author's study. However, there is one significant difference, and this points toward a new perspective that can be brought to the consideration of clinical leadership. In both this author's study and the definitions given previously, clinical expertise, effective communication, empowerment and a desire to provide quality care can be identified. However, at no point in the author's research was vision identified as an attribute for which clinical leaders were identified or followed. It is not suggested that clinical leaders have no vision, only that it is not their vision that motivates their followers. Instead, it is the demonstration and translation of their values and beliefs into the actions and the functions of their role for which they are admired and followed. Both the questionnaire and interview results confirmed this perspective.

These findings also question the appropriateness of transformational leadership (House, 1976; Burns, 1978; Bass, 1985, 1990) as a leadership theory able to support an understanding of clinical leadership (NHS Confederation, 1999; Lett, 2002; Welford, 2002; Thyer, 2003; Stanley, 2004). Transformational leaders are described by Leithwood et al (1999) as being able to set direction, establish a vision, develop people and build relationships. Transformational leadership involves emotions, motives, ethics and incorporates visionary leadership (Northouse, 2004). However, visionary leadership was not identified as a characteristic sought or identified in clinical leaders. The main features of transformational leadership are set out in Table 1.

This author's research indicates that clinical leaders were recognized as visible, highly skilled or expert clinical nurses.

They had their actions and principles based on a foundation of care and their values and beliefs on show. They were role models for the finest attributes of care and nursing. They were open and approachable, communicated well and most definitely were not `controlling' others.They were themselves empowered and able to motivate their colleagues and others because they had the ability to help others feel confident, supported and encouraged.

The clinical leaders identified in this study,when approached, often did not recognize themselves as clinical leaders. They came from a wide spectrum of grades and, where present, in reasonable numbers. The common assumption, that the clinical leader in a ward or unit, is the most senior nurse, nurse manager or ward sister, was not evident in the research and indeed those nurses with any significant degree of management function within their role were commonly not recognized as clinical leaders.

The research pointed to a gap in the available leadership theories that failed to explain why clinical leaders were identified or followed. To fill this gap, congruent leadership is proposed. The author describes congruent leadership as where the values and beliefs match the leader's actions, deeds and involvement in care. The main features of congruent leadership are set out in Table 2.

Congruent leadership is based on the leader's values, beliefs and principles and is about where the leader stands.Congruent leaders (clinical leaders) are followed because their values and beliefs are matched by (congruent with) their actions. They are often not the most senior nurse and commonly fill no formal, structured leadership role. Often, nurses have been promoted away from the bedside, into `leadership' or `management' roles. These posts or roles, affiliated with a leadership or management function commonly placed nurses in positions of potential conflict (Firth, 2002) with their core nursing values. However, by accepting that clinical leadership is more to do with values and beliefs (not vision) nurses can

Table 1. Features of transformational leadership

l Establishes direction l Aligns people l Motivational and inspirational l Produces change ? often dramatic l About where you are going (vision) l Effective communicator l Creative and innovative

Table 2. Features of congruent leadership

l Motivational and inspirational l Approachable and open l Actions based on and match values and beliefs l About where you stand (principles) l Effective communicator l Visible l Empowered

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recognize the clinical leadership potential and function of nurses who remain at the bedside or in strong clinical posts. They are leaders because they are seen to be standing by their nursing care principles.

With this leadership theory in mind, and as a result of the research findings, clinical leadership needs to be redefined, although many elements from previous definitions should be retained. A new definition will point to a new understanding and hopefully clarify the concept of clinical leadership so that it may support more effective leadership development that is directed toward the most appropriate clinicians -- those at the bedside and in positions of significant clinical contact.

A new definition From this author's perspective, and in light of the research findings, a clinical leader can be defined as a clinician who is an expert in their field, and who, because they are approachable, effective communicators and empowered, are able to act as a role model, motivating others by matching their values and beliefs about nursing and care to their practice.

Conclusion

While it is acknowledged that `a new breed of clinical

leaders are needed' (DH, 1999, p52), it is also important to

understand what clinical leadership means and recognize

who the clinical leaders are. In order to effectively develop

an understanding of clinical leadership and leadership in

nursing, Rafferty, in the King's Management Fund discussion

paper (1993, p25), suggested that a, `number of different

models of leadership needed to be fostered'.

This article presents a brief discussion of the results of a

research project that sought to identify who the clinical

leaders are and what the characteristics and qualities of clinical

leaders might be. In addressing these questions it is suggested

that a new theory of leadership, congruent leadership, which

is based on a match between the leader's values and beliefs and

their actions, might lead to a better understanding and clearer

ability to recognize clinical nurse leaders.

BJN

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Key Points

n Clinical leaders are recognized as visible, highly skilled

or expert clinical nurses. There actions and principles

are based on a foundation of care and their values and

beliefs are on show.

n The assumption that the clinical leader in a ward or unit

is always the most senior nurse, nurse manager or ward

sister, is not evident in this research.

n Clinical leaders often did not recognize themselves

as such, are from a wide spectrum of grades and are

present in reasonable numbers.

n Congruent leadership is proposed as the most

appropriate leadership theory to support an

understanding of clinical leadership.

n Congruent leaders are followed because there is a match

between the leader's values or beliefs, and their actions.

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