Clinical Nurse Leadership: Roles, Development, and Practice

Introduction

Nurses are increasingly being called upon to fulfill clinical leadership roles as well as to maintain their traditional spheres of practice. This is a very important moment in nursing history. Nursing roles are changing. It has been a long struggle for nurses to be accorded the dignity and respect equal to that of doctors in healthcare. Now nurses are assuming many of the duties once relegated to physicians. Nurses must find ways to balance their roles as patient advocates with their roles managing members of their own profession and also with the work of other healthcare professionals.

Interview with a Clinical Nurse Leader

In the spirit of integrating practice with academic learning, this paper describes an interview conducted with a nurse leader in the field who discusses her roles, responsibilities, and challenges. It contextualizes the interview within the framework of existing research, and concludes with a summary of how what has been learned will affect personal long-term and short-term goals in the field of clinical leadership.

The clinical nurse leader interviewed was relatively early in her career, having graduated only five years prior. Her designated role is that of a clinical nurse educator. Clinical nurse educators serve the profession in a variety of capacities. They are nurses with advanced degrees and experience both in clinical practice and in the field of education; they may work in academia or in continuing education at a healthcare institution. This particular educator worked exclusively in the hospital setting, managing, planning, and coordinating education for student nurses, existing nurses, and newly employed and graduate nurses. She is also responsible for performance evaluations of nurses in all of these categories.

In addition to these formal qualifications, this nurse exhibited a great deal of personal charisma, which helped her lead others. She can be described as a true transformational leader in the sense that she motivates by example. She is also a great communicator because she communicates both by showing as well as telling. She embodies the values she wishes to transmit to other nurses. This has been particularly inspiring, as she serves as a mentor.

This clinical nurse leader defined leadership in her own practice first and foremost as the ability to unify people around a common set of values. A leader must inspire others and also establish a clear direction and purpose for the organization. This is why the nurse leader described her style as fundamentally transformative in nature, with some aspects of "congruent" leadership (Stanley 2008). Congruent leadership is defined by Stanley (2008) as matching actions with clearly demonstrated values and belief systems to create a positive impact on subordinates; conversely, a lack of congruency can be an impediment to leadership.

The concept of transformational leadership is repeatedly affirmed in the leadership-focused literature of nursing as a critical component of getting other nurses to support positive changes in the healthcare environment and to combat external stressors that affect healthcare, such as financial realities (Herzog & Zimmerman 2009). Without leadership that makes people want to perform above and beyond what they currently believe themselves capable of, there is no effective leadership. Leadership cannot simply be telling people what to do: subordinates must understand why they are doing something and why it is important. To inspire others in an intelligent fashion requires soliciting information from a variety of competent, professional sources.

According to the nurse leader, the workforce is changing and nurses must be prepared to change with it, specifically in their capacity to implement evidence-based practices into their work. There are many potential opportunities for nurses to exhibit and exercise leadership. But to do so, nurses must relate well to others. Knowing what to do in isolation is not exercising leadership; making people want to follow you without good communication skills is impossible. It is impossible to be an effective nurse leader without being a "people person" in every sense of the word: a nurse must be liked and trusted by the staff and also possess psychological insight and acuteness. She must also have a great deal of self-knowledge and understand her own limitations and prejudices, so she can rely on other people when needed and delegate appropriately if she is not suited to a particular task herself.

This need for self-knowledge was also affirmed in the literature review conducted. The work of Horton-Deutsch & Sherwood (2008) and Lucas, Laschinger, & Wong (2008) underlines that although there is a need for nursing theory and a grounding in data-driven analysis, the experiential component is necessary so nurses develop intelligence about how they operate in the field of practice and how others with different strengths and competencies do as well.

One maxim which this leader repeated when mentoring is that a true nurse leader does not wait until she has the title of "leader" to practice leadership. A good nurse always acts as if she is being a role model to other nurses and to patients. Leadership is earned through daily actions, not the winning of awards, titles, bonuses, and promotions.

Literature Review on Nursing Leadership

The nurse expressed her belief in the core role of preceptorship and mentorship in the development of all future nurse leaders. Even nurses without the formal role of clinical nurse instructor, she stressed, are always teaching other nurses and patients through explicit and implicit instruction. Leadership must be assumed confidently at all times and not designated to specific components of a nurse's day or career. Someone can be a leader without possessing a title, and someone can have the title of leader and fail to exercise leadership at all.

According to Bamford & Moss (2010), radical changes in healthcare are often resisted by nurses if they fear their authority is being subverted. However, with the appropriate integration and input of practitioners, leadership can ensure that people are more receptive to new ideas. Transformational leadership can have a real, significant impact on the workforce. It is not something esoteric, as noted by Budhoo and Spurgeon (2012): evidence-based practice indicates that instituting role modeling programs and fostering charismatic, transformational leadership can forge bridges between colleagues in service of the larger organization. There is even empirical, data-driven evidence to indicate that personal charisma can have a profoundly significant, positive impact upon a nurse leader's ability to exercise influence when coupled with a sense of clinical focus, resiliency, and a team-player attitude (Mannix, Wilkes, & Daly 2013).

The literature also resonates with the types of qualities described by the nurse leader. Burns (2009) notes that in addition to the traditional qualities demanded of nursing leadership in the past, such as transformational and charismatic potential, there is a great need for showing political astuteness and the ability to influence an organization on a strategic level. Organizations must understand the need to implement nursing-friendly policies such as reasonable shift length and having sufficient diversity among the ranks of nurses to meet multicultural needs. Nurses need adequate training and there must be enough staff so that nurses are not overburdened, which simply leads to burnout. Nurse leaders may be aware of this, but they must also be able to communicate this to management.

The idea of leadership training as something ongoing and not something confined to a specific time in the nurse's career was also confirmed by the literature. Learning outcomes and goals of the individual and the organization must constantly be reevaluated. Leadership should also be conceptualized as a dialogue, not a monologue, between more and less experienced participants. Younger nurses will be more motivated to contribute and ultimately more respectful of elder nurses if their input is solicited in a supportive and participative fashion (Dierckx de Casterle et al., 2008).

In reviewing the literature, it was also encouraging to read in Cummings et al. (2008) that leadership could be developed within one's character. Leadership is not something that is innate and only specific to certain individuals. Cummings et al. (2008) noted that hospitals which instituted specific leadership initiatives to educate nurses were more successful than those that did not. This was a profound insight regarding personal leadership potential. Starting early in one's career can sometimes feel discouraging, particularly when comparing oneself to more experienced leaders based on personality alone.

However, beginning work in a healthcare setting is just the start of a long career trajectory. There is a long time in which one can change and grow in professional capacity, including adding to leadership skills. The literature reinforces the hope that transformational approaches and ideals of strong mentors can be embodied over time.

Although this leadership style was not specifically affirmed by name in the interview, after reviewing the literature in conjunction with the interview, the approach can be characterized as an "authentic" leadership style, particularly in reference to the stress upon the need to humanize nursing leadership today (Giallonardo, Wong, & Iwasiw, 2010). Authentic leaders are honest, recognize that other nurses and patients are fellow human beings, and focus on fostering positive relationships and trust. Although accountability is important, too much focus on data-driven results can cause resentment in subordinate nurses, making them feel as though they are treated like children rather than as competent professionals.

Even though one is still a relatively new nurse, the ideal is to put into practice the principle of being a nurse leader at the very beginning of one's career as a nurse, as instructed by the leader interviewed. The goal is to act as a mentor and a role model for new nurses. The stereotype is that nurses "eat their young" or are very unsupportive of new nurses. Defying that stereotype through positive behaviors and actions is a meaningful professional commitment.

Conclusion