Clinical Nurse Leadership: Interview, Literature, and Goals

Introduction

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

In the spirit of integrating practice with academic learning, this paper describes an interview conducted with a nurse leader in the field, covering her roles, responsibilities, and challenges. It then contextualizes the interview within the framework of existing research. Finally, it concludes with a reflection on how what was learned will affect short- and long-term goals in the field of clinical leadership.

Interview with a Clinical Nurse Educator

The clinical nurse leader interviewed was relatively young, having graduated only five years prior. Her specific designated role was 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 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 her formal qualifications, this nurse exhibited a great deal of personal charisma, which helped her lead others. She would be described as a true transformational leader in the sense that she motivates by example. She is also a skilled communicator because she conveys messages both by showing and by telling, embodying the values she wishes to transmit to other nurses — an approach that has been particularly inspiring given her role as 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 establish a clear direction and purpose for the organization. This is why she 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 transformative leadership is repeatedly affirmed in the nursing leadership literature as a critical component of gaining support for positive changes in the healthcare environment and combating external stressors such as financial pressures (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 mean telling people what to do: subordinates must understand why they are doing something and why it matters. Inspiring 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, particularly in their capacity to implement evidence-based practices. There are many 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 strong communication skills is impossible. An effective nurse leader must be a people person in every sense: liked and trusted by staff, psychologically insightful, and possessed of a great deal of self-knowledge. She must also know her own limitations and biases so she can rely on others when needed and delegate appropriately. This need for self-knowledge is affirmed in the literature as well. Horton-Deutsch and Sherwood (2008) and Lucas, Laschinger, and Wong (2008) underscore that although nursing theory and data-driven analysis are necessary, the experiential component is equally important so that nurses develop practical intelligence about how they and others with different strengths operate in clinical settings.

One maxim this leader repeated at the start of her mentee's practice — and reiterated during the interview — 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 a role model to other nurses and to patients. Leadership is earned through daily actions, not through awards, titles, bonuses, or promotions.

The nurse expressed her belief in the core role of preceptorship and mentorship in developing 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 confined to specific components of a nurse's day or career. Someone can be a leader without possessing a title, and someone can hold the title of leader and fail to exercise leadership at all.

Literature Review

According to Bamford-Wade and Moss (2010), radical changes in healthcare are often resisted by nurses who fear their authority is being subverted. However, with appropriate integration and input from practitioners, leadership can ensure that people are more receptive to new ideas. Transformational leadership can have a real and significant impact on the workforce. 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 evidence to suggest that personal charisma, when coupled with clinical focus, resiliency, and a team-player attitude, can have a profoundly positive impact on a nurse leader's ability to exercise influence (Mannix, Wilkes, & Daly, 2013).

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

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

It was heartening to read in Cummings et al. (2008) that leadership can be developed as a characteristic rather than being innate to certain individuals alone. Cummings et al. (2008) found that hospitals that instituted specific leadership initiatives to educate nurses were more successful than those that did not. This was a profound insight regarding personal leadership potential. Being at the beginning of a career, one may be tempted to conclude that it is impossible to match the competency of an experienced nurse manager. However, having only recently begun working at a current hospital, there remains substantial time in which to change and grow professionally, including building leadership skills. The literature reinforced the hope that a transformational approach embodied by a mentor can indeed be developed over time.

Although this leadership style was not specifically named during the interview, reviewing the literature in conjunction with the interview led to the conclusion that the mentor's approach is best characterized as an authentic leadership style, particularly in reference to her emphasis on humanizing nursing leadership today (Giallonardo, Wong, & Iwasiw, 2010). Authentic leaders are honest, recognize nurses and patients as fellow human beings, and focus on fostering positive relationships and trust. Although accountability is important, an excessive focus on data-driven results can generate resentment among subordinate nurses, making them feel treated like children rather than competent professionals.