Clinical nursing leadership – perspectives on current topics

Abstract

Welcome to this themed edition that compiles articles focused on Clinical Nursing Leadership. We are very pleased to include international representation from authors writing on clinical nursing leadership in Australia, Canada, Finland, Norway, Sweden, the United Kingdom and the United States of America. The subjects of the papers are highly relevant to the current context of health care systems. Regardless of where in the world the authors are, the same issues and challenges are raised. Similarly, regardless of whether or not the topic is addressed from a practical, abstract or theoretical point of view, many of the external and internal pressures identified are the same: the reality of a decreasing and aging work force, the increasing demands of an aging population, increasingly complex medical care and ever-increasing financial imperatives. These factors all have significant impact for the nurses at the bedside and for their patients. Additionally, as a global society, we are evolving out of the industrial age. Cook (2001) noted that progression to the quantum age would inevitably impact health care and health care services. Whether one embraces the idea of the quantum or information age, changes are evident. It’s clear that organizations have begun to use different languages. They employ and apply new concepts such as meta-thinking, complex adaptive systems, adaptive capacity, purposeful work, outcomes orientation, fluid work requirements and variable effects. The dilemma then, for nursing, lies in the fact that both knowledge and practice are changing rapidly, dramatically and concurrently. While most would generally agree that good nursing leadership is required to achieve good quality nursing care, there is evidence that suggests our current understanding of clinical nursing leadership is lacking. The terminology and concepts, though developing, may not be evolving as rapidly as the environment and may not capture leadership as it is experienced in practice today. Cook (2001) noted that the concept of clinical nurse leadership was not clearly defined in literature that was published between 1992 and 1997 in the UK, USA and Australia. In fact, the term was sometimes used interchangeably with nursing management. Because the concept lacked definition, he was able to find very few experimental or empirical studies and most of the papers were anecdotal and opinion led. In 2006, Stanley (2006) noted that while there was a great deal of literature on nursing leadership, there was still very little that specifically considered clinical nurse leadership. He discussed the contributions of several authors but again noted that there was no general agreement on a definition and the concept remained elusive. He described three different contexts in which clinical leadership had been presented in the literature: (1) clinical leadership programs or evaluations, (2) work of managers who work in clinical settings and (3) work of clinicians who practice at an expert level and who have or hold a leadership position. Obviously, the various authors understood the concept quite differently. When we recently conducted our own literature search (see Box 1) using the CINAHL, PubMed, and Ovid databases, we found no more agreement on a definition of clinical nurse leadership than either Cook or Stanley. We propose that a clinical nurse is certainly one involved in clinical practice with knowledge, experience and understanding of providing nursing care. We suggest that leadership implies authority in the broadest sense of the word, is non-hierarchical and not confined to a specific set of skills, attributes or traits. One can deduce, then, that clinical nursing leadership reflects all of the complexity of the culture, the organization, the practice setting and situational variables of each clinical nurse leader. To date, we have not found a body of work that has captured the essence of the clinical nurse leader, the environment in which they operate or how and where the impact is felt. The Journal of Nursing Management has devoted several issues to various aspects of leadership in the past. This is the first time that there is an issue devoted entirely to clinical nursing leadership. While the concept remains elusive, the authors reflect on their own professional experiences, expertise and insights to illuminate the issues that they believe nursing managers need to consider. Each of the component pieces adds to our understanding of clinical nurse leadership and its links, for example, to job satisfaction, patient care outcomes, financial savings, burnout, education and developments in organizational infrastructure. The articles in this themed issue are arranged in order according to their content and how they add to our current knowledge. The first articles, while having pragmatic implications also elucidate theoretical, philosophical and moral underpinnings. Following this, the articles speak to education, infrastructure and practice. Next, two articles underscore the importance of providing support for leaders. Finally, we draw from the experiences within our own hospital to introduce a US initiative that materializes clinical nursing leadership as a new role. Our first authors, Cutcliffe and Wieck deconstruct the desire for professional nursing status in a comprehensive literature review. They propose a discourse in which the central and underpinning values of nurses and clients are seen as equal, though different from, the values of the current dominant discourse. With this, there is an opportunity for transformational nursing leaders to focus on a genuine ‘health’ oriented health care system. Next, Cummings et al. look at the relational leadership model through original research and its impact on job satisfaction. They suggest that visible leaders focusing on modifiable factors, along with positive relationships in the workplace create an environment in which nurses can continue to provide valuable services in spite of stressful work assignments. In his commentary paper, Stanley proposes congruent leadership as the most appropriate leadership theory to develop an understanding of clinical leadership. This is based on the match between the clinical leaders’ actions and their values and beliefs about care and nursing. In fact, he states that leaders are followed because they translate their values and beliefs about care into action. In an original research study spanning the early 1990’s and 2000’s, Surakka presents a model that shows that nurse managers have actually integrated different leadership models into their daily patterns. Interestingly, she notes that the shared governance model seems to have helped with the integration of the various approaches. In their original research paper, Sorensen et al. note that the changing agenda of health care is bringing nursing knowledge and skills back into contention such that nurses and nurse managers can begin to confront the moral injustices that they and their patients experience. They state that the profession will need to move beyond a reliance on professional clinical models to become interdisciplinary team members and advocates who will be able to drive the process of change in health care and to enact and embed nursing leadership in healthcare organizations. Allan et al., in their literature review, discuss the leadership for learning. They identify unresolved questions that have important implications for workforce planning and role modeling. Lammintakanen et al., in their original research, propose human resource development as a strategy that expands learning beyond individual needs to include the goals of the organization. They underscore the importance of this to maintaining high quality care. Akerjordet and Severinsson, in a literature review, discuss the interesting leadership characteristic of emotional intelligence. They describe how positive empowerment processes can create a favorable work environment that enhances organizational, staff and patient outcomes. Sellgren et al., in their original research, show the positive relationship between a creative work climate and job satisfaction. A manager’s ability to foster such an environment can have a significant impact on retention. Sirola-Karvinen and Hyrkäs, in their original research, introduce administrative clinical supervision as a means by which to support leaders in their work. They find that it is beneficial and appreciated, even as it varies in importance over time. Lashinger and Finegan, in their original research, show that both personal and situational factors contribute to nurse manager burnout. They suggest ways to create work environments that foster positive health for the nurses and for patients. The final section of this theme issue reports on a movement by nursing leadership in the United States to address its current and overwhelming health care systems problems. Tornabeni and Miller provide an overview of the origins of a new nursing role, the Clinical Nurse Leader (CNL). Their commentary focuses on the development process as a collaborative partnership between academia and practice. Stanley et al., summarize the findings of three case studies in which they describe and evaluate the CNL’s impact in practice. They show that the CNL represents an exciting and promising opportunity for nursing to take a leadership role, in collaboration with practice partners, and implement quality improvement and patient safety initiatives across all health care settings. Poulin-Tabor et al., comment on their experiences as the first generation of CNL’s in their hospital. They discuss the varied utilization of the role, its flexibility and early successes. They show gains in quality outcomes, cost savings, improved patient flow, increased safety, nurse satisfaction and increasing organizational capacity. The last paper describes the future of nursing as a partnership with patients, families, and other disciplines. This is dramatically different from the outmoded systems that are common in the US today. Wiggins proposes a new model of nursing care delivery and presents an analysis of its core concept. It’s interesting to note that many of the authors aspire to the philosophy and essence of nursing as health-focused rather than disease-focused, patient and family centered, and as an integrative discipline. This is in contrast to models popular today and more nearly reflects the origins of nursing. When faced with the challenge of articulating effective nursing outcomes in an unbalanced environment, it is especially important for nursing management to question assumptions and reflect objectively on the realities of what it is to be a nurse today. Successfully adapting to change may require that managers find new and innovative ways to integrate knowledge and practice. Encouraging a dialogue that reminds nurses and leadership that nursing is both an art and a science may revitalize and reconnect us to the essence of nursing. We hope that the studies, comments and conclusions from the articles in this themed issue provide ideas for nurses, managers, administrators, educators and researchers as they enable and empower nurses to excel as leaders in their professional clinical practice. We would like to thank all of the authors for sharing their perspectives and working to illuminate this very important subject.