Leadership in Nursing
Leadership in Nursing
Leadership in Nursing
Chapter 14
Leadership in Nursing
Leadership in Nursing
http://dx.doi.org/10.5772/65308
Abstract
The nursing literature, until recently presents the phenomenon of leadership as
associated with nurse executives and formal leadership roles. That is leadership is
defined in terms of an interactive process where followers are motivated and empow‐
ered to accomplish specific goals. The purpose of this chapter is to present the
phenomena of nursing clinical leadership and leadership at the bedside, which is a new
area of research in nursing. This chapter proposes that leadership is not merely linked
to top management levels, but it can be developed and implemented at bedside for
nurses. Clinical leadership skills focus on patients and healthcare teams rather than
formal leadership position. In addition, clinical leadership relates to nursing professio‐
nal activities, which provide direct care at bedside, which differs from the traditional
nursing leadership notion. Thus, acquiring clinical leadership skills is crucial for nurses
who provide direct patient care. This allows nurses to direct and support patients and
healthcare teams when providing care. Furthermore, it is crucial that nurses develop an
effective leadership role to deliver high‐quality care and ensure patient safety while
engaging in numerous daily leadership roles. Moreover, it emphasized the importance
of the cooperation between nursing education programs and healthcare organizations
in preparing nurses to be effective leaders by 2020 for the new era of health care.
1. Introduction
Healthcare systems worldwide are facing number of complex and multifaceted challenges in
providing high quality, safe, and cost effective care into the future [1]. The ever‐evolving
systems, increased patients’ disease acuity, technology innovation, and the increase in the costs
of health care are some of the problems that need to be addressed. Therefore, it is a priority to
sustain and improve the quality of care provided, which in turn may lead to a shift in
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© 2017 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons
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and reproduction in any medium, provided the original work is properly cited.
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252 Contemporary Leadership Challenges
healthcare delivery, an alteration in healthcare models, and the role that all healthcare
members play [2]. Being a leader in the healthcare professions is crucial in the continuum of
care era. Leaders are challenged on a daily base with problems that need to be solved utilizing
critical thinking. Leaders make key decisions that may have consequences, which can impact
patient lives. Specifically, leadership in health care is a fundamental skill that allows healthcare
providers navigate the complex and ever changing healthcare system effectively in solving
problems and making decisions related to issues from cost to quality healthcare services and
access [3]. Hence, it is essential that leaders are well equipped and trained to make the
appropriate decisions at the right time [4].
The concept of leadership is significant to the nursing profession. There is no dearth of
literature that discusses leadership in nursing [5–7]. It is crucial that nurses develop an effective
leadership role to deliver high‐quality care and, therefore, ensure patient safety [8], while
engaging in numerous daily leadership roles. Although, the phenomenon of nursing leader‐
ship was studied in the past six decades of the twentieth century, it continues to be current and
of crucial importance [9]. Oliver [7] stated that “the word ‘leader’ has developed from the root
meaning of a path, road or course of a ship at sea. According to Adair [10] it is a ‘journey word’
(p. 39). In addition, an integrative literature review stated that the current research in the
leadership field is taking a more holistic view of leadership, examining the occurrence of the
process of leadership and examining leadership in numerous ways [11].
This chapter presents some of the basic definitions of leadership, nursing leadership, nursing
clinical leadership, and leadership at the bedside. It will also discuss the impact of nursing
clinical leadership, characteristics of an effective nurse clinical leader, and the factors that
contribute to nursing clinical leadership. Furthermore, this chapter provides an overview of
nurses that must be equipped with leadership skills in order to be able to lead the delivery of
patient care and improve patient safety. In addition, it discusses methods of preparing nursing
leaders.
2. Definition of leadership
A leader is a person that others follow voluntary and willingly. In 1959, Bennis [12] defined
leadership as the process by which an individual influence a follower to behave in a desired
manner. Kouzes and Posner [13] defined leadership as, “the art of mobilizing others to want
to struggle for shared aspirations” (p. 30). Additionally, Ledlow and Coppols (p.13) [3] defined
leadership as “the ability to assess, develop, maintain, and change the organizational culture
and strategic system to optimally meet the needs and expectations of the external environ‐
ment”. Leadership is mainly about developing a vision and allowing individuals to work
toward change. It involves creating a shared mission; tackle political, organizational, and
resource barriers; and inspiring and motivating others [14].
Leadership is defined as influence and it includes the use of interpersonal skills to induce others
to achieve a specific goal [15]. Furthermore, leadership is defined as the art of influencing others
to strive voluntary and enthusiastically toward the achievement of goals [16]. According to
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Roussel et al. [17] (p. 165), leadership is “the process of influencing the activities of an organized
group in its efforts towards goal setting and goal achievements”. Furthermore, “a leader must
be an effective trustworthy advocate that inspires courageous action by using 2‐way commu‐
nication to interpret needs of all included in the environment” (p. 320) [18]. Spector [19] states
that leadership is the process of influencing other people attitudes and behaviors. Leadership
is mainly about influencing others to accomplish a shared goal.
Leadership has been have investigated by many scholars, as it is evidenced by the plethora of
definitions that exist. It is apparent that there is no single accurate definition of leadership.
However, these definitions may help to get to a better understanding of the leadership
phenomenon and offer various viewpoints of the concept and the factor that may influence
leadership [20, 21].
3. Leadership in nursing
Leadership has been illustrated in the nursing literature as a difficult and multifaceted process.
It includes providing direction and support, motivating, coordinating, collaboration, effective
communication, and advocating for patients to achieve optimal patient outcomes [22–24]. In
nursing, leadership is showing the followers how things are done, guiding their way, and the
course of actions [25].
Additionally, nurses as part of the health intradisciplinary team must be capable of leading in
this era of high patient acuity, fast paced, and highly complex environment. The Institute of
medicine (IOM) [26] states that nurses must be able to lead interprofessional teams and
healthcare systems. Furthermore, studies conducted on nursing leadership have shown the
effectiveness of leadership in a nursing role on patient outcomes such as patient safety [23,
27]. According to O’Connor [28], “effective communication is central to leadership in clinical
settings” (p. 235). Nursing leadership has been defined as influencing others to improve the
quality of care along with the direct participation in clinical care [29].
Leadership in nursing involves an environment that has a clear vision, and where staff are
motivated and empowered [30]. Nursing leaders are agents who have followers in the
healthcare team [31]. According to Cook and Holt [32], nursing leadership is about having a
vision and empowering staff. They also added that nurse leaders must have skills, such as self-
confidence, valuing others, and being able to build teams effectively. Similarly, Lett [31] defined
nursing leadership as providing followers with a vision and empowering others. Leadership
is contained in the professional nursing role and practice, as all nurses’ roles are leadership
roles [21]. However, most often nursing leadership is linked to nurse executives and is less
often connected to bedside nursing practice.
In nursing literature, until recently, the leadership phenomenon has reflected the general
leadership. That is leadership is defined in terms of an interactive process where followers are
motivated and empowered to accomplish specific goals. Nevertheless, leadership is not merely
linked to top management levels, but it can be developed and implemented at bedside for
254 Contemporary Leadership Challenges
nurses. Thus, acquiring clinical leadership skills is crucial for nurses who provide direct patient
care. This allows nurses to direct and support patients and healthcare teams when providing
care [33].
Nursing clinical leadership skills focus on clients and healthcare teams such as those advo‐
cating for patients, communicating with the healthcare team, patients, and their families;
compared to individuals reporting to and working with a nurse in a formal leadership position.
In fact, the nursing profession is very autonomous where it requires nurses to make decisions
and take responsibility for their actions [34]. Nurses are at the first level of decision‐making,
and granting them independence in this area will help them to form the foundations of
leadership in the nursing role.
Nursing leadership at the patient bedside is a new area of research [33, 35–37]. The IOM [38]
report discussion increased the interest in clinical leadership at clinical settings due to the
emphasis on a nurse’s fundamental role in maintaining patients’ safety. Additionally, this
report stated that nurses are instrumental in providing effective communication between
various healthcare disciplines and assuring patient care continuity. Clinical leadership skills
focus on patients and healthcare teams rather than formal leadership positions.
According to Patrick et al. [33], clinical leadership is defined as “staff nurse behaviors that
provide direction and support to clients and the healthcare team in the delivery of patient care.
A clinical leader is a registered nurse who influences and coordinates patients, families and
health care teams for the purpose of integrating the care they provide to achieve positive
patient outcomes” (p. 450). Based on this definition, all registered nurses are clinical leaders,
particularly nurses at the bedside [39]. However, in nursing literature, the concept of nursing
clinical leadership is usually associated with nurse executives and formal leadership roles. In
fact, nursing leadership is rarely linked to bedside nursing practice leaders [36, 37]. Cook [40]
defined a clinical leader as “a nurse directly involved in providing clinical care that continu‐
ously improves care through influencing others” (p. 39). According to Harper [41], a clinical
leader is “one who possesses clinical expertise in a specialty practice area and who uses
interpersonal skills to enable nurses and other health care providers to deliver quality patient
care” (p. 81). According to Patrick et al. [33], five characteristics define clinical leadership skill
as follows: clinical expertise, effective communication, collaboration, coordination, and
interpersonal understanding. Clinical leaders are experts in their field, effective communica‐
tors, empowered decision makers, clinically knowledgeable and competent, provide a vision,
support others, provide guidance to patients and their families, and drive change by providing
high‐quality care [31].
Furthermore, Stanley [42] defined a clinical leader as “a clinician who is an expert in [her or
his] 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” (p. 111). All of these definitions demonstrate that clinical
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leadership can be at the bedside and clearly does not need to be linked or limited to manage‐
ment or senior levels.
Thus, the concept of nursing clinical leadership relates to nursing professional activities, which
provide direct care at bedside, which differs from the traditihe nurse leader’s actions at the
bedside through professional nursing practice utilizing their clinical skills and also by
demonstrating therapeutic relationship between the nurse and patients and the healthcare
practitioners. Nurses are accountable for their patients, so it is crucial for nurses to provide
constant observation and assessment of patients, to set priorities, work effectively, and
efficiently to recognize critical situations, which may necessitate the nurse to monitor the
patient closely. Nurses must also make clinical decisions about a required intervention; or, if
needed, communicate with other healthcare team members for assistance, support, or
guidance; or call the primary healthcare provider. Hence, it is essential that bedside nurses
acquire leadership skills to improve patient outcomes and safety through the care provided.
Nurses are considered leaders in providing patient care, as leadership is a key part of effective
nursing care. Nurses are the frontline of healthcare delivery, thus, they are pivotal to providing
safe, high‐quality care, and assuring positive patient outcomes [43]. Nurses direct, support,
and coordinate healthcare teams, families, and patients to maintain patients’ health [24]. In
fact, nurses are required to be resilient and acquire effective communication skills, such as the
capability of influencing others to achieve a shared objective and working toward change.
Nursing clinical leadership includes critical thinking, decision making, action, and advocacy.
Nurses in their role at the bedside demonstrate clinical leadership skills by providing,
facilitating, and promoting the best possible care for their patients. In addition, nurses at the
clinical practice when providing direct client care are expected to show leadership skills when
collaborating with healthcare teams. Therefore, there is need for functional nursing clinical
leadership at all levels and domains of nursing practice to assure effective collaboration of
group to ensure highest quality of care provided.
Nursing clinical leadership is crucial for various reasons. First, clinical nurse leaders play a
critical role in sustaining the efficiency, production, and cost-effectiveness of nursing services
[2]. Effective clinical leadership skills empower nurses while providing care with the abilities
to direct and support patients and healthcare teams [37]. It also improves the care delivered
to patients, which in turn improves patient outcomes. In addition, clinical nursing leadership
impacts the safety and quality of care provided [44]. It is indeed vital to highlight the influence
that nursing clinical leadership has on patient outcomes. Nurse leaders consider patients’
safety as a priority while performing nursing care such as medication management, wound
care, infection control, and patient education [45] to achieve optimal patient outcomes.
In their systematic review, Wong et al. [46] found a relationship between nursing leadership
practices and patient outcomes. Their findings indicated that effective leadership has been
256 Contemporary Leadership Challenges
associated to reduced length of stay, lowering rates of medication errors, patient falls, urinary
tract infections, and pneumonia. Additionally, the nursing literature proposes that clinical
leadership improves the quality of care provided, patient outcomes, and lower patient
mortality [47–50]. Nurses who possess clinical leadership skills influence the clinical setting
and improve patient safety [37]. Thus, it can be said that clinical leadership serves to achieve
safe care and optimal patient outcomes, which emphasizes its importance.
A successful nurse clinical leader is one who is a critical thinker, lifelong learner, and open to
new ideas. The nurse clinical leader must be knowledgeable, maintain professional growth,
and stay current in the profession. In fact, they should be clinically competent and clinically
knowledgeable [33, 51]. In addition, leaders must have a vision, the art of knowing how to
elect the best from others. In short, thriving leaders make others do their best to accomplish
the intended outcome. An effective leader demonstrates confidence, as it is a key leadership
skill. Knowing what needs to be done, being proactive and approaching every patient with a
confident and competent attitude to improve patient outcomes.
Furthermore, motivating people toward goal‐directed behavior, which in turn contributes to
the interest of the organization is of crucial importance. The leader should be able to commu‐
nicate clearly and effectively. Being a good listener is a valuable attribute, as patients and
colleagues may talk to the nurse and ask for guidance. Effective leaders use problem‐solving
processes by being solution‐focused to improve a situation. The nurse clinical leaders should
be empowered decision makers utilizing evidence‐based research to make clinical decisions
[33]. Additionally, the effective nurse clinical leader must be authentic by recognizing the
strengths and weakness of self and others [52]. This will allow clinical nurse leaders to
demonstrate integrity while delivering care through making sound decisions that will create
added value to the healthcare team.
An effective nurse clinical leader possesses self‐awareness, which means knowing how to read
one’s own feelings and how they can affect others. For example, if a nurse is taking care of a
patient in a pediatric unit and the mother expresses her concerns that her child did not receive
a standard treatment when the nurse had already provided the treatment. The nurse may have
mixed emotions such as irritation or anger. In this situation, it is crucial that the nurse identifies
these emotions and considers how expressing them would influence the situation. The nurse
can recognize her/his feelings by keeping a journal, meditating, or exercising. Additionally,
the nurse clinical leader should be accountable, as it will result in better performances.
Time management is also an important skill that the nurse clinical leader should posses in
order to organize, plan, and prioritize daily tasks and responsibilities that need to be accom‐
plished for patients. They are also dynamic, empathic, caring, and passionate about their
patients’ needs and values. In addition, effective nurse clinical leaders have the ability to
nurture, inspire others, seek maximum standards, and maintain high‐quality benchmarks. An
effective nurse clinical leaders’ performance positively influences the outcomes of the health‐
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care organization. It also improves the quality of care provided to the patient, which in turn
affect quality outcomes [43].
Successful nurse clinical leaders are highly motivated, committed to organizational vision,
mission, and goals, and thus deliver patient care with greater effectiveness [53]. A clinical nurse
leader must be highly committed and focused on teamwork in order to accomplish a common
goal. She/he should start with a clear understanding of the destination that the team wants to
achieve. An effective nurse clinical leader must develop skills of collaboration, delegation, and
conflict resolution that will facilitate her/his work within teams. Successful nurse clinical
leaders are honest, trust worthy, and respectful.
Furthermore, nurse clinical leaders are an advocate for patients by providing and promoting
the best possible available care. The effective nurse clinical leader will act as a liaison between
patients and healthcare teams in advocating for the rights and welfare of patients [54, 55] and
by emphasizing the importance of a safe health setting for providing care. The nurse clinical
leader will also challenge poor practices and assist patients’ access to appropriate healthcare
information and allow them to be engaged in decision making of their care [54]. These
characteristics are critical for nurse clinical leaders to have, as it will help them to be successful
and provide high quality care. Nurses must apply these characteristics to their profession to
gain trust and respect of healthcare members and patients, which will in turn direct the
development of nursing clinical practice.
Research evidence indicates that there are various factors, which contribute to nursing clinical
leadership skills, such as nurse characteristics, education, and experiences. According to
Patrick et al. [33], age affects leadership skills; in this study, there was a weak positive but
significant correlation between age and clinical leadership skills (r = 0.14, p < 0.01). Although
there are contradictory results in the nursing literature regarding the relationship between age
and clinical leadership skills [33, 56–58], studies show that improved clinical leadership skills
were associated with older nurses [21, 59].
Furthermore, research shows that education has an effect on clinical leadership skills [21, 59,
60]. A survey was conducted in 2001 to examine chief nursing officers’ preferences of recruiting
nurses with a baccalaureate degree as opposed to a diploma degree. Seventy‐two percent of
these directors stated that there are differences in practice between baccalaureate‐prepared
nurses compared to nurses with a diploma degree, as the former have higher clinical leadership
skills [61].
In a study conducted by Patrick et al. [33], it was found that leadership experience had a
relationship to clinical leadership skill, although small it was significant (r = 0.10, p < 0.05) [33].
This is congruent with Bandura’s Self-Efficacy Theory, in which successful leadership experi‐
ences may be translated to different settings [63]. In addition, Wood [64] studied the factors
that influence leadership skills and how they interact to facilitate the development of leader‐
ship skills and expertise among nurses. Wood reported that personal life factors such as marital
status significantly influenced the development of nurses’ leadership skills. A review study
found that demographic data (marital status, race, and type of nursing degree) significantly
affected nurses’ leadership [65]. However, this integrative literature review found that there
is a gap related to the factors that influence nurses’ leadership skills; therefore, there is a need
for more research in this area.
Ninety percent of leadership can be learned [3]. Thus, nursing education is the first line to
prepare leaders. To be a nurse leader, nursing students need to be exposed to an environment
that provides opportunities to exercise their leadership skills, that is they should encounter
actual problems that need solutions [21]. However, nurses are not sufficiently prepared for the
leader role throughout their nursing education. This creates a gap between education and the
requirements of the clinical practice, which can result in ineffective nursing leadership.
According to Cowin and Hengstberger‐Sims [66], it is unrealistic to expect new nurse gradu‐
ates to be ready to assume leadership role. They will need some time to find out their strengths
and weakness, and opportunities to allow them to discover themselves. This will occur through
job training, mentorship, and residency programs. These programs can offer the new graduate
nurses’ experiences that will allow them to incorporate essential leadership skills into their
clinician role. And this will improve patient safety and outcomes, because there is a direct
relationship between leadership and quality of care provided [35, 36, 67]. According to AL‐
Dossary et al. [37], nurse residency programs equip new gradate nurses to transition from the
student roles to become independent practitioners and bedside leaders. In addition, residency
programs help to improve the new graduate nurses’ leadership skills [43]. In fact, “residency
programs can offer the new graduate nurses experiences that will allow them to incorporate essential
leadership skills into their clinician role” (p. 156) [37].
Hence, nursing educators should enhance students’ personal and professional leadership
opportunities. In addition, they should encourage the leader role within their field as nurses
and the community. It is imperative that nursing education programs and healthcare organi‐
zations unite to prepare nurses to be effective leaders by 2020. This can happen through
improving the communication between academia and healthcare organizations to address the
academic‐practice gap. As a matter of fact, there should be partnerships between nursing
schools and healthcare agencies to support new graduate nurses’ transition process, which is
traditionally extremely stressful [37].
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In addition, it is significant that the essential skill sets that a nurse clinical leader will need to
be identified [68]. This will require formal education and training to be part of most manage‐
ment development programs [69]. Nurses should acquire the following skills: a multidiscipli‐
nary perspective about healthcare and professional nursing issues, technology skills, clinical
decision‐making skills, creating organizational cultures that promote quality and patient
safety, collaborative and team work skills, and the ability to envision and proactively adapt to
a ever changing healthcare system [68].
Therefore, it appears reasonable to come up with a conclusion that the development of nursing
clinical leadership should start as early as the first year of nursing education. Emphasizing that
leadership is a fundamental part of nursing clinical practice and that all nursing roles include
leadership roles. In addition, having clinical leadership skills will be a predictor of many new
graduates success in the ever‐changing healthcare systems [70].
9. Summary
This chapter focused on the definition of leadership, nursing leadership, and nursing clinical
leadership. It also discussed the impact of nursing clinical leadership, characteristics of an
effective nurse clinical leader, and the factors that contribute to nursing clinical leadership.
There was specific emphasis on clinical leadership as it applies to the bedside and does not
need to be linked or limited to management or senior levels. This chapter also provided the
reader with an overview of the leadership skills that nurses must be equipped with in order
to be able to lead the delivery of patient care and improve patient safety. It also presented the
impact of nursing clinical leadership on patients’ outcomes. In addition, it discussed preparing
nursing leaders for the new era of health care and how nursing education and healthcare
systems should work together to prepare nurses who are able to face the new healthcare
challenges.
Author details
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