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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
leaders values and beliefs and their actions.
Key words: Leadership

Models and theories

Nursing: role

ullally (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 Governments 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

108

...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.

British Journal of Nursing, 2006, Vol 15, No 2

clinical leadership
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. Letts (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.

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

British Journal of Nursing, 2006, Vol 15, No 2

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

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

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)

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 authors 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 authors 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
authors 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 authors research indicates that clinical leaders were
recognized as visible, highly skilled or expert clinical nurses.

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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 leaders actions, deeds
and involvement in care. The main features of congruent
leadership are set out in Table 2.
Congruent leadership is based on the leaders 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
Establishes direction
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
l
l

Table 2. Features of congruent leadership


Motivational and inspirational
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
l
l

British Journal of Nursing, 2006, Vol 15, No 2

clinical leadership
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 authors 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 Kings 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 leaders values and beliefs and
their actions, might lead to a better understanding and clearer
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British Journal of Nursing, 2006, Vol 15, No 2

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 leaders values or beliefs, and their actions.

111