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‘Watching an artist at work’: aesthetic leadership in clinical nursing

Judy Mannix, Lesley Wilkes and John Daly

Aims and objectives. To explore how clinical leaders enact aesthetic leadership in
clinical nursing workplaces. What does this paper contribute
Background. Clinical leadership is heralded as vital for safe and effective nursing. to the wider global clinical
Different leadership styles have been applied to the clinical nursing workplace over community?
recent years. Many of these styles lack an explicit moral dimension, instead focusing • Reveals how clinical leaders can
on leader qualities and developing leader competence around team building, quality positively affect outcomes in clin-
and safety. Aesthetic leadership, with its explicit moral dimension, could enhance ical settings through their leader-
ship skills and knowledge.
clinical leadership effectiveness and improve nursing workplaces. How aesthetic
• Supports aesthetic leadership as a
leadership is enacted in clinical nursing settings requires exploration. suitable style of leadership for
Design. A qualitative design, employing conversation-style interviews with experi- clinical leaders to incorporate
enced registered nurses and written responses gathered from an online descriptive into their leadership practice.
survey. • Contributes to an enhanced
Methods. Narrative data were gathered from interviews with 12 registered nurses understanding of the importance
of being visible and composed as
and written accounts from 31 nurses who responded to an online survey. Together,
clinical leaders.
transcribed interview data and the written accounts were subject to thematic analysis. • Reinforces the importance of
Results. Three main themes emerged: Leading by example: ‘be seen in the clinical nursing values in the day-to-day
area’; Leading with composure: ‘a sense of calm in a hideous shift’; and Leading activities of clinical leaders.
through nursing values: ‘create an environment just by your being’.
Conclusions. Aesthetic leadership was shown to enhance clinical leadership activi-
ties in the nursing workplace. The capacity for clinical leaders to be self-reflective
can positively influence the nursing workplace. It was apparent that clinical leader
effectiveness can be enhanced with nursing values underpinning leadership activi-
ties and by being a visible, composed role model in the clinical workplace.
Relevance to clinical practice. Aesthetic leadership can enhance clinical nursing
workplaces with its explicit moral purpose and strong link to nursing values.
Clinical leaders who incorporate these attributes with being a visible, composed
role model have the capacity to improve the working lives of nurses across a
range of clinical settings.

Key words: aesthetic leadership, clinical leadership, nursing, qualitative design

Accepted for publication: 21 June 2015

Authors: Judy Mannix, RN, MN, Senior Lecturer, Director of Aca- Faculty of Health, University of Technology, Sydney, NSW, Aus-
demic Programs – Postgraduate, School of Nursing & Midwifery, tralia
University of Western Sydney, Sydney; Lesley Wilkes, PhD, RN, Correspondence: Judy Mannix, Senior Lecturer, School of Nursing
Professor of Nursing, School of Nursing & Midwifery, University & Midwifery, University of Western Sydney, Locked Bag 1797,
of Western Sydney/Nepean Blue Mountains Local Health District, Penrith, NSW 2751 Australia. Telephone: +61 2 46203760.
Penrith, NSW; John Daly, PhD, FACN, FAAN, Professor & Dean, E-mail:

© 2015 John Wiley & Sons Ltd

Journal of Clinical Nursing, 24, 3511–3518, doi: 10.1111/jocn.12956 3511
J Mannix et al.

Introduction and background mixed-methods study took a qualitative approach to col-

lect narrative data from two sources. Using convenience
Health care systems across the world increasingly are required sampling, the first source of data involved online recruit-
to provide quality health care services with seemingly fewer ment of nurses via e-learning platforms and online social
resources. The responsibility for providing quality health care networks to complete an online descriptive survey, details
in this environment can be collectively shared across the health of which are reported elsewhere (Mannix et al. 2014).
workforce. However, the burden of responsibility for ensuring The online survey included an invitation to respondents
that quality care is produced and delivered consistently in clin- to provide a written account of an experience of aesthetic
ical settings settle on the shoulders of clinical leaders and man- leadership from a clinical leader in their clinical nursing
agers. These expectations occur in clinical workplaces that world. Using purposive sampling, the second source of
have been described metaphorically as perfect storms due to narrative data were drawn from individual, in-depth con-
workforce shortages, staff skill mix problems, patient versation-style interviews with experienced registered
demands and diminishing resources (Mannix et al. 2013). nurses employed in clinical leadership positions in nurs-
Effective clinical leadership has been put forward by profes- ing.
sional nursing organisations and government-sponsored In all, 31 nurses who completed the online survey pro-
enquiries as the remedy for the ills of the nursing workplace vided a written account of their experiences of aesthetic
(Mannix et al. 2013) and has been identified as a way to leadership. Twelve clinical leaders participated in a
increase job satisfaction among nurses (Kaddourah et al. digitally recorded interview with one member of the
2013). research team. The semi-structured interviews focused on
While transformational leadership is the dominant leader- participants’ views of effective clinical leadership and the
ship style in nursing in recent decades (Cummings et al. influence of aesthetics on the clinical setting. The
2010), it is not a style of leadership with specific application duration of the interviews ranged between 30–60 minutes.
to clinical leadership (Stanley 2008). Other relational-ori- As reported elsewhere (Mannix et al. 2015b), involving
ented and task-oriented leadership styles have been used to a this number of participants was established when data
lesser extent in nursing (Cummings 2012). Of these styles, saturation occurred. The study’s rigour was enhanced by
congruent leadership, proposed in recent years by Stanley having only one member of the research team conduct
(2008) is unique in that it has explicit application to clinical the interviews.
leadership in nursing. Many of the current leadership styles, The written accounts from the survey respondents [R]
including transformational and congruent leadership focus and the transcribed data from interviewees [I] were
on leader characteristics in the leader/follower dyad (Stanley subsequently combined and together were analysed fol-
2006, Hutchinson & Jackson 2013). In the current health lowing thematic analysis principles. Initially, narrative
care climate, it may be timely to consider a style of leadership data were read by a research team member to get a
style with a follower-centric focus to complement and over- sense of meaning (Borbasi & Jackson 2012), followed by
come shortcomings in these leader-focused styles (Mannix an inductive approach to uncover and expound themes
et al. 2015a). Aesthetic leadership is one style with a follower (Vaismoradi et al. 2013). To assess trustworthiness and
focus (Dinh et al. 2014), described as leadership with an credibility of the three emergent themes, another
explicit moral dimension, and a reliance on tacit knowledge researcher reviewed the findings to confirm that the
gained from largely indescribable know-how derived from intended meaning was represented truly (Graneheim &
sensory, emotional and somatic awareness (Mannix et al. Lundman 2004).
2015a). As well, this style of leadership sits well with nursing
because nurses have for many years acknowledged the valid-
ity of aesthetics to their knowledge and practice (Finfgeld- Findings
Connett 2008). However, the ways in which aesthetic leader- From analysis of the narrative data, three main themes
ship is enacted in the clinical nursing workplace is essentially emerged to reveal how aesthetic leadership is enacted by
unknown. This paper addresses that gap. clinical leaders in the workplace:
• Leading by example: ‘be seen in the clinical area’
Methods • Leading with composure: ‘a sense of calm in a hideous
Following approval for the study from the Institutional • Leading through nursing values: ‘create an environment
Human Research Ethics Committee, this part of a larger, just by your being’

© 2015 John Wiley & Sons Ltd

3512 Journal of Clinical Nursing, 24, 3511–3518
Original article Aesthetic leadership in clinical nursing

want to aspire to the same goal’ [I8]. At the same time, it

Leading by example: ‘be seen in the clinical area’
requires clinical leaders to respect their positional power
It was evident from both the conversations and the written they may have and to recognise their limitations, as one
accounts that for clinical leaders to be effective, they interviewee commented:
needed to show leadership through being involved in day-
I think a good leader isn’t scared of power. They welcome differ-
to-day activities in clinical settings. This required clinical
ence of opinion. They welcome other ideas because a leader has
leaders to have a physical presence in the clinical area,
got to be able to say I don’t know all the answers and sometimes I
whether it involved, as one interviewee stated, a ‘walk
need to see outside the box. [I5]
through every ward’ [I3], being ‘a resource person’ [I6] or
as one respondent wrote, ‘jump in and help do whatever It was also apparent that clinical leaders saw the impor-
she can to help me get back on track’ [R12]. The view that tance of empowering colleagues and fostering teamwork in
a clinical leader has ‘to be seen in the clinical area’ [I6] and the clinical workplace. Different strategies were employed
be seen ‘relating to other staff’ [I9] enables them to provide by clinical leaders to achieve this, including ‘following up
support to colleagues in various situations, either to individ- with the staff, making sure that they feel safe, empowering
ual colleagues or collectively in the clinical workplace. In the more junior staff, encouraging them to ask questions’
some cases, it involved supporting colleagues who was [I8], and producing a video involving staff, ‘to recognise
‘doing something new that they’ve never done before’ [I8], and acknowledge the great work done as individuals and as
while in other situations, it involved clinical leaders encour- a team’ [R4]. The importance of being involved with col-
aging staff in the workplace. For example, providing sup- leagues in the clinical setting was noted by a respondent
port to less experienced colleagues can have a positive who wrote:
effect on the nursing workplace, as one interviewee
My clinical leader used aesthetic leadership skills to engage his staff
in frontline management work. The staff were asked what they
. . .[you] build up their confidence and hopefully that then encour- were passionate about, what drove them crazy every day? The clin-
ages them to be creative because we go through hard times in the ical leader them empowered the staff to improve these processes
health system. Once you get staff who are confident and feeling and correct issues. [R17]
happy in their environment, supported in their environment, they
feel valued and all that sort of thing. [I5]
Leading with composure: ‘a sense of calm in a hideous
Creating positive workplaces required clinical leaders to
be visible and involved in activities in clinical settings. As
part of this visible presence was the capacity to effectively There was an awareness of the impact effective clinical
communicate with colleagues, whether it involved ‘trying to leadership had on the clinical environment, especially the
be collaborative, to see what they think, listen to them, lis- effect on staff demeanour. A number of interviewees spoke
ten to their concerns, because a lot of the staff have differ- of a ‘sense of calmness’ [I11] as an indication of effective
ent skill levels’ [I8] or around nonclinical workplace issues, clinical leadership. This was summed up by one interviewee
such as an incident of bullying reported by one respondent: who commented:

. . .the victim felt like she could not continue in her work in the I think it [good clinical leadership] has a very calming effect. You
positive way she had always performed. This clinical leader sup- can walk on to a shift that is well led and you can also see the staff
ported her by communicating, listening, debriefing and discussing breathe a sigh of relief because the modern clinical era – in public
moving forward with her work in a new and positive light, and hospitals now, the patients are so sick and there is so much that
enabled strength in the person who previously felt disabled in prac- the nurses are expected to do, that if a shift is a bit out of kilter
tice. [R31] it’s just hell. [I7]

Clinical leaders also needed to have sufficient knowledge Composure from a clinical leader resulted in positive feel-
and skills to enhance workplace relations among colleagues. ings from staff with reports that clinical areas, although
As interviewees remarked, ‘they [colleagues] need to have when chaotic and busy there was a sense of a ‘harmonious
faith in you; they need to see you as a model . . . someone place’ [I8], of ‘organised chaos’ [I3], and ‘even if they’ve
to look up to, that kind of model’ [I6] and ‘if you’ve got a got two MET [Medical Emergency Team] calls going at the
goal or something you want to achieve, having the ability same time it still seems controlled’ [I7]. Also evident in
to sort of bring that across to other staff so that they also these busy clinical settings was a ‘sense of achievement’

© 2015 John Wiley & Sons Ltd

Journal of Clinical Nursing, 24, 3511–3518 3513
J Mannix et al.

[I7], getting ‘a very good feeling just by walking around I’m maturing as a nurse leader, I’m learning to not take other peo-
and seeing how people are interacting without them saying ple’s negativity or criticisms personally, and recognising stress and
anything to you’ [I3], and observing nursing staff ‘with burnout in other people, and also trying to recognise it in myself,
smiles on their faces’ [I9]. These attitudes and behaviours but not taking other people’s negativity on. I think a positive out-
tended to have a flow-on effect to how the clinical setting look is really important . . . to keep focused on what we’re trying
functioned, as one interviewee noted: to achieve and just bringing it back to why are we actually all here
– working together and all those kind of things. [I9]
it [ward] just runs, it ticks over, the staff are stable, they don’t
have the huge turnovers, in fact, sometimes there’s waiting lists to
get in because they are such a good cohesive team and some of
Leading through nursing values: ‘create an environment
these wards you know, no matter what sort of day they have they
just by your being’
pull together, you know like it doesn’t matter if that’s not my buz-
The narrative accounts revealed that nursing values
zer or I’m sitting near this phone so I’ll answer it. [I3]
around caring, professionalism and collegiality were
This type of composed leadership also resulted in a important elements in how clinical leaders demonstrated
heightened level of confidence among staff in the manage- aesthetic qualities in their day-to-day practice. As was
ment of clinical situations. As one interviewee com- remarked, as a clinical leader ‘you should look profes-
mented, the confidence shown by a clinical leader ‘gives sional, you’re a leader, people look to you’ [I10], and
me confidence just to go out and do what I’ve been doing ‘the environment has a huge impact on their [patient/
but with even more confidence’ [I11]. Effective and com- staff] sense of well-being’ [I9]. Aspects of professionalism
posed clinical leaders were able to instil confidence in col- evident among clinical leaders were reflected in a number
leagues and ‘foster relationships, respect and credibility’ of areas, including expectations of how the clinical set-
[R10] among staff, as described in the following written ting presents and how one feels when in the area. As
account: one interviewee commented, ‘the ward looks neat, clean,
tidy, calm’ [I7] when a professional stance is taken by a
Clinical leader delineated hierarchy and professional divides to cre-
clinical leader. A clinical environment that presents in
ate an integrated clinic rehab service, brought clinicians, support
this way can be reassuring to those entering the area, as
and admin staff together regularly and encouraged innovation to
one interviewee remarked, ‘if things look organised, then
redesign the service and support new pathways. [R23].
I know that someone’s on the ball’ [I9]. It can also foster
Similarly, leader composure was required to facilitate professionalism among those working in the area, as one
positive attitudes among staff in a clinical area experiencing comment reflected:
change. In this situation:
I think when the environment’s right they [nursing staff] are
. . .a number of colleagues were distressed by the challenges existing believed in and nurtured, I think pride in their appearance and the
services directed at them, to justify what they were doing and why. ward’s appearance, and the aesthetic qualities follow . . . I think we
. . .established reflective practice groups to enable active discussion need to look at our appearance on the ward. What can we do?
and feedback from each other regarding the implementation issues. You put it in such a way to get them to own it. [I5]
In facilitating the group I provided home baked goodies, and good
The way a clinical area presents can also have positive
coffee, to enable staff to relax and enjoy the sessions as ‘separate’
effects on staff, as one respondent recounted a situation
to the daily demands of the job. [R6]
where a clinical leader emphasised the importance of the
For those in clinical leadership roles, it was evident aesthetics on staff and patient comfort. As the respondent
that they recognised the effect they could have on a clini- commented, the new environment ‘increased the morale of
cal setting and that they needed to ‘have insight’ [I10], the staff and has improved patient care by both leaders and
‘be self-aware of their weaknesses and strengths’ [I5], and staff being positive about their surroundings’ [R8]. In the
realise their influence. Clinical leaders can provide stabil- absence of a professional approach from clinical leaders, it
ity to a nursing team through their advanced knowledge can be ‘visually assaulting just to walk in to the ward, with
and skills and are able to ‘put out the little fires before so much ‘stuff’ on the walls, so many old notices and pos-
they become a big fire’ [I6]. This level of insight and ters’ [I2] and give the appearance of being ‘very cold and
self-reflection was encapsulated by one interviewee who impersonal, just very untidy and overcrowded, a bit fac-
remarked: tory-like’ [I9].

© 2015 John Wiley & Sons Ltd

3514 Journal of Clinical Nursing, 24, 3511–3518
Original article Aesthetic leadership in clinical nursing

It was evident that the physical appearance of any clini- viewee commented, ‘If people don’t like you or don’t trust
cal setting was regarded as an important aspect to how you, they’re not going to have a bar of what you’re going
patient care was delivered and that a professional approach to say or what you’re trying to bring across’ [I8]. Similarly,
from clinical leaders enhanced the patient and staff experi- the importance of trust was emphasised by another intervie-
ences. It was also evident that such positive experiences can wee who remarked, ‘If you lose trust, you’ve lost every-
stay with nurses and shape how they behave as clinical thing, I think, as a clinical leader’ [I6].
leaders. An early nursing career experience with a dying The centrality of recipients of care shaped how clinical
patient was recounted by one interviewee: leaders went about their day-to-day activities in clinical
areas. As one interviewee who worked in aged care com-
I just remember the room. There was aromatherapy burning. There
mented, ‘the residents should be the central point – that’s
were low lights, flowers, family were there, music playing and it
what everything radiates out of, including the relatives and
was just a very peaceful, serene environment and it was just so dif-
the doctors’ [I2]. Patient-centred nursing care focusing on
ferent from anything in the acute hospitals that I’d experienced
comfort and hygiene was regarded as not only a reflection
before. We washed this lady and she was so fragile but just so
of good nursing care but also of sound clinical leadership.
lovely. The nurse was very gentle and I thought: oh, this is really
As evident from the narratives, when patients have their
nice. I thought: wow, what a privilege. How privileged was I that
hygiene needs attended to and the area around their bed
the family let me come in at such an important time and it just
looking tidy, ‘they looked care for and that makes the
really struck me. [I9]
patient feel better’ [I1]. As a result of this, these ‘small
For clinical leaders, the importance of reflective practice details humanise the patient into a person’ [R1], and these
was evident in the way it affected their day-to-day clinical values can be retained in an evidence-based environment.
practice, especially in relation to the delivery of patient One of the ways in which clinical leaders apply their
care. One interviewee reflected on how an earlier experi- knowledge and skills to humanise patients while providing
ence of observing a clinical leader affected how they care and comfort was recounted in a narrative describing a
approached subsequent clinical situations: situation where treatment was being withdrawn from a
brain dead patient in an intensive care setting. The way in
. . . you walk into the patient’s room and it’s as though it’s their
which the clinical leader expertly orchestrated the transition
space now and I think you’ve got the ability as a nurse to create an
from a highly clinical setting to a palliative care space so
environment just by your being, your presence and the way it’s not
the family could be with the patient when he died ‘was just
about you and you can shove all that out the back and be that per-
like watching an artist at work, . . . comb his hair and do
son for the patient. I think if when I’ve observed people doing that,
things so that he would resemble more like the person that
I think that’s what I want to be like. That’s what I want to do,
he really was’ [I11].
you know. [I11]

Embracing nursing values around trust, equality and

advocacy by clinical leaders fostered collegiality in the clini-
cal workplace. One respondent remarked that in addition The findings from the combined 12 interviews and 31 written
to ‘being an advocate for staff and patients’ [R10], clinical accounts reveal a rich narrative on how clinical leaders enact
leaders can be a ‘link between them and administration’ aesthetic leadership in the clinical nursing world. It was
[R10]. The importance of clinical leaders valuing colleagues important for clinical leaders to be visible and accessible to
and acknowledging their contributions were also reflected colleagues in the clinical setting and in doing so, practise with
in the narratives. As was commented, good leaders were a professionalism and competence reflective of nursing val-
those nurses ‘who mentored, who valued the juniors and ues. These findings support previous studies that have
valued education and valued the patient, and are able to reported the positive effect leader visibility has on the nursing
transfer that information’ [I5], and acknowledge that ‘we’re workplace (Cummings et al. 2008), as well as the preference
all equal, we work as a team’ [I10]. An example of how for clinical leaders to be accessible and approachable (Stanley
clinical leaders can value colleagues was evident when a 2014). Clinical leaders portrayed nursing values and a profes-
clinical leader ‘acknowledged the positive difference having sional image through their actions and behaviours and in
music in the outpatient day setting had on the environment doing so, influenced colleagues’ behaviours and shaped clini-
and the mood in the department’ [R7]. Establishing trusting cal outcomes. This modelling of professionalism has flow-on
relationships with colleagues and patients was also an effects in clinical settings, especially for recipients of nursing
important value for clinical leaders to possess, as one inter- care. As Hatfield et al. (2013) report, patients have been

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Journal of Clinical Nursing, 24, 3511–3518 3515
J Mannix et al.

shown to link nursing competence to a professional image,

Visible role

Table distilled from: Cleary et al. (2011), Hutchinson and Jackson (2013), Jackson (2008), Kalshoven et al. (2011), Ladkin and Taylor (2010), Mannix et al. (2015a), Stanley (2006).
including how they present and they interact with patients

and colleagues.
As would be expected in study involving participants from
a practice-based discipline, a number of the leadership attri-

Insightful &
butes to emerge from the findings had an obvious clinical
focus around clinical leader competence and also reflective
of the centrality of caring in nursing. Participants recounted
situations where the clinical skills and knowledge of the clin-

Explicit moral
ical leader impacted positively on their own practice. It was

also apparent that for clinical leaders to be effective, they
were collegial and supportive in the workplace. Clinical lea-
der attributes focusing on clinical competence and collegial
support of followers have been reported previously (Stanley

discipline values
2006, 2014, Mannix et al. 2013), but as Mannix et al. high-
light, most of the attributes previously reported are indica-

tive of the technical and practical skills and knowledge
required for clinical competence and leader effectiveness.
Technical and practical knowledge and skills have been

Creative &
theorised by Habermas (1972) to be aspects of two of three

types of cognitive interests, empirical and interpretive
respectively, with critically oriented, emancipatory knowl-
edge and cognitive interests being the third. These emanci-

Collegial & fosters

patory interests and knowledge facilitate the central notion
of self-reflection that enables an individual to critique exist-
ing systems and practices (Habermas 1972). In the current
study, attributes reflective of emancipatory knowledge and teamwork
interests are a feature in all three themes, especially where
nursing values and beliefs shape the practice of clinical
leaders. By practising self-reflection, clinical leaders have
Clinically skilful &

demonstrated composure in their leadership activities that


instils confidence in colleagues and facilitates a positive

clinical workplace. This finding has not been previously
Table 1 Clinical leader attributes evident in leadership models

reported in the nursing literature.

Shaded cells indicate attribute evident in leadership model.

The way in which aesthetic leadership is enacted by clini-
cal leaders as reported in this study revealed a number of
Composure &

attributes. A comparison of extant leadership models


revealed some attributes common to other leadership mod-

els used in varying degrees in nursing (see Table 1).
From this table of leadership models, it is not surprising
that aesthetic leadership shares a number of attributes with
Accessible &

other leadership models that focus on moral behaviours


and are values-oriented, such as authentic, ethical and ser-

vant leadership (Mumford & Fried 2014). However, it is
evident that there are no similarities with transactional
Leadership model


leadership and few similarities with transformational lead-


ership, the most common leadership model in the nursing


discourse (Cummings et al. 2010). The similarities with



congruent leadership, the only leadership model specific to

clinical leadership in nursing (Stanley 2006), support the

© 2015 John Wiley & Sons Ltd

3516 Journal of Clinical Nursing, 24, 3511–3518
Original article Aesthetic leadership in clinical nursing

appropriateness of aesthetic leadership to clinical settings. workplace. The capacity for clinical leaders to be self-reflec-
As shown in the table, leading with composure and calm- tive was shown to positively influence the nursing work-
ness were the only attributes not identified in any other place. It was apparent that clinical leader effectiveness can
leadership model. While these attributes are unique only to be enhanced with nursing values underpinning leadership
the model of aesthetic leadership, it has been found by activities and by being a visible, composed role model in
Ennis et al. (2014) that when clinical leaders remain calm the clinical workplace. While some of the attributes to
in a crisis in mental health settings, it positively contributes emerge from this study are apparent in other leadership
to clinical practice. models, leading with composure is an attribute for clinical
leaders to consider in their practice.

Strengths and limitations

Relevance to clinical practice
One strength of this study is the number of participant narra-
tives available for thematic analysis. Together, they provided Aesthetic leadership was shown as a leadership model to
a rich source of data on aesthetic leadership. As with other enhance clinical nursing workplaces. With aesthetic leader-
qualitative approaches to research a limitation of the study is ship’s explicit moral purpose and strong link to nursing val-
that the findings are not generalisable. Nonetheless, the find- ues, clinical leaders who incorporate these attributes with
ings of the study contribute to an understanding of how aes- being a visible, composed role model have the capacity to
thetic leadership is enacted by clinical leaders in nursing. improve the working lives of nurses across a range of clini-
cal settings.

The way in which aesthetic leadership was portrayed in the
43 narratives analysed for this study illuminates how Study design: JM, LW, JD; Data collection and analysis:
effective clinical leadership can be practised in the nursing JM, LW; Manuscript preparation: JM, LW, JD.

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