leadership in mental health nursing essay

• DOI: 10.1111/j.1365-2834.2011.01237.x
• Corpus ID: 26259053

Leadership and management in mental health nursing.

• N. Blegen , E. Severinsson
• Published in Journal of Nursing Management 1 May 2011
• Medicine, Psychology

23 Citations

The importance of communication for clinical leaders in mental health nursing: the perspective of nurses working in mental health, leadership, support and acknowledgement of registered nurses work in acute mental health units., the influences of nursing transformational leadership style on the quality of nurses’ working lives in taiwan: a cross-sectional quantitative study, the new clinical leadership role of senior charge nurses: a mixed methods study of their views and experience., authenticity, creativity and a love of the job: experiences of grassroots leaders of mental health nursing in queensland, global research trends in nursing leadership from 1985 to 2022: a bibliometric analysis., psychiatric nursing managers' attitudes towards containment methods in psychiatric inpatient care., an exploration of the perspectives of associate nurse unit managers regarding the implementation of smoke-free policies in adult mental health inpatient units, action-logics of veterans health administration magnet nurse executives and their practice of supporting nurses to speak up, transformational leadership and ethical leadership: their significance in the mental healthcare system., 34 references, the role of the mental health nursing leadership., leadership styles in nursing management: preferred and perceived., the relationship between nursing leadership and patient outcomes: a systematic review update., solution focused nursing: a fitting model for mental health nurses working in a public health paradigm, nurse executive transformational leadership and organizational commitment, observation: the original sin of mental health nursing, community mental health nursing: keeping pace with care delivery, mental health team leadership and consumers satisfaction and quality of life., the development, implementation, and evaluation of a clinical leadership program for mental health nurses, community psychiatric nurses and the care co-ordinator role: squeezed to provide 'limited nursing'., related papers.

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12 Leadership

• Published: October 2015
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Mental health nursing should inspire, support, and create the conditions under which people will flourish. To improve patient experience and sustain recovery-based outcomes, nurses must collaborate with other healthcare professionals, work alongside managers to support operational systems, and work in partnership with service users and their carers and families. This chapter provides a rationale for and summary of transformational leadership and how to develop, lead, and manage effective teams. It also describes two examples of inspirational leaders, reviews teamworking, and provides an overview of the different team and care settings in which mental health nurses work, including the acute psychiatric ward, the community mental health team, collaborative care, multi-agency working, and working with advocacy services. In addition, it discusses clinical supervision, management supervision, and personal development and appraisal.

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The role of the mental health nursing leadership

• 18(4):463-71

• Høgskulen på Vestlandet

• University of South-Eastern Norway

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• Volume 7, Issue 3
• Attributes, skills and actions of clinical leadership in nursing as reported by hospital nurses: a cross-sectional study
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• http://orcid.org/0000-0001-8401-4976 Majd T Mrayyan 1 ,
• http://orcid.org/0000-0002-6393-3022 Abdullah Algunmeeyn 2 ,
• http://orcid.org/0000-0002-2639-9991 Hamzeh Y Abunab 3 ,
• Ola A Kutah 2 ,
• Imad Alfayoumi 3 ,
• Abdallah Abu Khait 1
• 1 Department of Community and Mental Health Nursing, Faculty of Nursing , The Hashemite University , Zarqa , Jordan
• 2 Advanced Nursing Department, Faculty of Nursing , Isra University , Amman , Jordan
• 3 Basic Nursing Department, Faculty of Nursing , Isra University , Amman , Jordan
• Correspondence to Dr Majd T Mrayyan, Department of Community and Mental Health Nursing, Faculty of Nursing, The Hashemite University, Zarqa 13133, Jordan; mmrayyan{at}hu.edu.jo

Background Research shows a significant growth in clinical leadership from a nursing perspective; however, clinical leadership is still misunderstood in all clinical environments. Until now, clinical leaders were rarely seen in hospitals’ top management and leadership roles.

Purpose This study surveyed the attributes and skills of clinical nursing leadership and the actions that effective clinical nursing leaders can do.

Methods In 2020, a cross-sectional design was used in the current study using an online survey, with a non-random purposive sample of 296 registered nurses from teaching, public and private hospitals and areas of work in Jordan, yielding a 66% response rate. Data were analysed using descriptive analysis of frequency and central tendency measures, and comparisons were performed using independent t-tests.

Results The sample consists mostly of junior nurses. The ‘most common’ attributes associated with clinical nursing leadership were effective communication, clinical competence, approachability, role model and support. The ‘least common’ attribute associated with clinical nursing leadership was ‘controlling’. The top-rated skills of clinical leaders were having a strong moral character, knowing right and wrong and acting appropriately. Leading change and service improvement were clinical leaders’ top-rated actions. An independent t-test on key variables revealed substantial differences between male and female nurses regarding the actions and skills of effective clinical nursing leadership.

Conclusions The current study looked at clinical leadership in Jordan’s healthcare system, focusing on the role of gender in clinical nursing leadership. The findings advocate for clinical leadership by nurses as an essential element of value-based practice, and they influence innovation and change. As clinical leaders in various hospitals and healthcare settings, more empirical work is needed to build on clinical nursing in general and the attributes, skills and actions of clinical nursing leadership of nursing leaders and nurses.

• clinical leadership
• health system
• leadership assessment

Data availability statement

Data are available on request due to privacy/ethical restrictions. https://authorservices.taylorandfrancis.com/data-sharing/share-your-data/data-availability-statements/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/leader-2022-000672

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WHAT IS ALREADY KNOWN ON THIS TOPIC

Clinical leadership was limited to service managers; however, currently, all clinicians are invited to participate in leadership practices. Clinical leaders are needed in various healthcare settings to produce positive outcomes.

WHAT THIS STUDY ADDS

This study outlined clinical leadership attributes, skills and actions to understand clinical nursing leadership better. The current study highlighted the role of gender in clinical nursing leadership, and it asserts that effective clinical nursing leadership is warranted to improve the efficiency and effectiveness of care. The results call for nurses’ clinical leadership as essential in today’s turbulent work environment.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

Nurses and clinical leaders need additional attributes, skills and actions. Clinical nursing leaders should use innovative interventions and have skills or actions to manage current work environments. Further work is needed to build on clinical nursing in general and the attributes, skills and actions of clinical nursing leadership. Clinical leadership programmes must be integrated into the nursing curricula.

Introduction

Clinical leadership is a matter of global importance. Currently, all clinicians are invited to participate in leadership practices. 1 This invitation is based on the fact that people deliver healthcare within complex systems. Effective clinicians must understand systems of care to function effectively. 1 2 Engaging in clinical leadership is an obligation, not a choice, for all clinicians at all levels. This obligation is more critical in nursing with many e merging global health issues , 2 such as the COVID-19 pandemic.

The systematic literature review of Cummings et al 3 shows the differences in leadership literature. In early 2000, clinical leadership emerged in scientific literature. 4 It is about having the knowledge, skills and competencies needed to effectively balance the needs of patients and team members within resource constraints. 4 Clinical leadership is vital in nursing as nurses face complex challenges in clinical settings, especially in acute care settings. 4 Although developed from the management domain, leadership and management are two concepts used interchangeably, 5–9 leading to further misunderstanding of the relationship between clinical leadership and management. While different types of leadership have been evident in nursing and health industry literature, clinical leadership is still misunderstood in clinical environments. 8 Clinical leadership is not fully understood among health professionals trained to care for patients, as clinical leadership is a management concept, leaving the concept open to different interpretations. 10 For example, Gauld 10 reported that clinical leaders might be professionals (such as doctors and nurses) who are no longer clinically active, mandating that clinical leaders should also be involved in delivering care. 10

There is no clear definition of ‘clinical leadership’. However, effective clinical leadership involves individuals with the appropriate clinical leadership skills and attributes at different levels of an organisation, focusing on multidisciplinary and interdisciplinary work. 10 The main skills associated with clinical leadership were having values and beliefs consistent with their actions and interventions, being supportive of colleagues, communicating effectively, serving as a role model and engaging in reflective practice. 4–9 The main attributes associated with clinical leadership were using effective communication, clinical competence, being a role model, supportive and approachability. 4–9 Stanley and colleagues reported that clinical leaders are found across health organisations and are presented in all clinical environments. Clinical leaders are often found at the highest level for clinical interaction but not commonly found at the highest management level in wards or units. 4–9

With the increasing urgency to improve the efficiency and effectiveness of care, effective nursing leadership is warranted. 4 11–17 Clinical leaders can be found in various healthcare settings, 4 most often at the highest clinical level, but they are uncommon at the top executive level. 6–9 18–24 In the UK, the National Health Service (NHS) 25 empowers clinicians and front-line staff to build their decision-making capabilities, which is required for clinical leadership. This empowerment encourages a broader practice of clinical leadership without being limited to top executives alone. 25 26

Purpose and significance

This study assesses clinical nursing leadership in Jordan. More specifically, it answers the following research questions: (1) What attributes are associated with clinical nursing leadership in Jordanian hospitals? (2) What skills are important for effective clinical nursing leadership? (3) What actions are important for effective clinical nursing leadership? (4) What are the differences in skills critical to effective clinical nursing leadership based on the sample’s characteristics? (5) What are the differences in effective clinical nursing leaders’ actions based on the sample’s characteristics?

Nursing leadership studies are abundant; however, clinical leadership research is not well established. 8 27 Until fairly recently, clinical leadership in nursing has tended to focus on nursing leaders in senior leadership positions, ignoring nurse managers in clinical positions. 8 There has been significant growth in research exploring clinical leadership from a nursing perspective. 4 8 9 14–17 24 26–32 A new leadership theory, ‘congruent leadership’, has emerged, claiming that clinical leaders acted on their values and beliefs about care and thus were followed. 6–9 20 This study is the first in Jordan’s nursing and health-related research about clinical leadership. Clarifying this concept from nurses’ perspectives will support greater healthcare delivery efficiencies.

Search methods

The initial search was done using ‘clinical nursing leadership’ at the Clarivate database and Google Scholar database from 2017 to 2021, yielded 35 studies, of which, after abstracting, 14 studies were selected. However, Stanley’s work (12 studies), including those before 2017, was included because we followed the researcher’s passion and methodology of studying clinical leadership; also, some classical models of clinical leadership because they were essential for the conceptualisation of the study as well as the discussion, such as the NHS Leadership Academy (three studies; ref 25 33 34 ).

Another search was run using the words ‘attributes’, ‘skills’ or ‘actions’ using the same time frame; most of the yielded studies were not relevant, this search year was expanded to 2013–2021 because the years 2013–2015 were the glorious time of studying these concepts. Using ‘clinical leadership’ rather than ‘leadership studies’, 15 studies were yielded; however, Stanley’s above work was excluded to avoid repetition, resulting in using three studies (ref 29 30 35 ). A relevant reference of 2022 similar to our study (ref 36 ) was added at the stages of revisions. The remaining 16 of 49 references were related to the methodology and explanation of some results, such as those related to gender differences in leadership. The following limits were set: the language was English; and the year of publication was basically the last 5 years to ensure that the search was current.

Clinical leadership

Clinical leadership ensures quality patient care by providing safe and efficient care and creating a healthy clinical work environment. 4 10–17 27 31 32 It also decreases the high costs of clinical litigation settlements and improves the safety of service delivery to consumers. 4 11–17 32 For these reasons, healthcare organisations should initiate interventions to develop clinical leadership among front-line clinicians, including nurses. 8 9

Literature was scarce on clinical leadership in nursing. 4 8–10 14–17 27 28 31 Stanley and Stanley 8 defined clinical leadership as developing a culture and leading a set of tasks to improve the quality and safety of service delivery to consumers.

Clinical leadership is about focusing on direct patient care, delivering high-quality direct patient care, motivating members of the team to provide effective, safe and satisfying care, promoting staff retention, providing organisational support and improving patient outcomes. 31 Clinical leadership roles include providing the vision, setting the direction, promoting professionalism, teamwork, interprofessional collaborations, good practice and continued medical education, contributing to patient care and performing tasks effectively. 31 Moreover, the researchers added that clinical leadership is having the approachability and the ability to communicate effectively, the ability to gain support and influence others, role modelling, visibility and availability to support, the ability to promote change, advise and guide. 31 Clinical leadership competencies include demonstrating clinical expertise, remaining clinically focused and engaged and comprehending clinical leadership roles and decision-making. In addition, clinical leadership was not associated with a position within the management and organisational structure, unlike health service management. 31 33

Clinical leadership is hindered by many barriers that include the lack of time and the high clinical/client demand on their time. 8 9 Clinical leadership is limited because of the deficit in intrapersonal and interpersonal capabilities among team members and interdisciplinary and organisational factors, such as a lack of influence in interdisciplinary care planning and policy. 37 Other barriers include limited organisational leadership opportunities, the perceived need for leadership development before serving in leadership roles and a lack of funding for advancement. 38

This paper aligns with the theory of congruent leadership proposed by Stanley. 19 This theory is best suited for understanding clinical leadership because it defines leadership as a congruence between the activities and actions of the leader and the leader’s values, beliefs and principles, and those of the organisation and team.

Attributes of clinical leadership

The clinical leadership attributes needed for nurses 8 28 to perform their roles effectively are: (1) personal attributes: nurses are confident in their abilities to provide best practice, communicate effectively and have emotional intelligence; (2) team attributes: encouraging trust and commitment to others, team focus and valuing others’ skills and expertise; and (3) capabilities: encouraging contribution from others, building and maintaining relationships, creating clear direction and being a role model. 8 28 Clinical leadership attributes are linked to communicating effectively, role modelling, promoting change, providing advice and guidance, gaining support and influencing others. 28–30 Other attributes to include are clinical leaders’ engagement in reflective practice, 29 provision of the vision; setting direction, having the resources to perform tasks effectively and promoting professionalism, teamwork, interprofessional collaborations, effective practice and continued education. 27 28 31

Skills of clinical leadership

Clinical leadership skills include (1) a ‘clinical focus’: being expert knowledge, providing evidence-based rationale and systematic thinking, understanding clinical leadership, understanding clinical decision-making, being clinically focused, remaining clinically engaged and demonstrating clinical expertise; (2) a ‘follower/team focus’: being supportive of colleagues, effectively communicating communication skills, serving as a role model and empowering the team; and (3) a ‘personal qualities focus’: engaging in reflective practice, initiating change and challenging the status quo. 17 30 32 Clinical leaders have advocacy skills, facilitate and maintain healthier workplaces by driving changes in cultural issues among all health professionals. 17 29 Moreover, the overlap between the attributes and skills of clinical leaders includes being credible to colleagues because of clinical competence and the skills and capacity to support multidisciplinary teams effectively. 17 29 32

Actions of clinical leadership

A clinical leader is anyone in a clinical position exercising leadership. 26 The clinical leader’s role is to continuously instil in clinicians the capability to improve healthcare on small and large scales. 26 Furthermore, Stanley et al 9 demonstrated that clinical leaders are not always managers or higher-ups in organisations. Clinical leaders act following their values and beliefs, are approachable and provide superior service to their clients. 9 Clinical leaders define and delegate safety and quality responsibilities and roles. 14 32 39 They also ensure safety and quality of care, manage the operation of the clinical governance system, implement strategic plans and implement the organisation’s safety culture. 14 32 39 The Australian Commission on Safety and Quality in Health Care 39 also reported that clinical leaders might support other clinicians by reviewing safety and quality performance data, supervising the clinical workforce, conducting performance appraisals and ensuring that the team understands the clinical governance system.

In summary, clinical leadership attributes, skills and actions were outlined to understand clinical nursing leadership. The literature shows limited nursing research on clinical leadership, calling for clinical leadership that paves the road for nurses in the current turbulent work environment.

Study design

A descriptive quantitative analysis was developed to collect data about the attributes and skills of clinical nursing leadership and the actions that effective nursing clinical leaders can take. A cross-sectional design was employed to measure clinical leadership using an online survey in 2020. This design was appropriate for such a study as it allows the researchers to measure the outcome and the exposures of the study participants at the same time. 40

Sample and settings

The general population was registered nurses in medical centres in Jordan. The target population was registered nurses in teaching, public and private hospitals. Most nurses in Jordan are females working at different shifts on a full-time basis in different types of healthcare services. The baccalaureate degree is the minimum entry into the clinical practice of registered nurses. As previous nurses, we would like to attest that nurses in Jordanian hospitals commonly use team nursing care delivery models with different decision-making styles. The size of the sample was calculated by using Thorndike’s rule as follows: N≥10(k)+50 (where N was the sample size, k is the number of independent variables) (attributes, skills, actions), the minimum sample size should be 80 participants. 40 From experience, the researcher considers the sample’s demographics and subscales as independent variables (k=17); the overall sample should not be less than 220.

Research participants were recruited through a ‘direct recruitment strategy’ from the hospitals where the nursing students were trained. A survey was used to collect data using non-random purposive sampling; of possible 450 Jordanian nurses, 296 were recruited from different types of hospitals: teaching (51 of possible 120 nurses), public (180 of possible 210 nurses) and private (65 of possible 120 nurses), with a response rate of 66%, which is adequate for an online survey. The inclusion criteria were that nurses should work in hospital settings, and any nurses who work in non-hospital settings were excluded. No incentives were applied.

Using a direct measurement method, Stanley’s Clinical Leadership Scale ( online supplemental file 1 ) was used to collect the data using the English version of the scale because English is the official education language of nursing in Jordan. 8 9 The original questionnaire consists of 24 questions: 12 quantitative and qualitative questions relevant to clinical leadership, and 12 related to the sample’s demographics. Several studies about clinical leadership among nurses and paramedics in the UK and Australia used modified versions of a survey tool 5 8 9 18–24 ; construct validity was ensured using exploratory factor analysis or triangulation of validation. Cronbach’s alpha measures the homogeneity in the survey, and it was reported to be 0.87 8 9 and 0.88 in the current study.

Supplemental material

Several questions were measured on a 5-point Likert scale in the original scale, and others were qualitative. The survey for the current study consists of 12 quantitative and qualitative questions related to clinical leadership and 14 questions related to the sample’s demographics. However, the qualitative data obtained were scattered and incomplete; thus, only the quantitative questions were analysed and reported, and another qualitative study about clinical leadership was planned. For the current study, three quantitative questions only focused on clinical leadership, leadership skills and the actions of clinical leaders, and 14 questions focused on the sample’s characteristics relevant to the Jordanian healthcare system developed by the first author. The sample characteristics were gender, marital status, shift worked, time commitment, level of education, age, years of experience in nursing, years of experience in leadership and the number of employees directly supervised. Other characteristics include the type of unit/ward, model of nursing care, ward/unit’s decision-making style, formal leadership-related education (yes/no) and formal management-related education (yes/no). Before data collection, permission to use the tool was granted.

Ethical considerations

Nurses were invited to answer the survey while assuring the voluntary nature of their participation. The participants were told that their participation in the survey was their consent form. Participants’ anonymity and confidentiality of information were assured; all questionnaires were numerically coded, and the overall results were shared with nursing and hospital administrators. 40

Patient and public involvement

There was no patient or public involvement in this research’s design, conduct, reporting or dissemination.

Data collection procedures

After a pilot study on 12 December 2020, which checked for the suitability of the questionnaire for the Jordanian healthcare settings, data were collected over a month on 23 December 2020. Data were collected through Google Forms; the survey was posted on various WhatsApp groups and Facebook pages. Using purposive snowball sampling, nurses were asked to invite their contacts and to submit the survey once. To assure one submission, the Google Forms was designed to allow for one submission only.

No problem was encountered during data collection. The two attrition prevention techniques used were effective communication and asserting to the participants that the study was relevant to them.

The researchers controlled for all possible extraneous and confounding variables by including them in the study. A possible non-accounted extraneous variable is the organisational structure; a centralised organisational structure may hinder the use of clinical nursing leadership.

Data analyses

After data cleaning and checking wild codes and outliers, all coded variables were entered into the Statistical Package for Social Sciences (SPSS) (V.25), 35 which was used to generate statistics according to the level of measurement. A descriptive analysis focused on frequency and central tendency measures. 40 Part 1 of the scale comprises 54 qualities or characteristics to answer the first research question. Responses related to skills were measured on a 1–5 Likert scale; thus, means and SDs were reported to answer the second research question. Eight actions were rated on a 1–5 Likert scale; thus, means and SDs were reported to answer the third research question. Independent t-tests using all sample characteristics were performed to answer the fourth and fifth research questions.

The preanalysis phase of data analysis was performed; data were eligible and complete as few missing data were found; thus, they were left without intervention. The assumption of normality was met; both samples are approximately normally distributed, and there were no extreme differences in the sample’s SDs.

Characteristics of the sample

There were 296 nurses in the current study from different types of hospitals: teaching (51 nurses), public (180 nurses) and private (65 nurses), with a response rate of 66%. Most nurses were females (209, 70.6%), single (87, 29.4%), working a day shift (143, 48.3%) or rotating shifts (92, 31.1%), on a full-time basis (218, 73.6%), with a baccalaureate degree (236, 79.7%), aged less than 25 years (229, 77.4%) and 25–34 years (45, 15.2%), respectively. Also, 65.1% (166) of nurses reported having less than 1 year of experience in nursing; thus, they have few nurses under them to supervise (145, 49% supervise one to two nurses), and 23.3% (69) of nurses reported having 1–9 years of experience in leadership. Nurses reported that their unit or ward has a primary (81, 27.4%) or team nursing care delivery model (162, 54.7%), with a mixed (94, 31.8%) or participatory decision-making style (113, 38.2%), and had formal leadership-related education (191, 64.5%), and had no formal management-related education (210, 70.9%) ( table 1 ).

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Sample’s characteristics (N=296*)

Attributes of clinical nursing leadership

Nurses were asked to think about the attributes and features of clinical leadership. Based on Stanley’s Clinical Leadership Scale, 8 9 nurses were given a list of 54 qualities and characteristics and asked to select the most strongly associated with clinical leadership, followed by those least strongly associated with clinical leadership. Table 2 shows the respondents’ ‘top ten’ selected qualities in ranked order.

'Most’ and ‘Least’ important attributes associated with clinical nursing leadership (N=296)

Skills of effective clinical nursing leaders

On a Likert scale of 1–5, respondents were asked to rank the skills of effective clinical leaders from ‘not relevant’ or ‘not important’ to 5=‘very relevant’ or ‘very important’. The top skills were having a strong moral character, knowing right and wrong and acting appropriately which received a high rating, with a mean of 4.17 out of 5 (0.92). Being in a management position to be effective was ranked as the least skill of an effective leader, with a mean value of 3.78 out of 5 (1.00). As indicated by respondents, other skills of effective clinical leaders are shown in table 3 .

Skills of effective clinical nursing leaders (N=296)

Actions of effective clinical nursing leaders

On a Likert scale of 1–5, respondents were asked to rank the actions of effective clinical leaders. Leading change and service management achieved a high rating of 4.07 out of 5 points (0.90). Influencing organisational policy was rated last, with a mean score of 3.95 out of 5 (1.01), which may reflect the very junior nature of the majority of the sample. As described by respondents, some of the other actions of effective leaders are shown in table 4 .

Actions effective clinical nursing leaders can do (N=296)

Significant differences in skills of effective clinical nursing leaders based on gender

Independent t-tests using all sample’s characteristics were performed to answer the fourth research question. Gender was the only characteristic variable that differentiated clinical leadership skills. An independent t-test demonstrates that males and females have distinct perspectives on 3 out of 10 items measuring clinical leadership skills. Female participants outperform male participants in terms of ‘working within the team (p value=0.021)’, ‘being visible in the clinical environment (p value=0.004)’ and ‘recognizing optimal performance and expressing appreciation promptly (p value=0.042) ( table 5 )’.

Significant differences in skills and actions of effective clinical nursing leaders based on gender (n=296)

Significant differences in actions of effective clinical nursing leaders based on gender

Independent t-tests using all sample’s characteristics were performed to answer the fifth research question. Gender was the only characteristic variable that differentiated clinical leadership actions, and it was discovered that five of the eight propositions varied in their actions: the way clinical care is administered (p=0.010); participating in staff development education (p=0.006); providing valuable staff support (p=0.033); leading change and service improvement (p=0.014); and encouraging and leading service management (p=0.019). The independent t-test results revealed that female participants scored higher in those acts, corresponding to effective leaders’ competencies. The mean values of participants’ responses to the actions of effective clinical leaders are shown in table 5 .

The characteristics of the current sample are similar to those of the structure of the task force in Jordan. The remaining question is how men in Jordan be supported in nursing to develop clinical leadership skills on par with females. Al-Motlaq et al 41 proposed using a part-time nurses policy to address nurses’ gender imbalances. Although this is necessary for both genders, we propose to develop a clinical leadership training package to promote working male nurses’ clinical leadership. In Jordan, we apply the modern trend of using leadership in nursing rather than management. About 65% of the nurses reported having formal leadership-related education, while around 71% reported no formal management-related education.

The findings clearly showed what nurses seek in a clinical leader. They appear to refer to a good communicator who values relationships and encouragement, is flexible, approachable and compassionate, can set goals and plans, resource allocation, is clinically competent and visible and has integrity. They necessitate clinical nursing leaders who can be role models for others in practice and deal with change. They should be supportive decision-makers, mentors and motivators. They should be emphatic; otherwise, they should not be in a position of control. These findings align with other research on clinical leadership. 7–9 21 Clinical leaders should be visible and participate in team activities. They should be highly skilled clinicians who instil trust and set an example, and their values should guide them in providing excellent patient care. 8 9

Participants chose other terms or functions associated with leadership roles less frequently or perceived as unrelated to clinical leadership functions. Management, creativity and vision were among the terms and functions mentioned. The absence of the word ‘visionary’ from the list of the most important characteristics suggests that traditional leadership theories, as transformational leadership and situational leadership, do not provide a solid foundation for understanding clinical leadership approaches in the clinical setting. This result can also be influenced by the junior level of the majority of the sample.

Skills of clinical nursing leadership

Numerous studies have documented the characteristics and skills of clinical leaders. 27 29 31 Clinical leaders’ skills include advocacy, facilitation and healthier workplaces. 27 29 31 Our participants were rated as having high morals (similar to other studies) 27 29 31 and worked within teams. 29 In turn, they were flexible and expressed appreciation promptly. 7–9 21 They were clinically competent; thus, they improvised and responded to various situations with appropriate skills and interventions. They recognised optimal performance, initiated interventions, led actions and procedures and had the skills and resources necessary to perform their tasks.

The lowest mean was ‘ being in a management position to be effective ’. This lowest meaning ‘ somehow ’ makes sense; all nurses can be effective leaders rather than managers, assuming effective clinical leadership roles without having management positions. 28 42

Actions of clinical nursing leadership

Influential nursing leaders are clinically competent and can initiate interventions and lead actions; these skills translate to actions. Clinical leaders are qualified to lead and manage the service improvement change (similar to Major). 42 This role will not suddenly happen; it requires clinical nursing leaders who encourage and participate in staff development education (consistent with Major). 42 This is an essential milestone and an example of providing valuable staff support. As these were the lowest reported actions, clinical nursing leaders should initiate and lead improvement initiatives in their clinical settings, 42 resulting in service improvement. They also have to influence evidence-based policies to improve work–life integration 43 and enhance patients, nurses and organisational outcomes. These outcomes include quality of care, nurses’ empowerment, job satisfaction, quality of life and work engagement. 4 11–17 32

Female nurses had more clinical leadership skills. Because the findings of this study have never been reported in the previous clinical leadership research literature, they are considered novel. This finding indicates that one possible explanation is that the overwhelming majority of respondents were females, with the proportion of females in favour (70.6%) exceeding that of males (29.4%). Furthermore, the current findings could be explained because the study was conducted in Jordan, a traditionally female-dominated gender nursing career.

This study discovered that there are gender differences in the characteristics of nurses and their clinical leadership skills, with female clinical nursing leaders scoring higher on the t-test than male clinical nursing leaders in the following areas: this is contrary to Masanotti et al , 43 who reported that male nurses have a greater sense of coherence and, in turn, more teamwork than female nurses, who commonly have job dissatisfaction and less teamwork. These could apply to female clinical nursing leaders. These female nurses had more ‘visibility in the clinical environment’, as expected in female-dominated gender nursing careers. As they were commonly dissatisfied as nurses, 43 clinical nursing leaders would be competent in caring for their nurses’ psychological status. These leaders know that even ‘thank you’ is the simplest way to show appreciation and recognition; however, this should be given promptly.

In Arab and developing countries, the perception that females have more skills with effective clinical leadership characteristics than males is consistent with Alghamdi et al 44 and Yaseen. 45 They found that females outperform males on leadership scales, which may also apply to clinical leadership. This study shows consistency between female and male clinical nursing leaders’ general perceptions of clinical leadership skills in female-dominated gender nursing careers but not in male-dominated, gender-segregated countries, including Jordan.

Female nurses had more clinical leadership actions, which differed in five out of eight actions. Female clinical nursing leaders were better at impacting clinical care delivery, participating in staff development education, providing valuable staff support, leading change and improving service.

It is aware that the nursing profession has a difficult context in some Arab and developing countries. For example, a study conducted in Saudi Arabia could explain the current findings that male nurses face various challenges, including a lack of respect and discrimination, resulting in fewer opportunities for professional growth and development. 46 The researchers reported that female clinical nursing leaders are preferred over male nurses because nursing is a nurturing and caring profession; it has been dubbed a ‘female profession’. 46 Additionally, this study corroborates a study that found many males avoid the nursing profession entirely due to its negative connotations 47 ; the profession is geared towards females. These and other stereotypes have influenced male nurses to pursue masculine nursing roles.

The study’s findings are unique because they have never been published in the previous clinical leadership research literature. However, these results can be explained indirectly based on non-clinical leadership literature. Consistent with Khammar et al , 48 as it is a female-dominated profession, it is apparent that female clinical nursing leaders are better at delivering clinical care. This result could also be related to female clinical nursing leaders having a better attitude towards clinical conditions and managing different conditions. 48 Female clinical nursing leaders, in turn, are better at influencing patient care and improving patient safety 36 and overall care and services. This improvement will not happen suddenly; it should be accompanied by paying more attention to providing continuous support, especially during induced change.

The current study reported that female clinical nursing leaders supported staff development and education because it is a female-oriented sample. Yet, Khammar et al 48 reported that men had more opportunities to educate themselves in nursing; this is true in a male-dominated country like Jordan. They also noted that males could communicate better during nursing duties. Regardless of gender, all of us should pay attention to our staff’s working environment and related issues, including promoting open communication, providing support, encouraging continuing education, managing change and improving the overall outcomes.

Limitations

Even though the study’s findings are intriguing, further investigation is needed to comprehend them. Because of the cross-sectional design used in the current study, we cannot establish causality. For this reason, the results should be interpreted with caution. Also, the purposive sample limits the generalisability; thus, this research should be carried out again with a broader selection of nursing candidates and clinical settings. Moreover, the sample consists mostly of nurses with minimal experience compared with nurses in other international countries such as Canada, the UK and the USA. 5 The current study also included nurses in their 40s and above, with male nurses less represented, and this causes misunderstanding of the true clinical leadership in nursing.

Implications

For practice, our sample consists of nurses with minimal experience compared with nurses in other developed counties. Our sample reported ‘influencing organizational policy’ as the last clinical leadership skill, which reflects the very junior nature of the sample. Unlike our study, in their systematic review, Guibert-Lacasa and Vázquez-Calatayud 36 reported that the profiles of the care clinical nurses’ experience usually varied, ranging from recent graduates to senior nurses. If our nurses were more experienced, it might lead to different results. More nurses’ clinical experience would increase nurses’ abilities at the bedside, especially in areas related to reasoning and problem solving. 36 More experienced nurses tend to work collaboratively within the team with greater competency and autonomy. 36 More experienced nurses would provide high-quality care, 36 resulting in patient satisfaction. To generate positive outcomes of clinical nursing leadership, such early-career nurses should be qualified. Guibert-Lacasa and Vázquez-Calatayud 36 suggested using the nursing clinical leadership programme based on the American Organization for Nursing Leadership 34 competency model, pending the presence of organisational support for such an initiative. 36

‘Most’ important clinical nursing leadership attributes should be promoted at all organisational and clinical levels. Clinical nursing leadership’s ‘least’ important attributes should be defeated to achieve better outcomes. Clinical nursing leaders should use innovative interventions and have skills or actions conducive to a healthy work environment. These interventions include being approachable to enable their staff to cope with change, 28 using open and consistent communication, 28–30 being visible and consistently available as role models and mentors and taking risks. 28 Hospital administrators must help their clinical leaders, including nursing leaders, to effectively use their authority, responsibility and accountability; clinical leadership is not only about complying with the job description. A good intervention to start with to promote the culture of clinical leadership is setting an award for the ‘ideal nursing leaders’. This award will bring innovative attributes, skills and actions.

Moreover, as they are in the front line of communication, nurses and clinical nursing leaders should be involved in policy-related matters and committees. 49 An interventional programme that gives nurses more autonomy in making decisions is warranted. In turn, various patient, nurse and organisational outcomes will be improved. 13–17 32

The study’s findings revealed statistically significant differences in the skills and actions of effective clinical leaders, with female nurses scoring higher in many skills and actions. Hence, healthcare organisations must re-evaluate current leadership and staff development policies and prioritise professional development for nurses while also introducing new modes of evaluation and assessment that are explicitly geared at improving clinical leadership among nurses, particularly males.

For education, this study outlined clinical leadership attributes, skills and actions to understand clinical nursing leadership in Jordan better. Nevertheless, nurses and clinical leaders need additional attributes, skills and actions. Consequently, undergraduate nursing students might benefit from clinical leadership programmes integrated into the academic curriculum to teach them the fundamentals of clinical leadership. A master’s degree programme in ‘Clinical Nursing Leadership’ would prepare nurses for this pioneering role and today and tomorrow’s clinical nursing leaders. However, all nurses are clinical leaders regardless of their degrees and experience. Conducting presentations, convening meetings, overseeing organisational transformation and settling disagreements are common ways to hone these abilities.

For research purposes, it is worth exploring the concept of clinical leadership from a practice nurse’s perspective to provide insight into practice nurses’ feelings and perceptions. Thus, a longitudinal quantitative design or a phenomenological qualitative design might be adopted to assess the subjective experience of the nurses involved. It is better in future research to focus on both young and veteran clinical leaders; some of our nurses were aged 45 years and above, and those nurses may not be clinically focused.

Summary and conclusion

The current study put clinical leadership into the context of the healthcare system in Jordan. This study highlighted the role of gender in clinical nursing leadership. Nurses’ clinical leadership is a milestone for influencing innovation and change. The current study identified the ‘most’ and ‘least’ important attributes, skills and actions associated with clinical leadership. However, the male and female nurses found substantial differences in effective clinical nursing leadership skills and actions. This study is unique; little is known about the collective concepts of attributes, skills and actions necessary for clinical nursing leadership.

Nurses need leadership attributes, skills and actions to influence policy development and change in their work environments. Leadership attributes can help develop programmes that give nurses more autonomy in making decisions. As a result, nurses will be more active as clinical leaders.

Ethics statements

Patient consent for publication.

Not applicable.

Ethics approval

This study involves human participants and was approved by The Hashemite University, Jordan (IRB number: 1/1/2020/2021) on 18 October 2020. Participants gave informed consent to participate in the study before taking part.

Acknowledgments

The researchers thank the subjects who participated in the study, and Mrs Othman and Mr Sayaheen who collected the data.

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Supplementary materials

Supplementary data.

This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

• Data supplement 1

Contributors MTM developed the study conception, abstract, introduction, literature review and methods; collected the data and wrote the first draft of this research paper and the final proofreading. HAN analysed the data and wrote the results. AA wrote the discussion and updated the literature review. OK wrote the limitations, implications, and summary and conclusion. IAF and AAK did the critical revisions and the final proofreading. All authors contributed to the current work.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

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Leadership and management in mental health nursing

2011, Journal of Nursing Management

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Aim(s) To examine nursing leadership in contemporary health care and its potential contribution to health service organization and management.Background As the nursing profession repositions itself as an equal partner in health care beside medicine and management, its enhanced nursing standards and clinical knowledge are not leading to a commensurate extension of nursing’s power and authority in the organization.Method(s) An ethnographic study of an ICU in Sydney, Australia, comprising: interviews with unit nursing managers (4); focus groups (3) with less experienced, intermediate and experienced nurses (29 in total); and interviews with senior nurse manager (1).Results Inter- and intra-professional barriers in the workplace, fragmentation of multidisciplinary clinical systems that collectively deliver care, and clinical and administrative disconnection in resolving organizational problems, prevented nurses articulating a model of intensive and end-of-life care.Conclusion(s) Professional advocacy skills are needed to overcome barriers and to articulate and operationalize new nursing knowledge and standards if nurses are to enact and embed a leadership role.Implications for nursing management The profession will need to move beyond a reliance on professional clinical models to become skilled multidisciplinary team members and professional advocates for nurses to take their place as equal partners in health care.

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Leadership and management in mental health nursing

Affiliation.

• 1 Centre for Women's, Family and Child Health, Vestfold University College, Tønsberg, University of Stavanger, Norway. [email protected]
• PMID: 21569145
• DOI: 10.1111/j.1365-2834.2011.01237.x

Background: Mental health nurses are agents of change, and their leadership, management role and characteristics exist at many levels in health care. Previous research presents a picture of mental health nurses as subordinate and passive recipients of the leader's influence and regard leadership and management as distinct from the nurses' practical work.

Aim: The aim was to provide a synthesis of the studies conducted and to discuss the relationship between nursing leadership and nursing management in the context of mental health nursing.

Method: A literature search was conducted using EBSCO-host, Academic Search Premier, Science Direct, CINAHL and PubMed for the period January 1995-July 2010.

Results: Leadership and management in the context of mental health nursing are human activities that imply entering into mutual relationships.

Conclusion: Mental health nurses' leadership, management and transformational leadership are positively related in terms of effectiveness and nurses' skills.

Implication for nursing management: It is important to consider mental health nurses' management as a form of leadership similar to or as a natural consequence of transformational leadership (TL) and that ethical concerns must be constantly prioritized throughout every level of the organization.

© 2011 The Authors. Journal compilation © 2011 Blackwell Publishing Ltd.

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Models of leadership and their implications for nursing practice

S'thembile Thusini

MSc Student, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London

View articles · Email S'thembile

Julia Mingay

Lecturer, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London

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Leadership in today's NHS, either as a leader or follower, is everybody's business. In this article, an MSc student undertaking the Developing Professional Leadership module at King's College London describes two leadership models and considers their application to two dimensions of the NHS Healthcare Leadership Model: ‘Engaging the team’ and ‘Leading with care’. The author demonstrates the value of this knowledge to all those involved in health care with a case scenario from clinical practice and key lessons to help frontline staff in their everyday work.

The Ely inquiry into the systematic brutal treatment of patients in a Cardiff mental institution was the first formal inquiry into NHS failings ( Department of Health and Social Security, 1969 ). Since that time there have been more than 100 inquiries with inadequate leadership persistently identified as a major concern ( Sheard, 2015 ). National responses have included the NHS Healthcare Leadership Model, delivered by the NHS Leadership Academy and its partners (2013) . A range of online and face-to-face programmes aim to increase an organisation's leadership capacity by developing leaders who pay close attention to their frontline staff, understand the contexts in which they work and the situations they face and empower them to lead continuous improvements that enhance patient outcomes and safety ( NHS Leadership Academy, 2013 ).

At King's College London, ‘Developing Professional Leadership’ is a core module of the Advanced Practice (Leadership) pathway. The module critically appraises theoretical and professional perspectives on leadership and supports participants to take up leadership roles with attention to ethical practice. Both national and college leadership activities promote an understanding of vertical transformational leadership (VTL) and shared leadership (SL).

Vertical transformational leadership

VTL is a hierarchical leadership model that describes an individual leader who, through various influences and mechanisms, elevates himself or herself and followers towards self-actualisation ( Pearce and Sims, 2000 ). VTL values collaboration and consensus, integrity and justice, empowerment and optimism, accountability and equality, and honesty and trust ( Braun et al, 2013 ). A vertical transformational leader inspires others by interpreting complex data, creating a vision and formulating a strategy for its attainment ( Avery, 2004 ). They aim to create an organisation that is agile, responsive, open to learning and future ready through innovation and creativity. They do this by appealing to followers' emotions and internal motivations, and by building rewarding relationships and raising morale. They use delegation, consultation and collaboration to engage followers but retain power so that responsibility and accountability for a vision and its strategy rests with the leader ( Avery, 2004 ).

Behaviours associated with this leadership style have been classified by Avolio et al (1991) as the four ‘I's: idealised influence, individualised consideration, inspirational motivation, and intellectual stimulation:

• ‘Idealised influence’ represents the charismatic part of VTL. Leaders model integrity, optimism and confidence, and act with courage and conviction demonstrating their intellectual and technical skills
• ‘Individualised consideration’ requires self-awareness and an appreciation of the values, aspirations, motivations, strengths and weaknesses of others. From this perspective leaders need to be able to listen and communicate effectively, and may be called upon to teach, coach, mentor or counsel
• ‘Inspirational motivation’ necessitates a clearly communicated vision and belief in a team's abilities to achieve a desired goal
• Through ‘intellectual stimulation’ leaders support and facilitate independent thinking, encouraging followers to be more rational, creative and innovative in their decision-making and problem-solving.

Tse and Chiu (2014) have advised that leaders adopt a balanced approach to the use of the four Is that is contingent upon their followers' orientation. For example, if group cohesion is required then idealised influence and inspirational motivation are appropriate leader behaviours. However, if greater creativity is needed from staff, then a leader is advised to exhibit individual consideration and provide intellectual stimulation. Conversely, mismatching leadership behaviour to follower orientation can have detrimental effects. For example, providing intellectual stimulation with high expectations but offering insufficient individualised consideration.

During times of large-scale dramatic organisational change an effective vertical leader is necessary for recalibrating and reviving an organisation ( Binci et al, 2016 ). They can provide clarity, motivation and empowerment. There are several examples of positive VTL outcomes in NHS trusts that have managed to improve their Care Quality Commission ratings. This was achieved through measures to revive cultures and empower staff with open communications and active support ( Health Foundation, 2015 ). Critics argue that VTL dependence on a single figure can be futile for an organisation, especially if the individual is prone to dysfunctional behaviour ( Wang and Howell, 2012 ). In response, an ‘authentic leader’ is proposed ( Jackson and Parry, 2011 ); this is someone with a ‘high socialised power orientation’, who is humble, modest, deflects recognition for achievements, who celebrates the team, and exhibits vertical and shared leadership behaviours. Through self-awareness and reflecting on actions a VTL leader can exhibit authentic leadership behaviour.

VTL overlaps other leadership approaches including authentic, servant, charismatic, inspirational and visionary ( Avery, 2004 ). What often differentiates VTL is its motivation or focus, which is typically on achieving organisational goals. VTL is also associated with pseudo-transformational and transactional leadership. The former is a dysfunctional form of charismatic leadership, characterised by narcissistic behaviours associated with dictators and sensational political and corporate leaders. Transactional leadership is practised by positional managers whose job it is to set expectations and engage in corrective or autocratic measures that aim to maintain efficiency. Transformational leaders do utilise some transactional methods to achieve goals and the two leadership styles can be complementary. However, VTL is two-way leadership with follower influence whereas transactional leadership represents one-directional hierarchical leadership.

Shared leadership

SL is a non-hierarchical leadership model that describes leadership that emerges within a group, depending on the context and skills required at a given time ( D'Innocenzo et al, 2016 ). SL values openness and trust, engagement and inclusiveness, reciprocity and fluidity, democracy and empowerment, and networking and support ( Jameson, 2007 ). Shared leaders are peers who possess no authority over the group outside the context of their shared contribution. Individual leadership is de-emphasised and a vision and its strategy are created and owned by the group. Open discursive engagement is favoured for mutual sense making through the pooling of diverse skills, knowledge and experience. SL is dynamic, multidirectional and collaborative. Power is shared so that responsibility and accountability for a vision and its strategy rests with the group ( Avery, 2004 ).

SL is often associated with, but different conceptually from, co-leadership, distributed leadership, and self-managing teams. Carson et al (2007) suggested that these all lie on a continuum with co-leadership at one end and shared leadership at the other. Participation, consultation and delegation are used in SL as are the four Is of transformational leadership. SL has been described as a type of group transformational leadership as transformational behaviours within a shared leadership model achieve similar results to VTL ( Wang and Howell, 2012 ). SL necessarily exists in organisations such as the NHS where different professional groups with their own leadership structures need to collaborate. Transforming a culture through shared leadership requires patience and investment. It is an iterative process involving cycles of learning and reflection that require trust, personal and professional maturity, and organisational support.

SL leadership behaviours can become widespread within teams, lessening their dependence on one leader and the potential effects of rogue single leaders ( The King's Fund, 2011 ). This is vital in environments where problems are increasingly complex and leaders are required to possess multiple problem-solving skills. Cost efficiencies can result from diminishing hierarchical leaders' workloads and a consequent reduction in their posts among highly skilled cohesive groups ( Tse and Chiu, 2014 ). Critics argue that SL efficiency is influenced by group dynamics, which may be prone to relationship conflicts that lead to decision paralysis ( Pearce and Sims, 2000 ). Additionally, the emergence of a vertical leader who could manipulate the workforce for political or corporate gain may be an unintended consequence of SL.

Both VTL and SL are moderated by internal and external factors. VTL is influenced by levels of trust, follower receptiveness, personality traits, task complexity and urgency. Stress and burnout can lessen leadership benefits while trust can enhance performance outcomes ( Robert and You, 2018 ). SL is moderated by trust, time, group size and cohesion, skill mix, confidence, task complexity and interdependence ( Nicolaides et al, 2014 ). Trust, sufficient time, a balanced skill mix and group cohesion have a positive influence, while task complexity, especially at formative stages, hinders effective SL.

The two approaches are complementary. During the formative stages of shared leadership, a vertical leader is crucial to guide and sustain shared leadership. Some final decisions will need to rest with the hierarchical leader. As the team gains confidence, a vertical transformational leader's role evolves to consultant, mentor, facilitator and, at times, recipient of group leadership. A significant body of evidence associates VTL and SL with positive individual, group and organisational outcomes ( Wang and Howell, 2012 ; Nicolaides et al, 2014 ; D'Innocenzo et al, 2016 ). VTL predominantly influences individual and organisational outcomes while SL is more influential at the group and organisational levels. Table 1 summarises some of the differences between the approaches, although they share much more in common.