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