Journal of Psychiatric and Mental Health Nursing, 2015, 22, 616–622
Enabling professional development in mental health nursing: the role of clinical leadership G . E N N I S 3 RN B Sc i ( Pr a c De v ) Ce r t Ed , B . H A P P E L L 1 RN RPN BA ( Ho n s ) Di p Ed B Ed M Ed K . R E I D - S E A R L 2 RN RM BHl t h Sc MCl i n Ed Ph D
D
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PhD candidate, Professor and Executive Director, Research Centre for Nursing and Midwifery Practice, ACT Health, University of Canberra, Canberra, ACT, 2Professor and Executive Director, Nursing and Midwifery, Central Queensland University, Rockhampton, Qld, Australia, and 3Senior Nurse, NorthWestern Mental Health Service Parkville, Parkville, Victoria, Australia
Keywords: clinical leadership, clinical
Accessible summary
teaching, mental health, nursing, professional development, role modelling
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Correspondence: B. Happell Research Centre for Nursing and Midwifery Practice ACT Health and University of Canberra The Canberra Hospital Woden, 2606
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ACT Australia E-mail: [email protected] Accepted for publication: 16 March
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Clinical leadership is important for the strength of mental health nursing as a profession, particularly in utilizing clinical-based opportunities for the professional development of new graduates and nursing students. To date, there has been limited research examining the attributes of nurses considered by their colleagues to be clinical leaders. This study presents the views and experiences of mental health nurses who deliver care, about what they identify as important for effective clinical leadership. Clinical teaching and role modelling are two fundamental roles of effective clinical leaders; they are underpinned by the attributes of professionalism, honesty, willingness to share knowledge and approachability. Additional research is needed to consider the applicability of these roles and attributes across larger samples of nurses in mental health settings.
2015
Abstract doi: 10.1111/jpm.12221
Clinical leadership is acknowledged as important to the nursing profession. While studies continue to identify its significance in contributing to positive outcomes for consumers, the role that clinical leadership has in enabling and supporting professional development in mental health nursing is poorly understood. This study utilized a grounded theory methodology to explore the characteristics clinicians consider important for clinical leadership and its significance for mental health nursing in day-to-day clinical practice. Individual face-to-face, semi-structured interviews were conducted with nurses working in mental health settings. Participants described the important role that clinical leaders play in enabling professional development of others through role modelling and clinical teaching. They describe how nurses, whom they perceive as clinical leaders, use role modelling and clinical teaching to influence the professional development of nursing staff and undergraduate nursing students. Attributes such as professionalism and honesty were seen, by participants, as enablers for clinical leaders in effectively and positively supporting the professional development of junior staff and undergraduate nurses in mental health nursing. This paper examines clinical leadership from the perspective of mental health nurses delivering care, and highlights the important role of clinical leaders in supporting professional development in mental health nursing.
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Introduction There is an identified role for all nurses in the education and development of the next generation of nurses (Nursing and Midwifery Board 2006, Parry 2008, Servodidio 2008). The influence and added value that those recognized as clinical leaders can bring into this area of practice are less clearly understood. Clinical leadership uses evidence-based practice to collaboratively influence the practice of others in the delivery of care (Carney 2009) A clinical leader has been described as ‘. . . an expert clinician, involved in providing direct care, who influences others to improve the care they provide continuously’ (Cook 2001, p. 39). Leadership is important in nursing as it can directly impact on the retention of existing staff and the recruitment of new staff, as well as improvement of outcomes for consumers (Thompson 2008, Downey et al. 2011, Sherring 2012). There is clearly an important link between clinical leadership and professional development. Professional development opportunities in the clinical setting range from the more formal such as clinical teaching, and the less formal but equally important behaviours such as role modelling. Clinical teaching that occurs during the normal course of duties can provide valuable opportunities for professional development and knowledge exchange (Allan et al. 2008, Armstrong 2008, Price & Price 2009, Felstead 2013). These real-life scenarios allow undergraduate nursing students and less experienced nurses to develop skills and expertise in a supportive and safe learning environment (Armstrong 2008, Felstead 2013). Role modelling is also identified as a powerful agent or enabler of professional development (Illingworth 2009, Klunklin et al. 2011, Timmins 2011, Pestka et al. 2012). It reinforces approaches to leadership and delivery of care that other staff can aspire to (Armstrong 2008, Price & Price 2009, Kenward & Kenward 2011). Role models are mindful of the effects of role modelling in relation to interpersonal communication and will consciously choose to act in a particular way knowing that others are observing. They are aware that others are likely to mirror their approaches in particular clinical situations (Armstrong 2008, Price & Price 2009, Jones et al. 2010). This includes the ability to be honest with clients and other staff in a professional manner that is objective, constructive and develops a relationship of trust with others (Pearson et al. 2007, Carney 2009, Klunklin et al. 2011). Although developing trust is applicable in all nursing specialties (Pavlish & Ceronsky 2009, Wong et al. 2010), it is arguably more significant for mental health settings as nurses working in mental health rely heavily on the therapeutic use of self and interpersonal skills to support clients, especially in times of crisis (Cleary et al. 2012). © 2015 John Wiley & Sons Ltd
Research continues to reinforce the importance of clinical leadership and its potential benefits, particularly in relation to professional development (Akerjordet & Severinsson 2008, Long et al. 2011, Kutz 2012). However, there is little evidence in mental health nursing of the attributes or characteristics clinical leaders need and why they are deemed to be important. There is a paucity of research on the role that clinical leaders in mental health nursing have in supporting and encouraging staff to engage in professional development opportunities. It is important to understand how, if at all, they contribute to this process given the role that professional development plays in improving outcomes for consumers and in retaining and attracting staff (Hill 2010, Kooker & Kamikawa 2010).
Aims This paper aims to present findings from a study involving nurses working in mental health in relation to the attributes and characteristics of clinical leaders, specifically the role that enabling and supporting professional development plays in defining clinical leadership.
Methods Design A grounded theory methodology was used to explore clinical leadership in mental health nursing. This methodology aims to generate a substantive theory of an interaction or action, where there is little available evidence, by looking at the process through study participants’ experiences (Creswell 2007, Kooker & Kamikawa 2010). As there is little available peer-reviewed literature on clinical leadership in mental health nursing, grounded theory was identified as an appropriate methodology.
Setting The study was conducted in a public mental health service in Victoria, Australia. Nurses worked across a number of clinical teams in a variety of care settings. Theses settings included inpatient, community teams, and a dedicated crisis and mental health triage service.
Participants Twelve eligible participants were recruited from a group of registered nurses practising in a mental health setting. Participants were selected from nurses who had worked in the service for 12 months or more as they would be more likely to have an awareness of clinical leadership roles within a 617
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service or team. An initial e-mail was sent to potential participants outlining the research and asking them to accept or decline an offer to receive information on the study from the researcher. The organizational sponsor arranged for this e-mail to be sent, to enable potential participants to consider the request without pressure. Nurses who agreed to receive information on the study were then sent a follow-up e-mail with details of the study, including their involvement and a request to provide work contact details. The researcher subsequently arranged to meet with potential participants, and explain the study and the time involved, and obtained their consent if they agreed to participate. No participants refused to participate, and all were aware that they could withdraw from the study at any time. The participants were not known to the researcher prior to this study.
Procedure Collection of data involved individual semi-structured interviews that were conducted in the participants’ workplace by the principal author and were audio-recorded (with the consent of participants). These audio recordings were transcribed verbatim. Participants were asked to identify effective clinical leaders among the nurses they worked with. They were then asked to provide more information about what, in their view, were the characteristics and attributes that symbolized effective clinical leadership for them. The interviews were intended to develop an understanding of what participants considered to be the characteristics or attributes of effective clinical leaders in mental health nursing and why they felt they were significant. In keeping with grounded theory, an iterative process occurred whereby analysis was carried out after each interview and memos were noted and reviewed. The emerging data were constantly compared with previous interview analysis (Strauss & Corbin 1998, Creswell 2007, Wertz et al. 2011, Charmaz 2014).
Ethics Ethical approval for the study was obtained from both the mental health service where the research was carried out and the university human research ethics committee representing the research team. The study was undertaken in line with the National Statement of Ethical Research (National Health and Medical Research Council 2007). All participation in the study was voluntary, with each participant giving formal consent. Participants were informed they were not required to participate and could withdraw from the study at any time. Transcripts of interviews were 618
de-identified before transcription, and all information obtained during the course of this study was treated as confidential and stored securely with access only available to the research team. No names or other potentially identifiable information has been published.
Analysis An integral component of grounded theory is the procedure of constant comparative data analysis. This process involves analysing data as soon as possible after collection and constantly comparing it to previous data before proceeding with the next data collection. Data from each participant interview were coded, retaining as much of the participant’s own language and words as possible. This procedure, in conjunction with data coding, memo writing and categorization, ensures that any emergent theory is grounded in the data (Strauss & Corbin 1998, Wertz et al. 2011, Charmaz 2014). Data were analysed by the authors and coded line by line, retaining as much of the participant’s own language and words as possible. These codes, through analysis, review of memos and constant comparison with additional data, allowed a subcategory to emerge around how clinical leaders enabled and supported professional development in mental health nursing. The subcategory around enabling and supporting professional development was continuously reviewed to ensure that it was consistent with the data.
Results In this study, nurses working in a mental health setting identified that clinical leaders in mental health nursing have a positive impact on less experienced staff and undergraduate nursing students. Clinical leaders enabled and supported this through role modelling, clinical teaching, professionalism, honesty, willingness to share knowledge, and approachability. The findings outlined below present an overview of how nurses working in mental health described effective clinical leaders as role models and clinical teachers.
Role modelling Participants viewed clinical leaders as effective role models in a variety of clinical settings; for example, participant 1 stated: I think, someone who is a really good clinical leader is someone who lives by example, as a role model. So someone who doesn’t just talk the talk, but walks the walk; someone who, when having handover discussions, © 2015 John Wiley & Sons Ltd
Clinical leadership in mental health nursing
for example, is an example of how you conduct yourself professionally for that half hour.
Participant 2 illustrates how clinical leaders are able to inspire and motivate others:
Participant 10 outlines how clinical leaders’ role model approaches to dealing with day-to-day clinical presentations can influence the outcome for the consumer. A lot of it is common sense and instinct, for sure, but then there’s outstanding situations where you stand back and you watch somebody negotiate with a distressed person and it makes an impact, it leaves an impression and you take a lot away with you. I’ve learnt that way. I’ve had a lot of students talk to me regarding that; they like to watch a good clinician work. They get a lot of feedback from it and a lot of mileage. So it’s valuable.
I think someone who has the capacity to draw out the best in you. So they’re quite inspirational, and you look at them and it makes you feel like you want to do better yourself. . . . the best leaders that I’ve ever worked with have made me feel that way. They’ve made me go, ‘Oh, geez, I want to be the best that I can be’.
Reflecting on their own experiences, participant 3 outlines how important role models are for skill development. I think we focus on role models more than anything else. You can’t learn that skill from a textbook, and you blunder in the dark if you haven’t got somebody to teach you how to do this stuff.
The way clinical leaders in mental health nursing were seen to interact with others was deemed important as demonstrating, or role modelling, a sense of professionalism. Participant 3 describes how a clinical leader in mental health nursing has developed this sense of professionalism among peers. . . . one person who stood out for her skills. She’d been doing it for a lot of years. Her knowledge base was quite good; the way she carried herself, she was very professional; and she managed really safely and really well.
Clinical leaders in mental health nursing are seen by others as having and expecting high standards; for example, participant 5 states:
Clinical teaching Participants identified that clinical leaders were seen as effective clinical teachers. They were viewed as always being approachable, willing to share knowledge and identify learning opportunities for others. In describing effective clinical leaders in mental health nursing, participant 9 suggested: . . . the people that really stand out in my mind are the people who not only had . . . an amazing knowledge base, but were also prepared to facilitate your learning along the way.
A clinical leader’s attitude towards facilitating the learning of others is important. Participant 9 goes on to say that: . . . it’s about the [Clinical Leaders] persons’ willingness to be put in that role of mentor or preceptor.
Clinical leaders were seen by participant 11 as:
. . . they have standards and expectations, . . . and I think, they’re normally fairly high, of themselves as well as the people around them, their peers. . . .
. . . approachable and helpful and they will sit with people [undergraduate nurses/less experienced staff], and explain things and be patient. And knowing, I guess, in any team, knowing who those people are . . . and knowing that they are interested in that area and giving them opportunities to use their knowledge and share it, is really, really important.
Honesty, professionalism and integrity were considered an essential component for clinical leaders to be viewed as role models. Participant 4 reinforces this: Honesty. I think is absolutely categorically essential. I think that if you are going to be a good leader of any sort, whether it be in the clinical setting or in any area, you have to be honest, you have to accountable, you have to operate with integrity.
The following quote from participant 7 further highlights the link between honesty and clinical leadership as core to clinical leadership. Another thing that’s really, really important to me . . . is about integrity and honesty. So, being comfortable enough to advocate or speak openly and honestly with your peers about things . . . having that with honesty and integrity and mutual respect, all those sorts of things, all go together. And I think when you are a really good leader you have all those qualities. © 2015 John Wiley & Sons Ltd
The ability of clinical leaders in mental health nursing to be identifiable as colleagues who are willing and able to share information and experience in a supportive way is highlighted above. This is further reinforced by participant 6, who described clinical leaders in mental health nursing as: . . . prepared to share the information they know, and they’re interested in helping other people learn.
And: . . . people who are brilliant with the students, and they’re keen to teach them and keen to pass on their knowledge in a supportive and nurturing way and a bit mothering in a way as well.
Participant 12 reinforces this: 619
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. . . they [Clinical Leaders] impart knowledge without making the person they are imparting the knowledge to feel like they know bloody nothing. And what I’ve often said too, encouraging people to ask questions about clinical issues, to me, is a sign of a good clinical leader.
Discussion A supportive approach to the professional development of nursing staff and students has been identified in this study as an important attribute of effective clinical leaders in mental health nursing. Participants describe how clinical leaders use role modelling characterized by professionalism, honesty, willingness to share knowledge and approachability to influence the professional growth and development of staff. While other studies identify the importance and benefits of supporting professional development through the use of practice-based learning and role modelling (Armstrong 2008, Felstead 2013), it has not been previously identified specifically as an important characteristic of clinical leaders in mental health nursing. This approach to learning may in fact have increased importance in mental health nursing as it relies heavily on good communication skills and the therapeutic use of self (Dickinson et al. 2009, Cleary et al. 2012), concepts not easily taught in a classroom setting. Characteristics that had meaning and significance to participants in this study related to formal roles, such as clinical teaching, while others related to concepts that are less easy to identify, such as role modelling, professionalism and honesty. Role modelling has been identified as an essential method of teaching and imparting knowledge in clinical practice (Allan et al. 2008, Felstead 2013). The current study reinforces this. Furthermore, the significance of honesty and professionalism as characteristics of clinical leadership in mental health has been highlighted. Other studies have examined the importance of professionalism and honestly for nurses (Begley 2008, Hodkinson 2008, Stanley 2008, 2010, Hwang et al. 2009, Lloyd Storfjell & Christiansten 2010) but not in the context of clinical leaders enabling professional development in mental health nursing. Despite its identified importance for professional development, clinical leadership is poorly researched, and there are no formal programmes that aim to specifically develop clinical leadership in mental health nursing. This study establishes new evidence on the links between these attributes and effective clinical leadership in mental health nursing. These are significant new findings as they contribute to the growing evidence base on the relevance and importance of clinical leadership for nurses. Nurses working in mental health identify an interrelated and codependent set of attributes of clinical leadership as 620
opposed to individual characteristics. In essence, clinical leaders possess a combination of attributes that allows them to be effective enablers of clinical and professional development of less experienced staff and undergraduate nursing students. It is widely recognized that the therapeutic use of self is one of the skills that mental health nurses utilize in their clinical practice (Cleary et al. 2012, Ennis et al. 2014). The findings suggest that clinical leaders use this skill to demonstrate good clinical practice to influence the practice of less experienced staff or undergraduate nursing students. Developing clinical leadership is important for nursing as it has been shown to improve consumer outcomes, utilize evidence- base care, and assist in the recruitment and retention of nurses (Begley 2008, Hodkinson 2008, Hwang et al. 2009, Lloyd Storfjell & Christiansten 2010, Stanley 2010). A clearer understanding of the characteristics that clinical leaders need from the perspective of nurses working in mental health will assist in developing a skill set for the next generation of clinical leaders that builds on and strengthens the current evidence on this aspect of mental health nursing. This is imperative if a strong, effective mental health nurse workforce is to be sustained. The difficulties in attracting new graduates into mental health nursing have been extensively documented (Begley 2008, Hodkinson 2008, Hwang et al. 2009, Lloyd Storfjell & Christiansten 2010). Although the factors that influence the choices that undergraduates make in deciding what specialty they will choose are many (McKenna et al. 2010), there is ample evidence to suggest that the quality of clinical placement is a key influencing factor (Happell 2008, Zilembo & Monterosso 2008, McKenna et al. 2010). Undergraduate nurses commence mental health placements with anxieties and misconceptions about working with people with mental illness (Stevens et al. 2013). Approaches to learning that are enabling, supportive and role model mental health nursing favourably, enhance the clinical placement experience (Gough & Happell 2009, Happell & Gaskin 2012). Understanding the attributes nurses see as important in their clinical leaders is particularly important in mental health settings as it can directly impact on the career pathway of undergraduate nurses (Happell 2008, 2009, McKenna et al. 2010, Stevens et al. 2013). Clinical leaders can contribute to creating positive clinical environment for undergraduate nurses (Zilembo & Monterosso 2008, Happell & Gaskin 2012).
Implications for practice Clinical leaders have an important role to play in the development of the next generation of mental health nurses, in attracting new graduates into the profession and ensuring © 2015 John Wiley & Sons Ltd
Clinical leadership in mental health nursing
knowledge on what nurses delivering hands-on care in mental health settings identify as important for effective clinical leadership in mental health nursing.
that the existing nursing workforce has an opportunity to develop professionally. Although the literature describes the importance of clinical leadership in nursing, the impact on the professional development of other staff has not been considered. The current study identifies the role of effective clinical leaders in supporting and enabling a constructive environment to facilitate learning, and how this role contributes to them being seen as a clinical leader. Those deemed by their peers to be effective clinical leaders enable and support this professional development. Importantly, further research is needed to understand how clinical leaders develop these attributes and their usefulness, as a developable skill set, in influencing the next generation of clinical leaders. This paper highlights the pivotal role that clinical leaders have in mental health nursing. This work builds on the limited evidence base articulating the attributes and characteristics required for effective clinical leadership in this setting. Importantly, the paper adds new
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Enabling professional development in mental health nursing: the role of clinical leadership G . E N N I S 3 RN B Sc i ( Pr a c De v ) Ce r t Ed , B . H A P P E L L 1 RN RPN BA ( Ho n s ) Di p Ed B Ed M Ed K . R E I D - S E A R L 2 RN RM BHl t h Sc MCl i n Ed Ph D
D
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PhD candidate, Professor and Executive Director, Research Centre for Nursing and Midwifery Practice, ACT Health, University of Canberra, Canberra, ACT, 2Professor and Executive Director, Nursing and Midwifery, Central Queensland University, Rockhampton, Qld, Australia, and 3Senior Nurse, NorthWestern Mental Health Service Parkville, Parkville, Victoria, Australia
Keywords: clinical leadership, clinical
Accessible summary
teaching, mental health, nursing, professional development, role modelling
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Correspondence: B. Happell Research Centre for Nursing and Midwifery Practice ACT Health and University of Canberra The Canberra Hospital Woden, 2606
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ACT Australia E-mail: [email protected] Accepted for publication: 16 March
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Clinical leadership is important for the strength of mental health nursing as a profession, particularly in utilizing clinical-based opportunities for the professional development of new graduates and nursing students. To date, there has been limited research examining the attributes of nurses considered by their colleagues to be clinical leaders. This study presents the views and experiences of mental health nurses who deliver care, about what they identify as important for effective clinical leadership. Clinical teaching and role modelling are two fundamental roles of effective clinical leaders; they are underpinned by the attributes of professionalism, honesty, willingness to share knowledge and approachability. Additional research is needed to consider the applicability of these roles and attributes across larger samples of nurses in mental health settings.
2015
Abstract doi: 10.1111/jpm.12221
Clinical leadership is acknowledged as important to the nursing profession. While studies continue to identify its significance in contributing to positive outcomes for consumers, the role that clinical leadership has in enabling and supporting professional development in mental health nursing is poorly understood. This study utilized a grounded theory methodology to explore the characteristics clinicians consider important for clinical leadership and its significance for mental health nursing in day-to-day clinical practice. Individual face-to-face, semi-structured interviews were conducted with nurses working in mental health settings. Participants described the important role that clinical leaders play in enabling professional development of others through role modelling and clinical teaching. They describe how nurses, whom they perceive as clinical leaders, use role modelling and clinical teaching to influence the professional development of nursing staff and undergraduate nursing students. Attributes such as professionalism and honesty were seen, by participants, as enablers for clinical leaders in effectively and positively supporting the professional development of junior staff and undergraduate nurses in mental health nursing. This paper examines clinical leadership from the perspective of mental health nurses delivering care, and highlights the important role of clinical leaders in supporting professional development in mental health nursing.
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Introduction There is an identified role for all nurses in the education and development of the next generation of nurses (Nursing and Midwifery Board 2006, Parry 2008, Servodidio 2008). The influence and added value that those recognized as clinical leaders can bring into this area of practice are less clearly understood. Clinical leadership uses evidence-based practice to collaboratively influence the practice of others in the delivery of care (Carney 2009) A clinical leader has been described as ‘. . . an expert clinician, involved in providing direct care, who influences others to improve the care they provide continuously’ (Cook 2001, p. 39). Leadership is important in nursing as it can directly impact on the retention of existing staff and the recruitment of new staff, as well as improvement of outcomes for consumers (Thompson 2008, Downey et al. 2011, Sherring 2012). There is clearly an important link between clinical leadership and professional development. Professional development opportunities in the clinical setting range from the more formal such as clinical teaching, and the less formal but equally important behaviours such as role modelling. Clinical teaching that occurs during the normal course of duties can provide valuable opportunities for professional development and knowledge exchange (Allan et al. 2008, Armstrong 2008, Price & Price 2009, Felstead 2013). These real-life scenarios allow undergraduate nursing students and less experienced nurses to develop skills and expertise in a supportive and safe learning environment (Armstrong 2008, Felstead 2013). Role modelling is also identified as a powerful agent or enabler of professional development (Illingworth 2009, Klunklin et al. 2011, Timmins 2011, Pestka et al. 2012). It reinforces approaches to leadership and delivery of care that other staff can aspire to (Armstrong 2008, Price & Price 2009, Kenward & Kenward 2011). Role models are mindful of the effects of role modelling in relation to interpersonal communication and will consciously choose to act in a particular way knowing that others are observing. They are aware that others are likely to mirror their approaches in particular clinical situations (Armstrong 2008, Price & Price 2009, Jones et al. 2010). This includes the ability to be honest with clients and other staff in a professional manner that is objective, constructive and develops a relationship of trust with others (Pearson et al. 2007, Carney 2009, Klunklin et al. 2011). Although developing trust is applicable in all nursing specialties (Pavlish & Ceronsky 2009, Wong et al. 2010), it is arguably more significant for mental health settings as nurses working in mental health rely heavily on the therapeutic use of self and interpersonal skills to support clients, especially in times of crisis (Cleary et al. 2012). © 2015 John Wiley & Sons Ltd
Research continues to reinforce the importance of clinical leadership and its potential benefits, particularly in relation to professional development (Akerjordet & Severinsson 2008, Long et al. 2011, Kutz 2012). However, there is little evidence in mental health nursing of the attributes or characteristics clinical leaders need and why they are deemed to be important. There is a paucity of research on the role that clinical leaders in mental health nursing have in supporting and encouraging staff to engage in professional development opportunities. It is important to understand how, if at all, they contribute to this process given the role that professional development plays in improving outcomes for consumers and in retaining and attracting staff (Hill 2010, Kooker & Kamikawa 2010).
Aims This paper aims to present findings from a study involving nurses working in mental health in relation to the attributes and characteristics of clinical leaders, specifically the role that enabling and supporting professional development plays in defining clinical leadership.
Methods Design A grounded theory methodology was used to explore clinical leadership in mental health nursing. This methodology aims to generate a substantive theory of an interaction or action, where there is little available evidence, by looking at the process through study participants’ experiences (Creswell 2007, Kooker & Kamikawa 2010). As there is little available peer-reviewed literature on clinical leadership in mental health nursing, grounded theory was identified as an appropriate methodology.
Setting The study was conducted in a public mental health service in Victoria, Australia. Nurses worked across a number of clinical teams in a variety of care settings. Theses settings included inpatient, community teams, and a dedicated crisis and mental health triage service.
Participants Twelve eligible participants were recruited from a group of registered nurses practising in a mental health setting. Participants were selected from nurses who had worked in the service for 12 months or more as they would be more likely to have an awareness of clinical leadership roles within a 617
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service or team. An initial e-mail was sent to potential participants outlining the research and asking them to accept or decline an offer to receive information on the study from the researcher. The organizational sponsor arranged for this e-mail to be sent, to enable potential participants to consider the request without pressure. Nurses who agreed to receive information on the study were then sent a follow-up e-mail with details of the study, including their involvement and a request to provide work contact details. The researcher subsequently arranged to meet with potential participants, and explain the study and the time involved, and obtained their consent if they agreed to participate. No participants refused to participate, and all were aware that they could withdraw from the study at any time. The participants were not known to the researcher prior to this study.
Procedure Collection of data involved individual semi-structured interviews that were conducted in the participants’ workplace by the principal author and were audio-recorded (with the consent of participants). These audio recordings were transcribed verbatim. Participants were asked to identify effective clinical leaders among the nurses they worked with. They were then asked to provide more information about what, in their view, were the characteristics and attributes that symbolized effective clinical leadership for them. The interviews were intended to develop an understanding of what participants considered to be the characteristics or attributes of effective clinical leaders in mental health nursing and why they felt they were significant. In keeping with grounded theory, an iterative process occurred whereby analysis was carried out after each interview and memos were noted and reviewed. The emerging data were constantly compared with previous interview analysis (Strauss & Corbin 1998, Creswell 2007, Wertz et al. 2011, Charmaz 2014).
Ethics Ethical approval for the study was obtained from both the mental health service where the research was carried out and the university human research ethics committee representing the research team. The study was undertaken in line with the National Statement of Ethical Research (National Health and Medical Research Council 2007). All participation in the study was voluntary, with each participant giving formal consent. Participants were informed they were not required to participate and could withdraw from the study at any time. Transcripts of interviews were 618
de-identified before transcription, and all information obtained during the course of this study was treated as confidential and stored securely with access only available to the research team. No names or other potentially identifiable information has been published.
Analysis An integral component of grounded theory is the procedure of constant comparative data analysis. This process involves analysing data as soon as possible after collection and constantly comparing it to previous data before proceeding with the next data collection. Data from each participant interview were coded, retaining as much of the participant’s own language and words as possible. This procedure, in conjunction with data coding, memo writing and categorization, ensures that any emergent theory is grounded in the data (Strauss & Corbin 1998, Wertz et al. 2011, Charmaz 2014). Data were analysed by the authors and coded line by line, retaining as much of the participant’s own language and words as possible. These codes, through analysis, review of memos and constant comparison with additional data, allowed a subcategory to emerge around how clinical leaders enabled and supported professional development in mental health nursing. The subcategory around enabling and supporting professional development was continuously reviewed to ensure that it was consistent with the data.
Results In this study, nurses working in a mental health setting identified that clinical leaders in mental health nursing have a positive impact on less experienced staff and undergraduate nursing students. Clinical leaders enabled and supported this through role modelling, clinical teaching, professionalism, honesty, willingness to share knowledge, and approachability. The findings outlined below present an overview of how nurses working in mental health described effective clinical leaders as role models and clinical teachers.
Role modelling Participants viewed clinical leaders as effective role models in a variety of clinical settings; for example, participant 1 stated: I think, someone who is a really good clinical leader is someone who lives by example, as a role model. So someone who doesn’t just talk the talk, but walks the walk; someone who, when having handover discussions, © 2015 John Wiley & Sons Ltd
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for example, is an example of how you conduct yourself professionally for that half hour.
Participant 2 illustrates how clinical leaders are able to inspire and motivate others:
Participant 10 outlines how clinical leaders’ role model approaches to dealing with day-to-day clinical presentations can influence the outcome for the consumer. A lot of it is common sense and instinct, for sure, but then there’s outstanding situations where you stand back and you watch somebody negotiate with a distressed person and it makes an impact, it leaves an impression and you take a lot away with you. I’ve learnt that way. I’ve had a lot of students talk to me regarding that; they like to watch a good clinician work. They get a lot of feedback from it and a lot of mileage. So it’s valuable.
I think someone who has the capacity to draw out the best in you. So they’re quite inspirational, and you look at them and it makes you feel like you want to do better yourself. . . . the best leaders that I’ve ever worked with have made me feel that way. They’ve made me go, ‘Oh, geez, I want to be the best that I can be’.
Reflecting on their own experiences, participant 3 outlines how important role models are for skill development. I think we focus on role models more than anything else. You can’t learn that skill from a textbook, and you blunder in the dark if you haven’t got somebody to teach you how to do this stuff.
The way clinical leaders in mental health nursing were seen to interact with others was deemed important as demonstrating, or role modelling, a sense of professionalism. Participant 3 describes how a clinical leader in mental health nursing has developed this sense of professionalism among peers. . . . one person who stood out for her skills. She’d been doing it for a lot of years. Her knowledge base was quite good; the way she carried herself, she was very professional; and she managed really safely and really well.
Clinical leaders in mental health nursing are seen by others as having and expecting high standards; for example, participant 5 states:
Clinical teaching Participants identified that clinical leaders were seen as effective clinical teachers. They were viewed as always being approachable, willing to share knowledge and identify learning opportunities for others. In describing effective clinical leaders in mental health nursing, participant 9 suggested: . . . the people that really stand out in my mind are the people who not only had . . . an amazing knowledge base, but were also prepared to facilitate your learning along the way.
A clinical leader’s attitude towards facilitating the learning of others is important. Participant 9 goes on to say that: . . . it’s about the [Clinical Leaders] persons’ willingness to be put in that role of mentor or preceptor.
Clinical leaders were seen by participant 11 as:
. . . they have standards and expectations, . . . and I think, they’re normally fairly high, of themselves as well as the people around them, their peers. . . .
. . . approachable and helpful and they will sit with people [undergraduate nurses/less experienced staff], and explain things and be patient. And knowing, I guess, in any team, knowing who those people are . . . and knowing that they are interested in that area and giving them opportunities to use their knowledge and share it, is really, really important.
Honesty, professionalism and integrity were considered an essential component for clinical leaders to be viewed as role models. Participant 4 reinforces this: Honesty. I think is absolutely categorically essential. I think that if you are going to be a good leader of any sort, whether it be in the clinical setting or in any area, you have to be honest, you have to accountable, you have to operate with integrity.
The following quote from participant 7 further highlights the link between honesty and clinical leadership as core to clinical leadership. Another thing that’s really, really important to me . . . is about integrity and honesty. So, being comfortable enough to advocate or speak openly and honestly with your peers about things . . . having that with honesty and integrity and mutual respect, all those sorts of things, all go together. And I think when you are a really good leader you have all those qualities. © 2015 John Wiley & Sons Ltd
The ability of clinical leaders in mental health nursing to be identifiable as colleagues who are willing and able to share information and experience in a supportive way is highlighted above. This is further reinforced by participant 6, who described clinical leaders in mental health nursing as: . . . prepared to share the information they know, and they’re interested in helping other people learn.
And: . . . people who are brilliant with the students, and they’re keen to teach them and keen to pass on their knowledge in a supportive and nurturing way and a bit mothering in a way as well.
Participant 12 reinforces this: 619
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. . . they [Clinical Leaders] impart knowledge without making the person they are imparting the knowledge to feel like they know bloody nothing. And what I’ve often said too, encouraging people to ask questions about clinical issues, to me, is a sign of a good clinical leader.
Discussion A supportive approach to the professional development of nursing staff and students has been identified in this study as an important attribute of effective clinical leaders in mental health nursing. Participants describe how clinical leaders use role modelling characterized by professionalism, honesty, willingness to share knowledge and approachability to influence the professional growth and development of staff. While other studies identify the importance and benefits of supporting professional development through the use of practice-based learning and role modelling (Armstrong 2008, Felstead 2013), it has not been previously identified specifically as an important characteristic of clinical leaders in mental health nursing. This approach to learning may in fact have increased importance in mental health nursing as it relies heavily on good communication skills and the therapeutic use of self (Dickinson et al. 2009, Cleary et al. 2012), concepts not easily taught in a classroom setting. Characteristics that had meaning and significance to participants in this study related to formal roles, such as clinical teaching, while others related to concepts that are less easy to identify, such as role modelling, professionalism and honesty. Role modelling has been identified as an essential method of teaching and imparting knowledge in clinical practice (Allan et al. 2008, Felstead 2013). The current study reinforces this. Furthermore, the significance of honesty and professionalism as characteristics of clinical leadership in mental health has been highlighted. Other studies have examined the importance of professionalism and honestly for nurses (Begley 2008, Hodkinson 2008, Stanley 2008, 2010, Hwang et al. 2009, Lloyd Storfjell & Christiansten 2010) but not in the context of clinical leaders enabling professional development in mental health nursing. Despite its identified importance for professional development, clinical leadership is poorly researched, and there are no formal programmes that aim to specifically develop clinical leadership in mental health nursing. This study establishes new evidence on the links between these attributes and effective clinical leadership in mental health nursing. These are significant new findings as they contribute to the growing evidence base on the relevance and importance of clinical leadership for nurses. Nurses working in mental health identify an interrelated and codependent set of attributes of clinical leadership as 620
opposed to individual characteristics. In essence, clinical leaders possess a combination of attributes that allows them to be effective enablers of clinical and professional development of less experienced staff and undergraduate nursing students. It is widely recognized that the therapeutic use of self is one of the skills that mental health nurses utilize in their clinical practice (Cleary et al. 2012, Ennis et al. 2014). The findings suggest that clinical leaders use this skill to demonstrate good clinical practice to influence the practice of less experienced staff or undergraduate nursing students. Developing clinical leadership is important for nursing as it has been shown to improve consumer outcomes, utilize evidence- base care, and assist in the recruitment and retention of nurses (Begley 2008, Hodkinson 2008, Hwang et al. 2009, Lloyd Storfjell & Christiansten 2010, Stanley 2010). A clearer understanding of the characteristics that clinical leaders need from the perspective of nurses working in mental health will assist in developing a skill set for the next generation of clinical leaders that builds on and strengthens the current evidence on this aspect of mental health nursing. This is imperative if a strong, effective mental health nurse workforce is to be sustained. The difficulties in attracting new graduates into mental health nursing have been extensively documented (Begley 2008, Hodkinson 2008, Hwang et al. 2009, Lloyd Storfjell & Christiansten 2010). Although the factors that influence the choices that undergraduates make in deciding what specialty they will choose are many (McKenna et al. 2010), there is ample evidence to suggest that the quality of clinical placement is a key influencing factor (Happell 2008, Zilembo & Monterosso 2008, McKenna et al. 2010). Undergraduate nurses commence mental health placements with anxieties and misconceptions about working with people with mental illness (Stevens et al. 2013). Approaches to learning that are enabling, supportive and role model mental health nursing favourably, enhance the clinical placement experience (Gough & Happell 2009, Happell & Gaskin 2012). Understanding the attributes nurses see as important in their clinical leaders is particularly important in mental health settings as it can directly impact on the career pathway of undergraduate nurses (Happell 2008, 2009, McKenna et al. 2010, Stevens et al. 2013). Clinical leaders can contribute to creating positive clinical environment for undergraduate nurses (Zilembo & Monterosso 2008, Happell & Gaskin 2012).
Implications for practice Clinical leaders have an important role to play in the development of the next generation of mental health nurses, in attracting new graduates into the profession and ensuring © 2015 John Wiley & Sons Ltd
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knowledge on what nurses delivering hands-on care in mental health settings identify as important for effective clinical leadership in mental health nursing.
that the existing nursing workforce has an opportunity to develop professionally. Although the literature describes the importance of clinical leadership in nursing, the impact on the professional development of other staff has not been considered. The current study identifies the role of effective clinical leaders in supporting and enabling a constructive environment to facilitate learning, and how this role contributes to them being seen as a clinical leader. Those deemed by their peers to be effective clinical leaders enable and support this professional development. Importantly, further research is needed to understand how clinical leaders develop these attributes and their usefulness, as a developable skill set, in influencing the next generation of clinical leaders. This paper highlights the pivotal role that clinical leaders have in mental health nursing. This work builds on the limited evidence base articulating the attributes and characteristics required for effective clinical leadership in this setting. Importantly, the paper adds new
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