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AN INDEPENDENT VOICE FOR NURSING

Staff Nurse Clinical Leadership: A Concept Analysis Eduardo C. Chávez, MSN, RN, and Linda H. Yoder, PhD, MBA, RN, AOCN, FAAN Eduardo C. Chávez, MSN, RN, is a Doctoral Candidate, School of Nursing, The University of Texas, Austin, TX; and Linda H. Yoder, PhD, MBA, RN, AOCN, FAAN, is Associate Professor, Director, Nursing Administration Concentration, School of Nursing, The University of Texas, Austin, TX. Keywords Clinical leadership, concept analysis, frontline leadership, leadership, staff nurse clinical leadership Correspondence Eduardo C. Chávez, MSN, RN, School of Nursing, The University of Texas, Austin, TX E-mail: [email protected]

PURPOSE. The purpose of this article is to provide a concept analysis of staff nurse clinical leadership (SNCL). A clear delineation of SNCL will promote understanding and encourage communication of the phenomenon. Clarification of the concept will establish a common understanding of the concept, and advance the practice, education, and research of this phenomenon. METHODS. A review of the literature was conducted using several databases. The databases were searched using the following keywords: clinical leadership, nursing, bedside, staff nurse, front-line, front line, and leadership. The search yielded several sources; however, only those that focused on clinical leadership demonstrated by staff nurses in acute care hospital settings were selected for review. FINDINGS. SNCL is defined as staff nurses who exert significant influence over other individuals in the healthcare team, and although no formal authority has been vested in them facilitates individual and collective efforts to accomplish shared clinical objectives. CONCLUSION. The theoretical definition for SNCL within the team context will provide a common understanding of this concept and differentiate it from other types of leadership in the nursing profession. This clarification and conceptualization of the concept will assist further research of the concept and advance its practical application in acute care hospital settings.

Aim or Purpose of Analysis The Institute of Medicine (IOM) report, To Err is Human: Building a Safer Health System (1999), said that in the United States, up to 98,000 deaths occurred each year as a result of medical errors. In addition, medical errors are responsible for more than one million injuries each year (IOM, 1999; Landrigan et al., 2010). The IOM (1999, 2001) reports gave impetus to several healthcare quality improvement strategies that focused on national healthcare policies, systems, and work environments (McKinney, 2011). Despite noted improvements of the quality of health care since the

publication of those IOM (1999, 2001) reports, healthcare quality continues to lag (McKinney, 2011). The IOM (1999) goal to reduce medical errors by half within 5 years has not been achieved (Burhans & Alligood, 2010; Clarke & Aiken, 2006), and rates of preventable harm caused by medical care remain high and commonplace in U.S. hospitals (Landrigan et al., 2010; McKinney, 2011). Although numerous patient quality initiatives have been placed into practice, meaningful improvements have not met expectations (Burhans & Alligood, 2010). Bohmer (2013) argued that the successful implementation of healthcare initiatives that are designed 1

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Clinical Leadership: A Concept Analysis for service improvement is dependent on the leadership of frontline clinicians or clinical leaders. Clinical leaders influence the effectiveness of patient care teams and local operations in clinical units (Bohmer, 2013). In essence, improving the quality of health care requires leadership by the people who do the day-to-day work (Blumenthal, 1996, p. 891). Despite the increasing attention and frequent use of the clinical leadership concept, its meaning continues to be unclear. This is especially true when clinical leadership is used in the staff nurse context. Malby (1998) recognized the use of the term clinical leadership as a means of identifying the leadership qualities of staff nurses at the point of patient care, and to differentiate staff nurse clinical leadership (SNCL) from the leadership of nurses in formal administrative roles. Since that time, clinical leadership has become a common concept that is used widely throughout the nursing literature, and in various distinct contexts to include administration and management, advanced practice, education, and several specialties. In addition, clinical leadership terminology commonly appears throughout the healthcare literature in other disciplines (Lett, 2002; Stanley, 2006). The overuse of this conceptual terminology causes confusion and impedes the development of theory, education, and practice implementations of SNCL. Therefore, the purpose of this article is to provide a concept analysis of SNCL using the methodology described by Walker and Avant (2005). The theoretical underpinnings of emergent leadership in teams were used to inform this concept analysis. Emergent leaders are described as group members who exert significant influence over other members of the group, although no formal authority has been vested in them (De Souza & Klein, 1995, p. 476). There are two major patterns that distinguish how an individual achieves legitimacy as a leader (Hollander, 1976). Emergent leaders gain legitimacy informally from the acceptance and support of other team members (De Souza & Klein, 1995; Hollander, 1976, 1978). In contrast, formal leaders gain legitimacy by formal appointment rather than from team member support (De Souza & Klein, 1995; Hollander, 1976, 1978). Despite the original source of legitimacy, the maintenance of leadership for both emergent and formal leaders is contingent upon intra-team relationships (De Souza & Klein, 1995; Hollander, 1976, 1978). These intra-team relationships are based on the leader’s behaviors and the team members’ perceptions of these behaviors (De Souza & Klein, 1995). 2 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume ••, No. ••, ••-•• 2014

E. C. Chávez et al. The focus of emergent leader research has taken place primarily in the team/group context. Emergent leaders have been recognized to be as important in facilitating team task completion as formally appointed leaders (De Souza & Klein, 1995; Taggar, Hackett, & Saha, 1999). Teams are described as a group of individuals who assume responsibility for completion of various tasks, maintenance of team functions, work allocation, and problem solving in unstructured situations (Taggar et al., 1999). In addition, the role of leadership in teams involves the facilitation of the team process, and has been linked to both individual (i.e., emergent leader) and team performance (Taggar et al., 1999). The notion of emergent leadership is consistent with the type of work that takes place in SNCL regarding the nature of team integration and task completion in nursing. The role of clinical staff nurses in acute care hospital settings in the United States typically does not encompass a formal appointment of leadership or authority over individuals. Staff nurses are the linchpin of interprofessional collaborative healthcare teams that deliver direct patient care. Staff nurses work in highly autonomous clinical environments that require critical decision-making and problem-solving situations that are not well structured by clinical protocols (Bohmer, 2012). Staff nurses oversee the completion of various patient care tasks and procedures, and directly manage the provision of patient care. In the delivery of frontline patient care, staff nurses frequently engage in real-time problem solving and decision making for problems that do not have well-defined solutions.

Methods The concept analysis methodology described by Walker and Avant (2005) will be used to explain the concept of SNCL. The literature review was completed using the following databases: Academic Search Complete, Business Source Complete, Cumulative Index to Nursing and Allied Health Literature, Education Resource Information Center, Medline, Military and Government Collection, Professional Development, Science and Technology, PsycINFO, and Vocational and Career Collection. Each database was searched using the following keywords: clinical leadership, nursing, bedside, staff nurse, front-line, front line, and leadership. The search was not limited to any time period. The initial search contained 646 citations after excluding non-English language and duplicate citations. The

E. C. Chávez et al. primary screen consisted of reviewing titles and abstracts of the citations; articles were excluded if they were identified as advertisements, book reviews, interviews, conference proceedings, dissertations, articles not related to leadership in health care or allied health, and citations that were unable to be obtained for review. After the primary screen, 223 citations qualified for the secondary screening. The secondary screen consisted of a full-text review of the citations. During this screen, the goal was to exclude articles if they were determined to not be related to the topic and if clinical leadership was not primarily focused on the role of clinical staff nurses in hospital settings. A total of 14 articles were identified as articles that discussed clinical leadership within the context of the staff nurse, and they were used in this concept analysis. Uses of the Concept In the nursing literature, the concept clinical leadership originated from the need to differentiate the leadership potential of nurses at the bedside from the conventional leadership function of nurses in formal positions of authority within the organization (Malby, 1998). Subsequently, clinical leadership has been used in the literature to describe the leadership qualities of clinical staff nurses in the hospital setting (Adeniran, Bhattacharya, & Adeniran, 2012; Ågård & Lomborg, 2011; Cook, 2001; Cook & Leathard, 2004; Hyrkäs & Dende, 2008; Ioannilli, 1996; Lett, 2002; Patrick, Laschinger, Wong, & Finegan, 2011; Pepin, Dubois, Girard, Tardif, & Ha, 2011; Stanley, 2004, 2006; Supamanee, Krairiksh, Singhakhumfu, & Turale, 2011). In addition, the literature demonstrates that clinical nursing leadership and nursing leadership are terms that are sometimes used interchangeably with SNCL, generating inconsistencies in the language and confusion about the meaning of this phenomenon. A dictionary definition for clinical leadership provided a basic definition for the individual terms clinical and leadership that did not fully explicate the meaning of the concept. The online Oxford English Dictionary defined clinical as “pertaining to the sick-bed, specifically to that of indoor hospital patients” (Clinical, 2012). Leadership was defined as the “ability to lead; the position of a group of people leading or influencing others within a given context; the action or influence necessary for the direction or organization of effort in a group undertaking” (Leadership, 2012). Cook’s (1999) description of a leader in nursing provided a fundamental perspective for the concept

Clinical Leadership: A Concept Analysis of staff nurse clinical leadership. Later, Cook (2001) suggested that a clinical leader in nursing is “a nurse directly involved in providing clinical care that continuously improves care through influencing others” (p. 39). Essential to Cook’s definition are the elements of direction, influence, and empowerment of staff nurses (Cook, 2001). Stanley (2006) described staff nurse clinical leaders as expert nurse clinicians who are approachable, effective communicators, and empowered such that they are “able to act as a role model, motivating others by their values and beliefs about nursing and care to their practice” (p. 111). Other descriptions offer a social process perspective of SNCL. Hyrkäs and Dende (2008) suggested that SNCL is a complex social process that comprises cultural, organizational, practice setting, and situational factors. More recently, Patrick et al. (2011) suggested that it is “a process of leadership demonstrated in the leader behaviors of staff nurses providing direct patient care” (p. 450) that engages clinical clients as well as other individuals within the healthcare team. Practicing clinical leadership, as described by Ågård and Lomborg (2011), is staff nurse involvement in basic social processes to manage the healthcare needs of patients and their families. The literature indicates a considerable lack of consensus among descriptions of SNCL. While the descriptions identify attributes of SNCL and elements of the social process of the concept, they do not fully describe SNCL as individual team members who emerge as informal leaders. For the purposes of this concept analysis, no single definition that captured the essence of the concept in its entirety was identified. Therefore, the following working definition for SNCL is proposed: the process by which staff nurses exert significant influence over other individuals in the healthcare team, and although no formal authority has been vested in them facilitate individual and collective efforts to accomplish shared clinical objectives. An important distinguishing characteristic of SNCL is the manner in which the individual staff nurse clinical leader comes to be in a leader role or has achieved legitimacy as a leader (Hollander, 1976, p. 510). A key distinction between SNCL and other forms of nursing leadership is in the means by which the individual leader has achieved legitimacy as a leader (i.e., influence). As emergent leaders in healthcare teams, staff nurse clinical leaders first achieve legitimacy as a leader by virtue of the support from other members of 3

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Clinical Leadership: A Concept Analysis

E. C. Chávez et al.

Figure 1. Antecedents, Attributes, and Consequences of Staff Nurse Clinical Leadership in a Hospital Clinical Unit Environment Organizational culture

Antecedents

Integrative collaborative health care team

Attributes

Consequences

Leader status attainment

Facilitation of individual/team-level acheivement of shared clinical objectives

- clinical ability - effective communication - relational coordination

Maintenance of team processes

Professional nursing competence Leader status maintenance Structural empowerment

- ability to produce innovation - ability to produce change

the healthcare team. Conversely, nurses in formal leadership roles first achieve legitimacy as leaders by their formally appointed positions of authority and not from the support of the members of the healthcare team (De Souza & Klein, 1995; Hollander, 1963, 1976; Neubert & Taggar, 2004; Taggar et al., 1999). Defining Attributes Defining the essential attributes of SNCL assists the identification and understanding of the concept (Walker & Avant, 2005). Recognition of these attributes also assists with differentiation of SNCL from other uses of clinical leadership and other types of leadership in nursing. Emergent leadership is described by the interrelation of two processes: status attainment and status maintenance (Hollander, 1971). For the purpose of this concept analysis, the description of these two processes provided by Hollander (1971) will be used. Status attainment is the process that is necessary for an individual to gain status as a leader and emerge as a leader among the healthcare team. Status maintenance is the process that is necessary for the emergent leader to retain his/her influence as a leader among the healthcare team (Hollander, 1971) (Figure 1). 4 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume ••, No. ••, ••-•• 2014

Efficiency of health care team Higher quality of work life

Leader Status Attainment Most staff nurses have qualities that are associated with leadership, but some staff nurses may demonstrate more of these perceived leadership qualities and leadership behaviors more often than others (Patrick et al., 2011; Taggar et al., 1999). Despite not having been previously examined through the lens of emergent leadership, the literature suggests that there are defining attributes of SNCL that determine leader status attainment for staff nurses in healthcare teams in acute care hospital settings. Therefore, the following preliminary defining attributes of SNCL are considered factors that determine leader status attainment: (a) clinical ability (b) effective communication, and (c) relational coordination. Clinical ability. Although staff nurses’ roles in acute care hospital settings involve clinical practice, status attainment of the staff nurse clinical leader requires excellent clinical ability (Davidson, Elliot, & Daly, 2006; Patrick et al., 2011; Stanley, 2004, 2006; Supamanee et al., 2011). Clinical ability involves both clinical knowledge and hands-on clinical skills. Different clinical settings and situations involve different tasks, goals, and conditions to be fulfilled. This was demonstrated by Stanley’s (2006) findings that staff

E. C. Chávez et al. nurses perceived as clinical leaders had gained clinical credibility in their specific clinical area. The notion of clinical ability is supported by the emergent leadership research, which has frequently associated task ability with the emergence of leadership recognition (Carter & Nixon, 1949; De Souza & Klein, 1995; Hollander, 1963, 1976). Effective communication. Staff nurse clinical leaders establish interpersonal relationships with the healthcare team through effective communication (Lett, 2002; Patrick et al., 2011; Stanley, 2006; Supamanee et al., 2011). Effective communication involves both listening skills and clear articulation of information (Patrick et al., 2011; Stanley, 2006). In addition, staff nurse clinical leaders’ ability to effectively communicate influences their ability to share clinical observations and opinions (Stanley, 2006) while inspiring and empowering others (Patrick et al., 2011). Hollander (1976) also recognized verbal effectiveness, especially for individuals who first initiate communication in groups, as an attribute of emergent leadership that is consistent across various situations. Relational coordination. Relational coordination is necessary for maximizing healthcare team performance in the acute care hospital setting (Gittell, 2009). It is defined as the management of interdependent relationships between people performing interdependent tasks (Gittell, 2009). Therefore, relational coordination is critical in work environments, such as acute care hospital settings, that are characterized by high divisions of labor, multiple interdependent tasks, transmission of information, and uncertain outcomes (Gittell, 2009). In the clinical leadership literature, relational coordination is denoted by the concepts of collaboration and coordination (Davidson et al., 2006; Patrick et al., 2011; Supamanee et al., 2011). Patrick et al. (2011) suggested that clinical leaders demonstrate behaviors that influence others to see and understand clinical situations from various perspectives. However, descriptions of the specific relational coordination behaviors of staff nurse clinical leaders are scarce and require further explication.

Clinical Leadership: A Concept Analysis being perceived as a leader requires status maintenance (Hollander, 1971). Status maintenance is influenced by the effective management of innovation and change. Implementation of innovation and change within the team is guided by the emergent leader. It is required that the emergent leader manage innovation and change in a way that is perceived as consistent with the healthcare team’s social norms and needs. Status maintenance reflects the team’s continued support and willingness to follow the emergent leader over time and throughout various situations (De Souza & Klein, 1995; Hollander, 1971). Healthcare organizations are rapidly changing and are increasingly complex (Bohmer, 2012, 2013; Gittell, 2009; IOM, 2011). Healthcare teams are under intense pressure for cost reduction and quality improvement (Gittell, 2009) in environments that present clinical problems that are not well defined by science and clinical protocols (Bohmer, 2012). Therefore, staff nurse clinical leaders who effectively implement innovation and change at the point of care are most likely to maintain their status and credibility as clinical leaders. Cook (2001) identified innovation in staff nurse clinical leaders as having the ability to see what is new, seek new possibilities, generate new ways of working, and challenge the “taken for granted” (p. 34). In addition, staff nurse clinical leaders demonstrated the attribute of change through their support of others through the change processes. Davidson et al. (2006) also emphasized that innovation is a defining attribute of staff nurse clinical leaders; however, an explication of what “innovation” meant was not provided. Antecedents The antecedents of a concept are those conditions or experiences that must occur prior to the concept in order for the concept to exist (Walker & Avant, 2005). Although the antecedents of clinical leadership are necessary for clinical leadership to occur, the antecedents themselves do not qualify as attributes of clinical leadership. The following antecedents of SNCL were identified: (a) integrative collaborative healthcare team, (b) professional nursing competence, and (c) structural empowerment.

Leader Status Maintenance Integrative Collaborative Healthcare Team Innovation and change management. Although the process of leader status attainment is a continuous process, once the status is attained the preservation of

Staff nurse clinical leaders are leaders who emerge from integrative collaborative healthcare teams. These 5

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Clinical Leadership: A Concept Analysis integrative collaborative healthcare teams comprise the small group of individuals who work together to actually deliver care that the patient receives in the acute care hospital setting (Bohmer, 2012; Nelson, Godfrey, Batalden, Godfrey, & Lazar, 2011). In addition, team members engage in autonomous interdependent work that involves team-level decision making under conditions that often present poorly structured problems (Bohmer, 2012; Taggar et al., 1999). Integrative collaborative healthcare teams are believed to be necessary for the complex interpersonal processes that lead to the emergence of leadership of staff nurse clinical leaders (Gittell, 2009). Professional Nursing Competence Professional nursing competence is required of all staff nurses and it is an antecedent of SNCL. The American Nurses Association’s (2010) Nursing: Scope and Standards of Practice describes professional competence in nursing practice as professional performance that is achieved by effective integration of knowledge (e.g., act of thinking, understanding of standards of practice, insights gained from contextual clinical situations, practical experience, and personal capabilities), skills (e.g., psychomotor, communication, interpersonal, and diagnostic capabilities of the staff nurse), individual abilities (e.g., listening skills, integrity, selfawareness, emotional intelligence, and openness to feedback), and judgment (e.g., critical thinking, problem solving, decision making, and ethical reasoning). Professional nursing competence provides the foundation that staff nurse clinical leaders build upon to develop the professional qualities that later distinguish them as emergent clinical leaders in the healthcare team. The specific professional competencies required for SNCL will vary according to the situation and the social interactions within the healthcare team. Therefore, professional nursing competence is an antecedent to SNCL. Structural Empowerment Structural empowerment is recognized in organizations that provide employees with access to resources needed to support their work (Kramer & Schmalenberg, 2003). These empowerment structures influence the extent to which staff nurses are able to work effectively and thrive in the workplace (Kanter, 1993; Patrick et al., 2011). In addition, organizational 6 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume ••, No. ••, ••-•• 2014

E. C. Chávez et al. empowerment structures influence the degree to which employees perceive the power to accomplish their work (Kanter, 1993; Kramer & Schmalenberg, 2003; Patrick et al., 2011). Empowering work environments influence collaboration, coordination, and achievement of patient care goals (Laschinger & Havens, 1996; Patrick et al., 2011; Stewart, Stansfield, & Tapp, 2004). Magnet hospitals are recognized for having structures, such as shared governance, that involve staff nurses in organizational decision making, and therefore create empowering work environments that enable nurses to use their skills, knowledge, and expertise to influence their practice and provide quality patient care (Kramer & Schmalenberg, 2003; Upenieks, 2002).

Consequences The events or outcomes that occur as a result of the concept are considered consequences (Walker & Avant, 2005). Although the literature lacks empirical evidence and explication of the consequences of SNCL, four consequences of SNCL within the context of healthcare teams in acute care hospital settings are conceptualized. The proposed consequences for SNCL are the following: (a) facilitation of individual- and team-level achievements of shared clinical objectives, (b) maintenance of team processes, (c) efficiency of the healthcare team, and (d) higher quality of work life.

Facilitation of Individual- and Team-Level Achievement of Shared Clinical Objectives A central function of leaders who emerge from teams is to direct team activities (Hollander, 1976). Emergent leaders are team members who are most likely to influence the activities of other team members (De Souza & Klein, 1995). Furthermore, emergent leadership is associated with both individual and team performance (Cohen, Chang, & Ledford, 1997; Taggar et al., 1999). Bohmer (2013) emphasized that clinicians leading at the point of care are necessary for achieving the healthcare team’s shared clinical objectives. Therefore, staff nurses who engage in leadership and emerge as staff nurse clinical leaders are more likely to achieve their individual clinical objectives in addition to facilitating the clinical goals of integrated collaborative healthcare teams.

E. C. Chávez et al. Maintenance of Team Processes Leadership in teams influences the facilitation of team processes (Taggar et al., 1999). Team processes may include initiation and formulation of goals, interaction between team members, identification of the necessary resources for completion of clinical goals, fostering openness to different points of view, and consensus building among team members (Neubert & Taggar, 2004; Taggar et al., 1999; Yukl, 2005). Hollander (1976) noted that a team’s pattern of interaction is shaped by emergent leaders. Therefore, SNCL leads to sustainment of healthcare team processes that work for the benefit of the team and provision of quality patient care. Efficiency of Healthcare Team SNCL improves the efficiency of healthcare team operations (Bohmer, 2012, 2013). The efficiency of healthcare teams can be largely influenced by the staff nurse clinical leader’s influence on relational coordination (Gittell, 2009). The staff nurse clinical leader’s high level of coordination of tasks and interprofessional collaboration, or relational coordination, results in more efficient coordination of care and timely communication among members of the healthcare team (Gittell, 2009). For example, a staff nurse clinical leader’s ability to acquire and coordinate resources (i.e., material resources such as clinical equipment, and human resources such as a respiratory therapist) improves team readiness to address specific clinical demands. Higher Quality of Work Life There is evidence that individuals in self-managing teams are associated with higher quality of work life when compared with traditionally managed teams (i.e., teams that are characterized as highly autonomous and demonstrating self-leadership without necessarily functioning in complete absence of a formal manager vs. teams with low autonomy under the closer direction of an external or non-team member manager) (Cohen et al., 1997). Cohen and associates measured the quality of work life as four domains, to include job satisfaction, social needs satisfaction, group satisfaction, and organizational commitment. Overall, self-managed team members rated their quality of work life as better than individuals in traditionally

Clinical Leadership: A Concept Analysis managed teams; however, these differences were only significant for the domains of social needs satisfaction and organizational commitment (Cohen et al., 1997). It is expected that a staff nurse who is able to attain and maintain status as a leader in a healthcare team will, in general, experience more control and empowerment in the workplace, and therefore also experience a higher quality of work life (Kramer & Schmalenberg, 2003, 2008; Kramer et al., 2008). Cases The following is a model case that demonstrates all of the defining attributes of the concept (Walker & Avant, 2005). Jennifer is a staff nurse in a medical-surgical unit at Hospital A (HA). As a staff nurse, Jennifer’s primary role is to deliver direct patient care, and she is a member of an integrative collaborative healthcare team that delivers direct patient care. Jennifer chose to work at HA because it has adopted an organizational model that provides staff nurses with a voice in organizational decision making through shared governance, provides resources for professional development, and is focused on improving the image of nursing. Jennifer becomes active in the shared governance process by attending and participating in monthly meetings. She also takes advantage of professional development resources offered by HA, such as self-paced education modules related to topics such as leadership, conflict communication, and ethics, and topics related to her specific clinical area. Building on her foundation of professional nursing competencies and the influence of empowering structures at HA, Jennifer is able to excel at skills that are critical in her clinical specialty. Other members of the healthcare team become aware of Jennifer’s abilities as a clinician, as well as her ability to effectively communicate and effectively manage the coordination of shared tasks among various clinical and non-clinical staff (i.e., relational coordination). As a result, Jennifer begins to be perceived as a leader (i.e., status attainment). After a certain period of time, Jennifer’s legitimacy as a leader becomes dependent on her ability to preserve her leadership status in a healthcare environment that frequently experiences change and is under constant pressure to improve the quality of care. A new patient care policy requires drastic change in the way that care is provided in Jennifer’s unit. Jennifer promptly initiates problem-solving strategies and organizes a special committee with other members of 7

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Clinical Leadership: A Concept Analysis the healthcare team. After two short meetings, the special committee is able to propose a new patient care protocol that is evidence-based and aligns with the new patient care policy. Jennifer’s unique insight as a staff nurse was incorporated in the development of the new patient care protocol in her unit. Jennifer also takes the lead for introducing the new protocol to other staff nurses in her unit. The new patient protocol was well accepted by the nursing staff and its implementation was successful. The success of the new protocol was largely influenced by Jennifer’s leadership regarding innovation and change. Her support and reputation as a staff nurse clinical leader were maintained. Jennifer’s role as a staff nurse clinical leader enabled her and the healthcare team to achieve patient care objectives. Her leadership role with the development of the new protocol resulted in the maintenance of team processes, such as improved communication, collaboration, encouragement of diverse ideas, and organization of new ideas that were essential to the development of the new protocol. Jennifer’s leadership in innovation and change resulted in timely and efficient healthcare team operations that produced the new protocol. In addition, her ability to influence and have a certain level of control over her practice and work environment led to higher satisfaction with her work, relationships with coworkers, as well as her life outside of her job. Contrary Case Mindy is a staff nurse in a medical-surgical unit at Hospital B (HB). As a staff nurse, Mindy’s primary role is to deliver direct patient care. Although HB advocates integrative collaborative healthcare teams, Mindy has discovered that there is poor collaboration between the different clinical specialists. For example, she often finds it difficult to have discussions with the medical staff regarding the plan of care for her patients. Mindy also has learned that there are limited organizational resources for staff nurses at HB. Mindy was disappointed when she was told that HB did not offer continuing education materials for staff nurses. In addition, Mindy realized that there were no formal structures for staff nurses to influence their professional practice at HB. As a result, Mindy found it difficult to expand and build on her basic nursing competencies. Her professional experience at HB does not result in her emergence as a staff nurse clinical leader. 8 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume ••, No. ••, ••-•• 2014

E. C. Chávez et al. A new patient care policy requires drastic change in the way that care is provided in Mindy’s unit. Although Mindy tries to initiate a plan, she is met with resistance from other clinical disciplines and other nursing peers. After a week, the medical group introduces a new patient care protocol to meet the needs of the new policy. The nursing staff report that this policy is very physician-centric and they are slow to adapt to the new protocol. As a result, clinical objectives are not met, and the quality and safety of patient care are compromised. Mindy continued her role as a staff nurse, but the lack of organizational support and teamwork undermined her emergence as a staff nurse clinical leader.

Empirical Referents Empirical referents are measurable categories of the concept and can allow the demonstration of how the concept actually exists (Walker & Avant, 2005). To date, there are no instruments that measure SNCL or capture the meaning of the concept in its entirety. Patrick et al. (2011) described the development of the Clinical Leadership Survey (CLS), an instrument based on Kouzes and Posner’s Five Practices of Exemplary Leadership model. The CLS measures five domains derived from the literature that aligned with Kouzes and Posner’s model; these domains include clinical expertise, interpersonal understanding, effective communication, and collaboration (Patrick et al., 2011). These domains are measured as subscales of the CLS, and each subscale consists of three questions. Although the CLS includes the domains of clinical expertise and effective communications, which are similar to the attributes clinical ability and effective communication described in this concept analysis, they do not reflect the essence of SNCL as a phenomenon of emergent leadership within the healthcare team. The relational coordination survey has been used across airline, business, and healthcare industries to measure the management of interdependencies between people performing interdependent tasks for a common outcome (Gittell, 2009). The relational coordination survey measures elements of relationships and communication between defined groups of individuals, such as a healthcare team. Relationships are measured as shared goals, shared knowledge, and mutual respect. Communication is measured by the following qualities: frequency, timeliness, accuracy, and problem solving (Gittell, 2009). Although the

Clinical Leadership: A Concept Analysis

E. C. Chávez et al. relational coordination survey measures components of SNCL, it also does not capture the concept in its entirety. The science regarding SNCL is still in early stages of its development. The available literature does not offer an instrument that measures all of the defining attributes of SNCL, and it does not provide an instrument that approaches the concept of SNCL as a form of emergent leadership. Furthermore, more work is needed to develop measures that reflect the attributes of SNCL.

2005). In acute care hospitals, organizational culture centers on the quality and safety of patient care (Kramer, Schmalenberg, & Maguire, 2004). Organizational culture is influenced by leaders and influences leadership behaviors across the organization (Cassida & Pinto-Zipp, 2008; Tsai, 2011). Although it is within the purview of nursing leaders to help create and alter organizational culture, the responsibility of bringing this culture to the front lines of hospital-based health care rests with staff nurses (Kramer et al., 2004). Conclusion

Discussion The inherent difficulty of defining the concept of leadership affects the ability to explicate SNCL (Yukl, 2005). Scholars have been unable to identify a universal theory of leadership (Kilburg & Donohue, 2011; Yukl, 2005); as a result, the meaning of leadership remains highly subjective to individual perspectives and multiple definitions for leadership have been proposed (Yukl, 2005). However, common to most definitions are the assumptions that leadership involves intentional influence exerted by one person over other people to guide, structure, and facilitate activities and relationships in a group or organization (Cook, 2001; Patrick et al., 2011; Stanley, 2006; Yukl, 2005). This is consistent with the notion that staff nurses can be leaders who focus on provision of quality and safe patient care. However, much of what is known about SNCL is derived from a relatively small body of literature that does not include staff nurses in the United States. In addition, this literature is primarily based on opinion and very few sources that provide empirical evidence. Moreover, most of the current empirical knowledge of SNCL in acute care hospital settings is based on the works of Cook (1999) and Stanley (2004, 2006) that were conducted in the United Kingdom. Therefore, the capacity to make inferences about SNCL between international nursing workforces that have different professional scopes of practice, cultures, and function within fundamentally different national healthcare systems is limited. It is also important to consider that SNCL occurs within the context of organizational culture. Organizational culture defines the values, assumptions, and beliefs of an organization, thereby influencing the sense of how things should be done within that organization (Scott-Findlay & Estabrooks, 2006). It drives how organizations and units within organizations understand and respond to the environment (Yukl,

This concept analysis presented the concept of SNCL by identifying defining attributes, antecedents, consequences, empirical referents, and a model case. Clarification of the basic elements of the concept will advance the application of SNCL to improve the quality of direct patient care that is delivered by healthcare teams in acute care hospital settings. This concept analysis is also useful for clarifying the difference between SNCL and other similar terms, such as the American Association of Colleges of Nursing’s clinical nurse leader. In addition, it clearly explicates the distinction of SNCL from other catchphrase (Walker & Avant, 2005) terms in the literature that have lost their specific meaning, such as clinical leadership. Delineation of the meaning, structure, and function of the concept contributes to the advancement of SNCL practice, education, theory development, and research. Staff nurses can use the attributes of the concept as a foundation for their practice and role as an emergent leader in healthcare teams. Nurse educators may use the various components of the concept analysis to educate staff nurses about their unique leadership potential as emergent leaders in healthcare teams. The science of SNCL is emerging and more work is still needed. Therefore, nurse researchers may also use the various components of this concept analysis as a foundation for further theory development and research of SNCL. Acknowledgments. The authors would like to thank the Jonas Center for Nursing Excellence and Jennifer Murray-Chavez. This work was facilitated through the Jonas Nurse Leader Scholarship. References Adeniran, R. K., Bhattacharya, A., & Adeniran, A. A. (2012). Professional excellence and career advancement in 9

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Staff nurse clinical leadership: a concept analysis.

The purpose of this article is to provide a concept analysis of staff nurse clinical leadership (SNCL). A clear delineation of SNCL will promote under...
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