Understanding strategies that foster nurses to act as clinical leaders in hospitals: A realist review.

AIM: To identify strategies that develop clinical nursing leadership competencies among staff nurses, and to explain the contextual elements and mechanisms that underpin the development of clinical nursing leadership competencies. DESIGN: Realist review according to the Realist and Meta-narrative Evidence Syntheses-Evolving Standards (RAMESES). DATA SOURCES: PubMed, Embase, CINAHL, Web of Science, Wiley Online Library, PsycInfo and ProQuest were searched from January 2000 until October 2022. REVIEW METHODS: Three iterative phases: (1) development of initial programme theory, (2) structured searches for relevant published and grey literature and (3) data synthesis and interpretation by researchers and theory triangulation, and discussions within the research group. RESULTS: Multiple context-mechanism-outcome configurations were extracted from 10 reports that explain how, under what circumstances and why strategies can facilitate (or discourage) staff nurses to act as clinical leaders. Reports were both quantitative and qualitative in design, originating from English-speaking countries only. CONCLUSIONS: A logic model was developed and suggests four contexts and five mechanisms underlying the development of clinical nursing leadership. Growth in clinical nursing leadership was mainly experienced through experiential learning, which was enhanced by a supportive relationship with a coach or mentor, the use of reflective practices and modelling from other leaders. Furthermore, a supportive work environment triggers ownership, confidence and motivation, and thereby growth in clinical nursing leadership competencies. IMPACT: Fostering competencies for clinical leadership among staff nurses requires multifaceted strategies. Strategies are successful if, and only if, they combine learning by doing, by knowing and by observing, and establish a responsive work environment. Hospital policy should ensure that staff nurses have access to reciprocal relationships with role models or a coach. In order to grow as clinical nurse leader, ownership and self-reflection on own leadership behaviour need to be facilitated. NO PATIENT OR PUBLIC CONTRIBUTION: Prospero ID CRD42021292290.

A Resident-as-Leader Curriculum for Managing Inpatient Teams.

PROBLEM: Leading inpatient teams is a foundational clinical responsibility of resident physicians and leadership is a core competency for inpatient physicians, yet few training programs have formal leadership curricula to realize this clinical skill. INTERVENTION: We implemented a 4-module curriculum for PGY1 internal medicine residents. The program focused on the managerial skills necessary for daily clinical leadership, followed by clinical coaching. Interns were first introduced to foundational concepts and then given the opportunity to apply those concepts to real-world practice followed by clinical coaching. CONTEXT: Using direct-observations and a previously published checklist for rounds leadership, this study sought to evaluate the workplace behavior change for novice residents leading inpatient teams for the first time. We conducted a prospective cohort study (March 2016 and August 2018) of internal medicine residents at a large tertiary academic medical center in Boston, MA. Trained faculty raters performed direct observations of clinical rounding experiences using the checklist and compared the findings to historical and internal controls. Questionnaires were distributed pre- and post- curriculum to assess satisfaction and readiness to lead a team. IMPACT: We trained 65 PGY1 residents and raters conducted 140 direct observations - 36 in the intervention group and 104 among historical controls. The unadjusted mean score in rounds leadership skills for the intervention group was 19.0 (SD = 5.1) compared to 16.2 (SD = 6.2) for historical controls. Adjusting for repeated measures, we found significant improvement in mean scores for behaviors linked to the curricular objectives (p = 0.008) but not for general behaviors not covered by the curriculum (p = 0.2). LESSONS LEARNED: A formal curriculum to train residents as leaders led to behavior change in the workplace in domains essential to rounds leadership. We also found that the curriculum was highly regarded in that all interns indicated they would recommend the curriculum to a peer. Moreover, the program may have assuaged some anxiety during the transition to junior year as 90% of interns surveyed felt more ready to start PGY2 year than historical trainings. We learned that while a robust, multi-faceted modular curriculum and clinical coaching successfully resulted in behavior change, the resources required to manage this program are significant and difficult to sustain. Future iterations could include asynchronous material and potentially peer-observation of rounds leadership to reduce the burden on faculty and program curricular time.

A comparative study of clinical leadership needs analysis (CLeeNa) as perceived by nurses.

AIMS: This study aimed to analyse nurses' perceptions of clinical leadership needs and compare their differences based on the sample's characteristics. Also, it aimed to compare nurses' perceptions of clinical leadership needs between nurses and nurse managers. BACKGROUND: Various professional organisations have identified the need to develop clinical leaders. Clinical leadership is about having clinical expertise in specialised fields and having professionals involved in clinical care. However, worldwide, little emphasis is placed on the clinical leadership needs of nurses. METHODS: Using STROBE (https://www.strobe-statement.org/index.php?id=available-checklists), a cross-sectional study was conducted in 2020 using a purposive sample of 349 Jordanian nurses who were surveyed using the CLeeNA instrument. Different descriptive and inferential statistics were used to analyse the data. The response rate in the current study was 69.8%. RESULTS: The 7-point CleeNa scale was reduced into 3 categories 1 = "not important (1-3)," 2 = "Neutral (4)" and 3 = "highly important (5-7)." The total mean score of perceived CleeNa was 2.61(SD = 0.50) indicating "very important." The highest perceived mean score of the subscales was for "leadership and clinical practice." In contrast, the lowest perceived mean score of the subscales was "financial and service management." The total mean scores of perceived CleeNa were higher among married nurses, nurse managers, those who have a master degree or more, aged 35 years or more, had more than 4 years of nursing experience or/and more than 4 years of leadership experience, supervised more than 10 employees and were working in teaching hospitals. The total mean scores of perceived CleeNa scale and subscales of staff and team development, patient safety and risk management, and perceived standards of care were higher among nurse managers when compared with nurses. CONCLUSION AND RELEVANCE TO CLINICAL PRACTICE: Results indicated that innovative clinical leaders are needed. A paucity of research identifies the extent to which clinical leadership is enacted in clinical nursing practice. Developing a clinical leadership programme is warranted to contribute positively to nurses' leadership roles and outcomes, patients' outcomes, and in turn, organisational outcomes.

Advanced practice role delineation within Hong Kong: A cross-sectional study.

A career ladder for nurses, including several levels of nursing practice and specific roles for advanced practice nurses, was introduced in Hong Kong around the start of the 21st century. To date no studies have distinguished the practices of advanced practice nurses in Hong Kong. This cross-sectional study, conducted between November 2020 and March 2021, aims to identify and differentiate the practice patterns of advanced practice nurses by utilizing the Advanced Practice Role Delineation tool. A total of 191 responses were obtained. Three roles were identified: nurse consultant, advanced practice nurse, and advanced practice nurse in management. Among the five advanced practice nursing domains, nurses were most frequently involved in Education and in Direct Comprehensive Care activities, while least active in Research and in Publication and Professional Leadership. Identifying activities in various nursing roles helps to differentiate their responsibilities and provides new insights for role utilization and support. Although the role characteristics are shaped by country contexts, research evidence on practice patterns may be used to support international discussion and efforts to promote role clarity and effective role introduction and optimization.

Nurses' clinical leadership in the hospital setting: A systematic review.

AIM: This study aims to identify the most effective interventions to facilitate nurses' clinical leadership in the hospital setting. BACKGROUND: There is a gap in the literature on the identification and measurement of effective interventions for leadership skill development among clinical nurses in hospitals. To the best of our knowledge, no systematic review has been performed on this issue. EVALUATION: A systematic review was conducted. The PubMed, CINAHL, PsycINFO and Cochrane databases were reviewed. Data extraction, quality appraisal and narrative synthesis were conducted in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. KEY ISSUES: The evidence reveals that interventions designed to promote nurses' clinical leadership are complex, requiring that cognitive, interpersonal and intrinsic competencies as well as psychological empowerment, emotional intelligence and critical reflexivity skills be addressed. CONCLUSIONS: The development of multicomponent, theory-based and mixed-format programmes may be more suitable to facilitate nurses' clinical leadership in the hospital setting. IMPLICATIONS FOR NURSING MANAGEMENT: Strategies to facilitate nurses' clinical leadership in the hospital setting should address simultaneously the knowledge and ability of bedsides nurses to solve the practical problem collaboratively with a sense of control, competency and autonomy. Hence, it would promote high quality care, satisfaction and retention of bedside nurses.

Using practical wisdom to facilitate ethical decision-making: a major empirical study of phronesis in the decision narratives of doctors.

BACKGROUND: Medical ethics has recently seen a drive away from multiple prescriptive approaches, where physicians are inundated with guidelines and principles, towards alternative, less deontological perspectives. This represents a clear call for theory building that does not produce more guidelines. Phronesis (practical wisdom) offers an alternative approach for ethical decision-making based on an application of accumulated wisdom gained through previous practice dilemmas and decisions experienced by practitioners. Phronesis, as an 'executive virtue', offers a way to navigate the practice virtues for any given case to reach a final decision on the way forward. However, very limited empirical data exist to support the theory of phronesis-based medical decision-making, and what does exist tends to focus on individual practitioners rather than practice-based communities of physicians. METHODS: The primary research question was: What does it mean to medical practitioners to make ethically wise decisions for patients and their communities? A three-year ethnographic study explored the practical wisdom of doctors (n = 131) and used their narratives to develop theoretical understanding of the concepts of ethical decision-making. Data collection included narrative interviews and observations with hospital doctors and General Practitioners at all stages in career progression. The analysis draws on neo-Aristotelian, MacIntyrean concepts of practice- based virtue ethics and was supported by an arts-based film production process. RESULTS: We found that individually doctors conveyed many different practice virtues and those were consolidated into fifteen virtue continua that convey the participants' 'collective practical wisdom', including the phronesis virtue. This study advances the existing theory and practice on phronesis as a decision-making approach due to the availability of these continua. CONCLUSION: Given the arguments that doctors feel professionally and personally vulnerable in the context of ethical decision-making, the continua in the form of a video series and app based moral debating resource can support before, during and after decision-making reflection. The potential implications are that these theoretical findings can be used by educators and practitioners as a non-prescriptive alternative to improve ethical decision-making, thereby addressing the call in the literature, and benefit patients and their communities, as well.

Leadership self-perception of clinical nurses at the bedside: A qualitative descriptive study.

AIM & OBJECTIVE: Explore leadership self-perception of clinical nurses at the bedside and their perception of leadership on patient care and outcomes. BACKGROUND: According to Institute of Medicine Future of Nursing Report, nurses are called to exhibit leadership at every level. Published research on nursing leadership is primarily focused on formal leaders. Research examining leadership at the clinical nurse level has either tested application of a particular leadership model or studied nurses who have been identified as informal clinical leaders. We took an inductive approach without any prior knowledge if participating clinical nurses viewed themselves as leaders. DESIGN: Descriptive qualitative method was used. METHODS: Four focus groups were conducted with a total of 20 clinical nurses from 2 hospitals within an integrated health system using a convenience sampling method until saturation was reached. The Consolidated criteria for Reporting Qualitative research (COREQ) was used to report findings. RESULTS: All participants identified qualities they admired in leaders. Fifty percent did not initially view themselves as leaders until they realised that they often demonstrated those same leadership qualities in providing nursing care to patients and families. Participants struggled to make a connection between their leadership at the bedside and patient outcomes. CONCLUSIONS: Clinical nurses assume a formal title is required to be a leader. Findings from this study imply that leadership attributes required at point of care are embedded in the nursing practice and look similar to servant leadership. RELEVANCE TO CLINICAL PRACTICE: Leadership is in the nature of nursing practice, and more work is required to increase awareness that every nurse is a leader. Further efforts need to be pursued to help clinical nurses become self-aware they are leaders in order to impact patient outcomes and transform health care from bottom-up and inside-out.

The interprofessional Veterans Affairs Quality Scholars program pre- and postdoctoral nurse fellow outcomes.

BACKGROUND: The Department of Veterans Affairs (VA) Quality Scholars (VAQS) program, an interprofessional fellowship that includes pre- and postdoctoral nurses, aims to inspire practice change leaders. Fellows participate in a national curriculum, lead improvement/research teams, and establish professional development plans with expert mentor guidance. PURPOSE: To describe the distinctive elements of the VAQS program, nurse fellow outcomes, and accomplishments of nurse alumni as leaders, researchers, and educators. METHODS: Data were reviewed and aggregated from past and current fellow surveys. FINDINGS: Nurse fellows completed research and improvement projects that benefitted both the VA and the local health systems. Scholarly outcomes include publications, conference presentations, grant submissions, teaching/leading quality improvement, and research initiatives. Graduates transition to positions as nurse scientists, academic faculty, and operational leaders. DISCUSSION: Fellows contribute to the strategic priorities of local and national VA and external health care organizations providing a pipeline of health system expert leaders, educators, and researchers. CONCLUSION: Doctoral nursing fellowship experiences build human capital for enhancing the science of improvement and implementation, interprofessional collaboration, and leadership.

Understanding clinical leadership behaviors in practice to inform baccalaureate nursing curriculum: a comparative study between the United States and Australia novice nurses.

OBJECTIVES: While the nursing profession recognizes the importance of leadership behaviors, limited evidence exists on essential clinical leadership behaviors that nursing students should exhibit upon graduation. The purpose of this study was to determine if there were common leadership behaviors exhibited by recently graduated baccalaureate clinical staff nurses in the United States and Australia. METHODS: A quantitative descriptive study with a comparative design was conducted using The Clinical Leadership Survey. RESULTS: Similar clinical leadership behaviors were reported by nurses from the two countries though there was a statistically significant difference in the overall frequency of behaviors between the two groups. Behaviors in the 'challenging the process' domain were less commonly practiced in both countries, identifying a clinical gap and opportunity for student development. CONCLUSIONS: This study identifies the central behaviors that should be included in baccalaureate nursing education curriculum in order to prepare students for successful transition into practice.

Clinical leadership development in Australian healthcare: a systematic review.

Despite clear priority and high costs of leadership capability programmes in healthcare, and significant investments into improving clinical leadership, there remains a prominent gap around evidence of effectiveness or impact on patient outcomes in Australia. We aimed to conduct a systematic review on postgraduate clinical leadership programmes to gather learnings on the processes, theoretical underpinnings, and impact of such programmes for medical and other health professionals. Our search included empirical, peer-reviewed evaluations of Australian clinical leadership development programmes published between November 2008 and March 2019 and yielded 3284 records. Four studies met criteria. Findings revealed that currently, little value is placed on formal evaluations and peer-reviewed publication including assessment of individual, organisational or system level impacts of clinical leadership development programmes, with limited evidence available on effective approaches to clinical leadership development in the Australian healthcare system.

Emergence of informal clinical leadership as a catalyst for improving patient care quality and job satisfaction.

AIMS: To analyse the critical attributes of clinical leadership and test a model linking clinical leadership behaviours of staff nurses to patient care quality and job satisfaction. BACKGROUND: Research has historically proclaimed the beneficial effects of clinical leadership for optimizing care and improving patient outcomes. Few studies, however, have assessed the influence of clinical leadership at the staff nurse level and empirically tested the concept. DESIGN: A predictive cross-sectional design was used in this study. METHODS: Data were collected during January 2016 using a survey questionnaire. A random sample of Registered nurses working in direct care positions in acute care hospitals was surveyed. The hypothesized model was tested using structural equation modeling in the analysis of a moment structures software. RESULTS: Nurses reported higher levels of clinical leadership skills in their practice. Staff nurses' use of clinical leadership behaviours directly and positively influenced the quality of care they given to patients and their satisfaction in the workplace. CONCLUSION: The findings indicate that informal leadership at the clinical level may be an underused asset in health care and if identified and developed, staff nurse clinical leaders have potential to improve the delivery of patient care and may offer a tangible solution to the patient safety conundrum.

Perceived importance and performance of clinical leadership in practice: A cross-sectional study of nurses and midwives of all grades.

AIM: To explore the differences in perceived importance and actual performance of clinical leadership for all grades of nurses and midwives engaged in clinical practice. BACKGROUND: Clinical leadership is central to the provision of person-centred care. However, little is known about how nurses and midwives perceive this in practice. METHODS: Data were collected on a sample of nurses and midwives in the Republic of Ireland, using a cross-sectional study design (n = 324). The clinical leadership needs analysis instrument was used to measure perceived importance and performance of clinical leadership in practice. Grades of nurses/midwives included; staff, manager, advanced practitioner and senior manager. RESULTS: Senior managers were more likely to report significantly higher scores than staff grades for perceived importance of Technology & Care Initiatives (p < .01) and Financial & Service Management (p = .02). Performance of Staff & Care Delivery was significantly higher for senior managers than staff grades [F(5,309) = 6.06 p < .01]. CONCLUSION: There was a mismatch between the perceived importance and actual performance of clinical leadership in practice between different grades of staff. IMPLICATIONS FOR NURSING MANAGEMENT: Leadership training for all grades and mentoring of staff grades can promote the building of confidence and empower staff in leading clinical practice.

Clinical leadership and rural and remote practice: A qualitative study.

AIM: To explore how clinical leadership is perceived by nurses in rural and remote areas of New South Wales, Australia. BACKGROUND: There are few empirical studies aimed at understanding clinical leadership from a rural and remote perspective. METHODS: A qualitative approach, based on interpretive phenomenology, used thematic analysis of recorded and transcribed interviews. Ethical approval was secured, 56 interviews were undertaken, across 14 different rural and remote health facilities, with nurses across the spectrum of practice. RESULTS: Thematic analysis led to five themes and findings that support an understanding of clinical leadership from a rural and remote context. Clinical leaders were seen to considerably impact on the initiation of change and quality of care. They also faced barriers if the health facility was poorly staffed, lacked support and if the community were strongly co-dependent. CONCLUSION: In rural and remote areas, clinical leadership is evident to support change, innovation and care quality. IMPLICATIONS FOR NURSING MANAGEMENT: Managers should be aware that staff shortages and challenges to staff retention or the initiation of change are affected by poor clinical leadership. This paper suggests that managers who facilitate clinical leadership are better able to support professional education and greater efficiencies in the delivery of quality health care.

Development and psychometric testing of the clinical leadership needs analysis (CLeeNA) instrument for nurses and midwives.

AIM: The aim of this study is to report the development and psychometric testing of the clinical leadership needs analysis instrument (CLeeNA). BACKGROUND: Limited emphasis is placed on the clinical leadership needs of nurses and midwives that are fundamental to supporting the delivery of high quality, safe patient care. METHODS: A development and validation study of CLeeNA was undertaken using cross-sectional data. A sample of 324 registered nurses and midwives completed the questionnaire using a 7-point adjectival scale. Principal component analysis was conducted to explore scale grouping of items (n = 103 items). RESULTS: Principal component analysis, item reduction and parallel analysis on the items of the instrument resulted in seven factors consisting of 56 items. These factors were identified as: Staff and Care Delivery; Technology and Care Initiatives; Self and Team Development; Standards of Care; Financial and Service Management; Leadership and Clinical Practice; Patient Safety and Risk Management. CONCLUSION: The identified factors are reflective of an ever-changing health care environment. IMPLICATIONS FOR NURSING MANAGEMENT: Potentially, after further testing, this instrument could be used by nursing management and educators to measure clinical leadership needs, inform the design of clinical leadership training programmes and provide valuable information about health care leadership development.

Perceptions of the impact of introducing administrative support for nurse unit managers: A qualitative evaluation.

AIM: To evaluate the impacts of introducing administrative support for nurse unit managers. BACKGROUND: Increased administrative load for nurse unit managers causes role stress and reduced opportunities for clinical leadership (state-wide review, Queensland, Australia). In response, a health organisation implemented a clerical 'Nurse Unit Manager Support Officer' position. METHODS: Qualitative descriptive evaluation, convenience sample (37 nurse unit managers and NUM Support Officers) and focus groups (13) provided data that were thematically analysed. RESULTS: Six impacts were identified: (a) improved nurse unit manager well-being; (b) more time to undertake clinical leadership; (c) greater efficiencies in finance, payroll and HR processes; (d) improved capacity for strategic leadership; (e) increased staff satisfaction and improved unit culture; and (f) improved succession planning. CONCLUSION: Findings reveal significant gains and benefits from the introduction of administrative support for the nurse unit manager role for the nurse unit manager and the units they manage. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse unit manager role stress can negatively impact organisational climate, performance outcomes, staff satisfaction and retention. Health organisations need to implement strategies to reduce the administrative burden for nurse unit managers. The introduction of administrative support frees up time for nurse unit managers to engage in clinical leadership, positively impacting organisational climate, performance outcomes, and staff satisfaction and retention.

Development and delivery of a clinical leadership programme for integrated community teams.

Neighbourhood teams were formed throughout Worcestershire in early 2018, which led to a change in staff roles and responsibilities, as these are multidisciplinary community teams. It became apparent during the transition that many of the staff in band 6 roles required additional support and education to enable them to develop their knowledge and skills. Therefore, a clinical leadership programme was developed specifically for these staff. The programme followed the principles of the NHS Leadership Framework and consisted of six full-day training sessions. During the programme, staff identified issues within their team and developed a plan to address these issues over the following 6-12 months. The next two cohorts of the programme included staff from out-of-hours community nursing teams. The feedback from all delegates and managers was overwhelmingly positive, and delegates continue to implement their plans.

Reflection on creating a coaching approach to student nurse clinical leadership development.

Coaching is an intervention that facilitates another person's learning, development and performance. Applied to student nurse practice placement learning, coaching has the potential to boost leadership learning that is student led, less focused on following the directions of a mentor and more focused on students taking responsibility for identifying their learning goals and objectives. This article gives personal perspectives about how a collaboration between four Greater Manchester (GM) universities and their partner practice organisations developed, implemented and evaluated a coaching approach to student nurse clinical leadership development and peer learning, while increasing practice placement capacity-the GM Synergy model. Perspectives are given on setting up a project team, testing the model before implementation and developing a robust evaluation framework. Coaching as a model for student support and clinical leadership development is in line with the Nursing and Midwifery Council's Future Nurse: Standards of Proficiency for Registered Nurses document, with the practice supervisor role complementing the role of the coach in clinical practice.

Developing and evaluating clinical leadership interventions for frontline healthcare providers: a review of the literature.

BACKGROUND: The importance of clinical leadership in ensuring high quality patient care is emphasized in health systems worldwide. Of particular concern are the high costs to health systems related to clinical litigation settlements. To avoid further cost, healthcare systems particularly in High-Income Countries invest significantly in interventions to develop clinical leadership among frontline healthcare workers at the point of care. In Low-Income Countries however, clinical leadership development is not well established. This review of the literature was conducted towards identifying a model to inform clinical leadership development interventions among frontline healthcare providers, particularly for improved maternal and newborn care. METHODS: A structural literature review method was used, articles published between 2004 and 2017 were identified from search engines (Google Scholar and EBSCOhost). Additionally, electronic databases (CINHAL, PubMed, Medline, Academic Search Complete, Health Source: Consumer, Health Source: Nursing/Academic, Science Direct and Ovid®), electronic journals, and reference lists of retrieved published articles were also searched. RESULTS: Employing pre-selected criteria, 1675 citations were identified. After screening 50 potentially relevant full-text papers for eligibility, 24 papers were excluded because they did not report on developing and evaluating clinical leadership interventions for frontline healthcare providers, 2 papers did not have full text available. Twenty-four papers met the inclusion criteria for review. Interventions for clinical leadership development involved the development of clinical skills, leadership competencies, teamwork, the environment of care and patient care. Work-based learning with experiential teaching techniques is reported as the most effective, to ensure the clinical leadership development of frontline healthcare providers. CONCLUSIONS: All studies reviewed arose in High-Income settings, demonstrating the need for studies on frontline clinical leadership development in Low-and Middle-Income settings. Clinical leadership development is an on-going process and must target both novice and veteran frontline health care providers. The content of clinical leadership development interventions must encompass a holistic conceptualization of clinical leadership, and should use work-based learning, and team-based approaches, to improve clinical leadership competencies of frontline healthcare providers, and overall service delivery.

Clinical leadership and nursing explored: A literature search.

AIMS AND OBJECTIVES: To explore what we know of the concept of clinical leadership and what the term means. Clues to the definition of clinical leadership, the attributes of effective and less effective clinical leaders, models of clinical leadership and the barriers that hinder clinical leadership development were explored. BACKGROUND: While nursing leadership and healthcare leadership are terms that have been evident in nursing and health industry literature for many decades, clinical leadership is a relatively new term and is may still be misunderstood. DESIGN: A search was undertaken of formal and informal literature using a library database and a range of search engines for the words "clinical leadership" and "clinical leadership in nursing." In each case, the full search parameters were employed with searches between 1974-2016. Full-text articles were requested, and English was the preferred language. RESULTS: In total, 3,259 publications were located through seven database search tools, although these included a large number of duplications. Following further informal searches and removing irrelevant material, 27 research or literature review focused papers were retained that included 17 qualitative studies, one quantitative study, one mixed method study, one Delphi study and two that compared other research studies. As well, five literature reviews were retained in the synthesis. The data synthesis resulted five categories: definitions of clinical leadership, characteristics most likely or least associated with clinical leadership, models applied to clinical leadership and limits to clinical leadership development. CONCLUSION: Clinical leaders are recognised for having their values and beliefs parallel their actions and interventions. They are found across the spectrum of health organisations, often at the highest level for clinical interaction, but not commonly at the highest management level in a ward or unit team and they are seen in all clinical environments. RELEVANCE TO CLINICAL PRACTICE: Clinical Leadership and an understanding on how clinical leaders contribute to the health service is central to the application of values-based practice and how clinical leaders impact on innovation, change and making care better.

Knowing how to get things done: Nurse consultants as clinical leaders.

BACKGROUND: Clinical leaders drive healthcare performance in the provision of safe, high-quality patient care by influencing others and augmenting change. Clinical leadership features strongly in nurse consultant roles and holds potential to strengthen the nurse consultant's place in healthcare teams, making their contribution as clinical leaders more recognisable. This study explores how clinical leadership is enacted through the nurse consultant role, providing understanding of the elements that influence their effectiveness as clinical leaders. DESIGN: This study presents qualitative findings from a larger sequential mixed-method study conducted in a large Local Health District in New South Wales, Australia. METHODS: Focus groups were held with nurse consultants, managers and other stakeholders from a variety of context including acute, primary and community care settings across metropolitan and rural locations. An online discussion forum was provided for nurse consultants unable to attend focus groups. Transcript data were analysed using iterative theming techniques. RESULTS: A total of 26 nurse consultants, 20 managers and 16 other stakeholders participated in focus groups and 22 nurse consultants contributed to the discussion forum. The role of the nurse consultant as clinical leader was a dominant feature, manifested through the following four themes: knowing and being known, being a collaborator, being a utility player and working across and within. CONCLUSIONS: Nurse consultants are cogent clinical leaders, recognised and valued for their contribution to interprofessional teams and service delivery. The nurse consultant role is seen as having a broad sphere of influence and is able to action change through clinical leadership. RELEVANCE TO CLINICAL PRACTICE: Findings give organisational leaders and other healthcare professional's greater understanding of nurse consultants as clinical leaders. This informs how nurse consultants are appointed and positioned and how they can be supported in fulfilling their clinical leadership potential.