Study Asks: Is Leadership Innate to Bedside Nursing?

In 2014 a team of clinical nurse specialists at Cleveland Clinic embarked on a study titled “Nursing Leadership at the Bedside.” The purpose was to explore the perceptions of bedside nurses regarding their leadership capacity.

The study was triggered by many events as follows:

• The 2010 Institute of Medicine Future of Nursing report that called for leadership at all levels1
• Literature that discussed that high-quality and cost-effective care required clinically active nurses to use leadership qualities2
• A Cleveland Clinic Nursing Image and Branding Committee in which researchers reported a need for improvement on leadership at the bedside

Lydia Booher, MSN, APRN, ACNS-BC, ONC

The principal investigator Lydia Booher, MSN, APRN, ACNS-BC, ONC, stated, “We decided to conduct a qualitative research study on nurses’ perceptions of their roles and factors that hindered leadership opportunities at the bedside.” The results, she says, were fascinating.

The research team invited a diverse group of nurses from two Cleveland Clinic hospitals – its main campus and Fairview Hospital – to participate in focus groups to answer questions about their roles in patient care. Data were collected and five key findings emerged:

1. Bedside nurses did not feel the need for formal leadership titles.
2. The hospital culture influenced how well nurses could lead.
3. It was important for nurse leadership to recognize clinical nurse leadership at the bedside.
4. Supportive relationships fostered a safe environment in which to be a leader.
5. Formal nurse leaders need to recognize issues that hinder leadership of clinical nurses at the bedside.

A Closer Look

In discussions with clinical nurse participants, a majority of them did not perceive themselves to be leaders. However, Booher noted that their actions illustrated something different. “Nurses delegated duties to others every day and they advocated for patients,” she said. “We saw innate leadership qualities in our bedside nurses.”

When leadership was expressed, Booher says, it was seen as a paradox. One nurse described it by saying, “We are the last guy at the bottom of the hill holding the bucket.” Booher and the research team concluded that nurses were acting as servant leaders – they shared power and put the needs of other people first (before themselves). “This is very fitting to the clinical nurse as a leader,” Booher concludes.

One area of concern that emerged from the study was that bedside nurses felt that work was often added to their list with nothing being eliminated. “New work expectations made it very challenging to keep up with the high volume of current work nurses had at the bedside,” says Booher, and it’s not a surprising finding.

The Good News

Booher says Cleveland Clinic implemented some important practices that are creating a culture of nurse leadership among clinically active nurses. Regular rounding with the medical team and team huddles at shift changes provide opportunities for clinical nurses to speak-up on behalf of their patients and on behalf of ensuring high-quality, safe care. Clinical practices that engage nurses to communicate and collaborate with other healthcare providers create empowerment behaviors that can help nurses to grow their leadership voice.

Cleveland Clinic, like many healthcare organizations, created leadership programs to empower charge nurses and nurse managers. This qualitative study provides a unique perspective on leadership opportunities for clinical bedside nurses.

“We need to continue to empower our nurses to be the leaders they are,” says Booher. “With this research, we have just gotten started,” Booher adds. “We need to build on our findings and keep the conversation going about nurse leadership at the bedside.”

Along with Booher, the research team included Erica Yates, MSN, RN, ACNS-BC, CRRN; Stacey Claus, MSN, RN, GCNS-BC, CNRN; Kelly Haight, MSN, APRN, ACNS-BC, PCCN; Myra Cook, MSN, RN, CCRN, CSC; and Esther Bernhofer, PhD, RN.

1American Nurses Association, the Institute of Medicine Future of Nursing Report, 2010.

2Wong, CA, Cummings, GG. The relationship between nursing leadership and patient outcomes: A systematic review. J Nurs Manag. 2007;15, 508-521.

Cleveland Clinic’s 13th annual Nursing Research Conference is May 3 – May 4. Register now!

Photo ©Anne O’Neill