Clinical Leadership of Staff Nurse: A Phenomenology Study

The purpose of this research was to explore nurses’ experiences of leadership. Six nurses who had worked on wards with at least 3 years experience in a university hospital. Data were analyzed by applying Colaizzi’s phenomenological methodology 1 . The following five themes were extracted. This phenomenological study broadens the meaning of leadership demonstrated by the clinical nurse and enables a new discovery about their roles.


Introduction
The leadership in nursing organization boosts productivity and efficiency of nursing works through developmental and innovative decision-making and inducing nurses to be voluntary, contributing to the realizing organizational goals and balanced development 2 . Especially, nursing manpower takes up 30-40 % of the whole manpower of a hospital, and, since nurses spend time with nursing objects more than other professionals, they play important roles related with medical services of the hospital in qualitative and quantitative aspects. So the effective manpower management and human leadership of a nursing organization can be said to be an essential element to upgrade the medical quality and cost-effectiveness in the rapidly changing hospital environment 3 .
In 4 said that it is very important to display nursing leadership equipped with specialty and regulating capacity, that the organization possessing nurses with leadership can develop, and that, an organization, to survive and succeed in the rapidly changing 21 st century, must have leaders. Consequently, the leadership of nurses should be the type of leadership where nurses want what they want by helping nursing objects solve their problems for themselves. Most of existing researches on nursing leadership are perception of staff nurses on the leadership of head nurse and manager 2,5,6 , and quantitative researches on the relationship among variables such as personality types depending on leadership types 7 , empowerment [8][9][10][11] , job satisfaction 6,9,[12][13][14][15][16] , organizational commitment 6,10,12,14,15,17 , organizational effectiveness 5 , and willing to leave the nursing job 12 . As qualitative researches, there are an ethnography 3 on the leadership of middle managers.
In contrast, there are fewer researches on the leadership displayed by staff nurses. Since 2000, there have been researches on leadership displayed by clinical nurses with the concept of self-leadership. However, since the tool designed to measure self-leadership consists of items used to company employees and college student in foreign countries, and does not consider differences in organizations and survey objects, it has limits to reflect leadership characteristics of domestic clinical nurses. Given that the roles of clinical nurses in the hospital organizations are being enlarged, and they play core roles in the hospital, it is necessary to explore in depth their real experiences related with leadership. Thus, this research tries to examine practices of leadership demonstrated by staff nurses, using a phenomenological method.

Methods
Phenomenology, a qualitative research method was used for the study. The six nurses with at least 3 years experience in a general unit were selected to articulate their experience of the phenomenon of leadership.

Data Collection and Analysis
Data was obtained by individual face-to-face, in-depth semi-structured interviews with each of the participants. Each interview lasted between 40 and 60 min was audio taped to facilitate accurate transcribing of information. Hand written notes were taken during the interviews, to assist clarification of points raised, and to facilitate the asking of further open-ended questions. Data was analysed using Colaizzi's six-steps of data analysis.

Results
Five of the identified themes of capacity related with works, the influence I display toward myself, the influence one displays others, displaying influence to contribute to the organization, understanding and affection toward patients were described (Table 1). Theme 1. Capacity related with works.
The collection of themes on <Capacity related with works> includes three subthemes; equipping with capacity my juniors want to copy, work treatment methods required in the unit, and work-related clinical knowledge is needed. The related statement on equipping with capacity my juniors want to copy is expressed below: "I think it is important to explain what needs to be explained to new nurses, and show them an example they want to follow, rather than forcing them to follow me, saying-I did it before, so you should do it". The related statement on work treatment methods required in the unit is as follows: "First, I prioritize works I should do in the ward: what is urgent, and which patients I should deal with first. I have no choice but to hurry in my working hours, in order not to leave a work to the next turn. Leaving my work to the next turn gives me stress". The related statement on work-related clinical knowledge is needed is expressed below: "When one does not know something, she should admit it, and ask about it to someone who knows it. Then, she will not make mistakes. But, new nurses frequently make accidents while trying to solve things by themselves without asking others. In order not to make such mistakes, you should study more. When I was a new member, I studied hard, and still study hard. We are the persons who access patients at the most close distance. Thus, clinical knowledge is more than anything else".
The collection of themes on <The influence I display toward myself> includes the following subthemes; motivating myself on work, rewarding myself on work performance, performing work with set goals, pleasure of working as nurse, using the clues to do works well, and observing myself on duty as nurse. The related statement on motivating me on work is as follows: "When patients are hospitalized, they look shady. They are diagnosed with cancers. But, after having tumors removed, "Looking back at the time I started my nursing job, I must have been clumsy. I used to obey my senior, and ask her whether there was something else I had to do. To survive in the ward, I have learned the job by experiences up to now". Theme 3. Work-related influence one displays on others.
The collection of themes on <Work-related influence one displays on others> includes two subthemes; harmonious relationships with colleagues, helping the adaptation of junior nurses. The related statement on harmonious relationships with colleagues is as follows: "When the doctor trusts me for giving proper notice, I feel that trust has been built between the doctor and me. I feel proud to have grown up as nurse".
"Since 3~4 nurses have to work together per duty, it is unavoidable to work sometimes with a nurse I feel uncomfortable. I make efforts not to give other nurses the impression, 'I don't like to work with her. I feel irritated". The related statement on helping the adaptation of junior nurses is expressed below: "If I have something to say to a junior nurse, I try to explain it step by step. Some nurses, finding something to be corrected in the behavior of junior members, tend to scold junior members without considering surroundings. But, in such a case, isn't it better to call her to a corner, and explain her calmly about the problem to lead her not to repeat the mistake?" Theme 4. Displaying influence to contribute to the organization.
The collection of themes on <Displaying influence to contribute to the organization> includes the following subthemes; efforts to change work-related environment, efforts for the development of organization. The related statement on efforts to change work-related environment is as follows: "What is hardest in the ward is enormous workload when a large number of patients are admitted to and leave the ward simultaneously. I often think that it will be desirable to run an elastic personnel system for such situations, and reduce the workload on nurses in such cases. Thus, I try to suggest my idea to the head nurse". The related statement on efforts for the development of organization is expressed below: "People seem to refuse to accept the opinions different from their own. But, considering that the development of the ward is that of the hospital, I try to offer suggestions as many as possible on the future directions of ward projects and the ways manuals are preceded at conference times, even if the suggestions can lead to added workloads to me". Theme 5. Understanding of patients and affection toward them.
The collection of themes on <Understanding of patients and affection toward them> includes one subtheme; treating patients as if they are my family members. The related statement on treating patients as if they are my family members is as follows: "I applied to this ward to spend time with patients with breast cancer. I often chat with them. As nursing is to treat people, it is difficult to work as nurse without affection on men. I treat them as if they are my sister, aunt, or mother, that is, my family members".
"I feel that I have special love for them".

Conclusions
This study, to examine the essence and meaning of experiences called leadership nurses display while playing their roles, used a phenomenological method. Data analysis revealed five themes and fourteen subthemes. Capacity related with works was the first theme that emerged from the data. Meaning units that led to the interpretation of this theme were knowledge, experience, role model, and professionalism. These beliefs are supported by the literature, as nurses are needed to exert professionalism and are being increasingly required to demonstrate leadership 18 .
The second theme that emerged from the data was the influence I display toward myself. The meaning units that contributed to this theme were confidence, motivation, achieving goals, rewarding, and self-criticism. Nurses should have a self-leadership as a leader capable of representing the organization because they are often the opportunity to exert an immediate coping skills and leadership while caring patients 4,19 .
The influence one displays on others was the third theme that emerged from the data. Meaning units identified for this theme were: harmony, helping, guide, respect, mentor, and communication. Effective nurse leaders realize that the "most effective and visible way to influence people is to lead by example" 19 .
The fourth theme that emerged from the data was displaying influence to contribute to the organization. Contribution, commitment, workplace improvement, and effort to change and development were the meaning units identified from the narratives for this theme. Nurses who view their work environments as empowering are more likely to demonstrate effective work practices that contribute to the delivery of high-quality patient care 20 .
Understanding and affection toward patients was the final theme that emerged from the data. Meaning units identified from the narratives were: treating, consideration, protecting, and insight. Staff nurses maintain that their professional practice is based on being able to get to know patients 21 . By gaining understanding of patient perceptions, nurses can plan patient-centered care.
Staff nurses use professional behaviors to influence patient outcomes through effective communication and collaboration with other health professionals and through the coordination of the necessary resources to provide patients with timely care 22 . This study highlights the need to address issues of staff nurse clinical leadership. These findings may assist with the implementation of strategies encouraging and developing leadership behaviors of staff nurses.
These findings serve that clinical leadership of staff nurse is as important as manager's leadership so it needs to be addressed. This may assist with the implementation of strategies encouraging clinical leadership such as attendance at training courses and leadership conferences. This is a qualitative study with a small sample size of only six participants limited to a single clinical setting. All participants interviewed were female so this study is not representative of other genders. There is a possibility of researcher bias whereby the researcher may have interpreted the narrative responses with preconceived notions. It is necessary to generalize the meaning of clinical leadership by expanding the sample size and to verify the effect of that over the further study.

Acknowledgements
I would like to thank all the nurses who participated in this study.