Marking out the clinical expert/clinical leader/clinical scholar: perspectives from nurses in the clinical arena

In the context of contemporary nursing the crucial need for clinical leadership and clinical expertise (proficiency) abounds. In conjunction with this there is a cry for clinical scholarship. In the late 1990s Sigma Theta Tau International [1] espoused that clinical scholarship was “an approach which enables evidence-based nursing and the development of best practice to meet the needs of clients efficiently and effectively” (p4). This influential international society goes on to state that this clinical scholarship can only flourish if both clinical and academic organisations embrace it. Clinical scholars are viewed as those nurses who are reflective, curious, critical thinkers who contribute to the clinical environment through sharing their knowledge with the broader nursing and general community [1]. In this paper we consider the notion of the clinical scholar, and question if it is any different from a clinical expert or a clinical leader.

In reviewing the literature on clinical scholarship/scholar no research data-based studies were found. The writings are discussion papers or views of experts in nursing. Mohide and Coker [2] suggest that clinical scholarship in nursing goes beyond expertise, linking it with evidence of practice. As Diers [3] so eloquently states, clinical scholarship is simply “the study of the nature and effect of nursing” (p2). This is affirmed by Roth [4] in a lecture to medical practitioners where he states clinical scholarship refers to clinical practice and includes clinical competence (expertise, proficiency). Thus, as Palmer [5] stated in the 1980s, nurses must bridge the gap between nursing action and nursing thought, or thinking/doing nursing. This reflects the idea of a theory/practice gap: an issue that has long confounded nursing scholars. In the 1990s Walker [6] highlighted the tensions between thinking and doing nursing; and this tension continues, despite increasing numbers of clinical nurses pursuing higher degree education and research [7, 8]. These pursuits are often seen internationally as essential criteria for clinical expert positions.

Within the current nursing agenda to improve nursing practice and patient/client outcomes, clinical leadership is often advocated as an essential element [9‐11]. Clinical leadership is often linked to solutions for clinical problems that can range from specific clinical problems [12] through to health workplace nursing roles [13]. From an extensive review of research-based literature on the clinical leadership construct, it was found that characteristics of clinical leadership more commonly focussed on practical and technical skills required to lead a team and practise in a clinically competent manner [14]. In this review of research papers it was found that clinical leadership attributes had a clinical focus, a follower/team focus or personal qualities focus; attributes necessary to sustain supportive workplaces and build the capacity and resilience of nursing workforces.

Clinical expertise can be seen as an essential component of clinical leadership. Studies on expertise in nursing became popular after the seminal work of Benner [15] in her description of growth from novice to expert. She described an expert as someone who knows how and knows that and has both personal and experiential knowledge to use intuition in practice, particularly in decision-making. The nurse expert is someone who has superior performance in their everyday work life [16]. Work into the 1990s and 21^st century has focussed on how expert nurses discern cues and make decisions differently to novice practitioners [16‐18]. In the context of what role they perform in practise they can be seen as advanced practice nurses. Much research is conducted in this area but Heals [19] sums up their role succinctly as: providing expert clinical practice, facilitating change, disseminating evidence-based practice and improving communication in and beyond the health team. Thornley and West [20] state these nurse experts have an obligation to share their knowledge with novice practitioners and should mentor these nurses.

If scholarship is at the heart of what a profession is, then clinical scholarship must be central to the nursing discipline [21]. The discipline’s philosophy, theory and practice are intertwined and as reflected in Boyer’s ideas, scholarship in nursing can come from four scholarly activities: discovery (research), integration (connections across disciplines), application (practice), and teaching. It is argued by Starck [22] that clinical scholarship, while having significant focus on practice, would also bridge the other three scholarly activities.

Over the decades, scholarship or scholarliness has been discussed and seen as an essential component of the discipline and its practice. Armiger [23] defines scholarliness as being able to argue various points of view, being dedicated and flexible. Others suggest it is being visionary, pursuing excellence, proficiency and mastering systematic knowledge [24, 25]. As Kitson [26] states emphatically, “true scholarship is both the breadth and depth of knowledge an individual has in a particular subject area” (p540) and its development is essential to the nursing discipline. Kitson [26] and others [22, 24, 27, 28] emphasise the need for post graduate students in nursing and in particular, doctorates grounded in clinical practice, to build a stronger culture of inquiry and scholarship in the clinical environment. No evidence of research-based data was found in the literature that explores whether nurses in the 21^st century see clinical scholarship as essential to their practice or more broadly to their discipline.

In this context, this paper reports the findings from a study in which it was sought to determine clinical nurses’ understandings of clinical scholarship. In this paper the emphasis is on the clinicians’ perceptions of the differences in the construct of the roles of clinical scholar, clinical expert and clinical leader.

A descriptive interpretative qualitative approach was used in this study which was conducted in three countries – England, Canada and Australia. The methodology utilised was naturalistic inquiry which has the premise that individuals understand the world differently, but by comparing and contrasting these views, a common understanding can be interpreted [29]. The primary focus of the major project was to define clinical scholarship.

Table 1 details the characteristics of the participants. The 18 participants for this study worked in three countries: England (13, 72.20%), Australia (4, 22.22%), and Canada (1, 5.56%). As seen in Table 1, there was a spread of ages with an average of 42.2 years with a range of 29 to 67 years. The first qualification in nursing for the group was spread fairly evenly across hospital certificate, diploma or bachelor degree. The most common highest tertiary qualification was a Master in Nursing (10, 55.56%). The average clinical experience of the group was 17 years with a range of 1.5 to 30 years. While two of the participants were working in academic positions, they worked part-time in clinical practice.

In their perceptions of the clinical expert, the participants in this study saw this nurse as similar to that proposed by Thornley [32], that is, as a role model who encourages, inspires and assists others to reach clinical competence. These experts have gone beyond the ‘doing nurse’ described by Walker [6]. They do link thinking and doing to improve nursing practice and patient care. In this way, they also embody attributes of leadership.

In the view of most of the participants, the clinical leader is described mostly in the context of hierarchical, positional leadership [33], such as a nurse manager where the process of organising a unit or ward (i.e., managing, making decisions, team building, communication) is emphasised. The participants have a fairly limited view of clinical leadership and their perceptions are varied, with few common views. However, the personal attributes of clinical leadership clearly emerge. Leadership styles and associated personal attributes such as those found with transformational leadership [34, 35] find the leader transforming the values of followers to support the vision of the organisation by fostering an environment where there is trust and where the vision is shared. In the clinical leadership literature, a transformational leadership style is often cited as the preferred style of clinical leadership to achieve positive outcomes for nursing staff in clinical settings [36‐38]. There were indications of this style of leadership in the clinical leaders discussed by the participants in this current study when describing the need for leaders to have vision and sharing this vision, as well as inspiring and motivating others. These attributes are similar to those identified by Stanley [39] who found clinical leadership to be based on personal values and beliefs of nursing and care. Similar to the current study Stanley found that “the attributes of the clinical leader were clinical competence, clinical knowledge, approachability, motivation, empowerment, decision-making, effective communication, being a role model and visibility” ([39] p 20). In this current study, visibility was not evident for the clinical leaders in the broader community of nursing, but rather in the local ward or unit.

The nurses’ perceptions of the clinical scholar reflect the theoretical work on the construct evident in the literature since the early 1980s [1, 3, 5, 24‐27]. The findings reflect the curiosity of the scholar, the linking of theory and practice by doing practice-based research, the development of an environment to share the results of research with a broader community, and the nature and effect of nursing. Motivation and inspiration are also important aspects of this role.

Stockhausen and Turale [40] found these essential features of Australian nursing scholars as perceived by recognised academic and clinical scholars. One essential feature of the clinical scholar is practice-based research where results are disseminated; knowledge shared and translated into practice both locally and to the broader community. These attributes have been highlighted in literature related to clinical scholarship in other health disciplines, for example occupational therapists [41], medicine [42]. There is an emerging emphasis in some nursing curricula to teach clinical scholarship [27, 28]. However, it may be a construct that needs to develop from practice rather than theory. An academic research focus by nurses can enhance this scholarship but the research needs to move from the academy to the clinic. It also needs to move from practice-based research to the academy [43].

Nurses in all three roles or their amalgam need to work together so that patient care is enhanced. There is a movement to basing research in practice and involving nurse clinicians by exploring their values of patient care and the context in which this care is being enacted. Practice development units in the late 20^thCentury tended to explore nursing rather than patient care [44, 45]. There are a number of movements globally, including Canada [46] and United Kingdom [44, 47] that emphasise translation of research to practice. These earlier translation models were very linear based [26, 44, 48]. More recently, a movement to establish a more action research approach within a transformational practice development framework in the practice arena has evolved with the development of a change culture addressing value development of the practitioners [45].

This approach has been advocated and taken up by a number of health services in Australia. The Essentials of Care program propagated by NSW Health [49] is one such program and this has encouraged research to promote patient care coming from the shared values of clinicians. From personal observation of the authors and feedback from clinicians and the health department at local seminars, significant clinical change is taking place with this approach to enhance patient care [50, 51]. However, one of the disadvantages of this approach is that there is tendency for the activity to be limited to one local area such as a ward or unit and not be disseminated to the broader nursing community. The participating clinicians see the program as quality assurance exercises and they do not go through the usual research ethics procedure to enable publication. Clinical scholars need to work collaboratively to challenge and change this thinking.

In order to achieve the goals of the roles of clinical expert and clinical scholar, education programs that emphasise these roles and concepts are needed. Nurses who are educated to a Masters or doctoral level are needed in both the academic and clinical arenas [8, 52]. These roles and their characteristics, however, need to be developed with a blend of academic and clinician input. Action based research is one method of achieving this.