As you read through this chapter, it is important as a beginning nurse to consider the attributes that you need to develop to become a nurse leader. It is never too early to start this process as effective leaders cultivate a reflective and iterative process, involving appraisal of their personal strengths and weaknesses and developing strategies for personal empowerment. It is also important for you to consider that leadership is evident and crucial at all levels of nursing practice—from novice to expert. As you observe the behaviours of your colleagues, you can see the characteristics of future nursing leaders. Perhaps, most importantly, even in your early days of practice you can shape the future of patient care and the nursing profession through engaging in critical discussion, reflective practice and developing your leadership skills (Allan et al., 2008, Daly et al., 2006 and Morgan, 2000).

Internationally, contemporary clinical, administrative and policy environments of healthcare provide challenges to both professionals and consumers. Increased demands for clinical services, rising healthcare costs and health workforce shortages are just some of the issues you will face as you begin your nursing career. In spite of these obstacles, the healthcare setting has never been so welcoming for dynamic nurse leaders and managers. This is because contemporary healthcare systems are no longer based upon hierarchical medical leadership but are more inclusive and interdisciplinary (Aiken et al 2000). At many levels of organisations you will see nurse leaders functioning in general as well as nursing-specific leadership positions (Davidson et al 2006a). Further, the growth of nursing research and scholarship has been able to demonstrate the unique and valuable contributions of nurses to health-related outcomes, particularly related to promoting care continuity and coordination of care.

In order for nurses to function effectively in dynamic clinical environments and, importantly, exert their influence to optimise patient care, they need to appreciate the multiple factors that impact upon nursing practice and healthcare delivery. These factors are as diverse as the nature of nursing practice itself. It is also important to consider that regardless of the healthcare system in which you will work, healthcare delivery is provided in a political context that is strongly influenced by economic factors and prevailing cultural and social values (Aldrich et al., 2003 and Beaglehole et al., 2007b). The crucial role of leadership has been recognised in the introduction of a clinical nurse leader role by the American Association of Colleges of Nursing (AACN) (Poulin-Tabor et al., 2008 and Stanley et al., 2008). In this chapter, we explore clinical leadership within the current healthcare environment.

Contemporary healthcare systems are often portrayed as a system in crisis as they battle increasing demands and diminishing resources (Harris 2000). Population ageing and the increasing burden of chronic conditions challenges a healthcare system largely designed for acute procedural care. Currently, the worldwide nurse staffing shortage continues to attract government and public comment (Cooper, 2008 and Siela et al., 2008). Nurses, along with many other professional groups, are experiencing workforce shortages (Cummings et al 2008). In healthcare systems commonly portrayed as being in a crisis state, pointing the finger at nurses and nursing models of education are an all too easy scapegoat (Jackson & Daly 2008). Yet the challenges facing health are global and strongly mediated by factors such as epidemiological transitions, increased migration and globalisation of economic factors (Davidson et al 2003). Taking the time to consider these forces is critical in assessing current clinical situations and planning for the future.

As you begin your nursing journey and struggle with acquiring skills and terminology, terms such as leadership and mentorship can appear distant and remote. However, it is important to consider that you and your colleagues are the nurse leaders of the future. Further, leadership is rarely an historical accident; rather, it is a set of knowledge, skills and attributes that is developed over time (Morgan 2000). Therefore, as you read over this chapter, consider the factors that you will need to develop to prepare yourself for a leadership role. As the skill mix of nursing diversifies in the clinical setting with growing numbers of enrolled nurses and assistant roles, the registered nurse role will increasingly take on a role of leadership and coordination. No matter how small or large your clinical team is, you will need to inspire and motivate and lead your team to achieve negotiated goals and deliver effective clinical care. Skills such as reflection, listening and critical thinking are crucial in developing these roles. Take the time to develop these skills and to seek feedback from your peers.

A commitment to equity and access are driving healthcare reforms in many countries, such as Australia, New Zealand and the United Kingdom (Australian Commission on Safety and Quality in Health Care 2008). Nurses undertake a crucial role in these reforms from the primary to tertiary care sectors. Technological innovation has improved clinical outcomes. Rates of deaths from infectious diseases continue to fall globally and we face an international burden of chronic conditions, such as heart disease and stroke (Beaglehole et al 2007a).

Healthcare professionals are increasingly challenged to deliver healthcare in an equitable and accessible manner, while dealing with issues of quality and safety (Ramanujam et al., 2008 and Rogers et al., 2008). Further, the increasing trend towards globalisation means that we have to consider issues beyond our local environment in healthcare policy and delivery (Ben-Shlomo and Kuh, 2002 and Davidson et al., 2003). The threats of avian influenza and increasing rates of tuberculosis are just some recent examples of living in a globalised world. Frequent travel, migration and other social and political factors can impact on the health and wellbeing of individuals and community through the spread of disease.

Within a climate of healthcare reform, nurses now also have increasing opportunities to influence healthcare policy and practice. This new position of power is evidenced by nurses holding influential positions and driving practice changes following credible scientific research. For example, in the United States, the National Institute for Nursing Research is the lead institute within the National Institute for Health (NIH) for end-of-life research, as recognition of nursing’s substantial contribution to palliative and supportive care.

Significant barriers continue to exist, such as opposition from powerful groups, including medical organisations, which challenge advanced practice nursing roles. However, these challenges are not insurmountable. There are examples across a range of nursing and midwifery practice where innovative models of care have improved patient outcomes by challenging traditional views and perspectives. Innovative models of midwifery care, such as early discharge care, have improved the experiences of mothers and their babies. Recognising that the greatest power base for nurses exists within the practice domain, with demonstration of clinical excellence and innovation, is an important factor in overcoming scepticism surrounding the role of nurses (Sorensen et al 2008). For example, nurses in the management of chronic heart failure have demonstrated their ability to influence patient outcomes and policies through nurse-coordinated programs and advanced practice nursing roles (Grady et al., 2000 and McAlister et al., 2004).

As a consequence, clinical leadership in the practice domain is an important tool, and strategies to achieve this are discussed below. A clinical leader is a nurse who demonstrates the ability to influence and direct clinical practice (Lett 2002). This clinical leader also has a vision for the direction of nursing practice. This vision is informed by expert knowledge and analysis of the social, political and economic trends influencing healthcare. Fedoruk and Pincombe (2000) suggest that current and future nurse leaders need to let go of traditional managerial practices and behaviours to focus on achieving change management and process reengineering. To achieve this goal, contemporary nursing leaders have to adopt flexible, innovative and collaborative practice models. Pressures on the healthcare system—for example, financial pressures and increasing chronic disease burden—represent significant challenges for nurses. However, innovative models of care, increasing emphasis on independent nursing practice, and institution of clinical governance structures will likely serve nurses in addressing these challenges (Davidson et al 2006b).

In order to engage an organisational system, direct change and assert leadership, it is important to appreciate what ‘drives’ this process. This observation is relevant at both a macro and a micro level of operation. Politics can be just as intriguing and complex within a hospital ward or community health centre as at the bureaucratic or parliamentary levels. However, at all levels it is important to be aware of social, political and economic factors that influence healthcare delivery (Davidson et al 2006a, 2006b). Politics in nursing is discussed in more detail in Chapter 13 of this text.

The working environment of nurses is influenced by the social, economic and political systems of the healthcare system. Table 17.1 compares the policy environments and roles of nurses in Australia, New Zealand, the United Kingdom, Taiwan and the United States. In some instances, policy can be either a barrier or facilitator to clinical leadership. The emerging role of the nurse practitioner in Australia is an example where significant policy and legislative reform has created a context to promote advanced nursing practice in spite of opposition and scepticism from some medical professional groups (Driscoll et al., 2005 and Gardner and Gardner, 2005). Internationally, healthcare professionals strive to ensure the delivery of safe and effective evidence-based care. Frameworks such as clinical and shared governance serve as a structure to achieve this goal.

Clinical governance is a mechanism through which healthcare organisations are held accountable for adhering to evidence-based practice standards, continuously improving the quality of their services and ensuring high standards of care (Marshall 2008). As you engage in your clinical placements and nursing studies, consider the factors in which nursing care can shape the outcomes of patients. Falls prevention, mouth care and pressure care are examples of essential nursing care that influence patient outcomes (Berry & Davidson 2006).