10.1 Introduction

The role of the clinical nurse specialist (CNS) is multifaceted and encompasses several components. There is a consensus within the nursing professions that leadership is one component that defines the advanced practitioner’s role; the others are consultant, clinician, educator and researcher (De Grasse and Nicklin 2001). Beauman (2006, p. 22) highlights an overlap in these sub‐roles, stating, ‘One cannot educate effectively without being a clinical expert, one cannot implement research without education, and one cannot consult without knowledge of research and clinical expertise’, and argues that none of these roles can be performed effectively without leadership. This chapter presents definitions of leadership and provides an overview of the importance of self‐recognition of leadership for the CNS. Leadership in the context of the CNS role is difficult to delineate; however, this will be discussed under two distinct headings – clinical leadership and professional leadership – in an attempt to enable CNSs to articulate their leadership role.

Ruth Thompson is one of the authors and her role has changed recently. Please change this in the introduction to ‘Ruth Thompson is Associate Director of Nursing Policy and Practice at the Royal College of Nursing, and was previously the Interim Clinical Manager for Cancer Services in a Health and Social Care Trust in Northern Ireland. The second author, Monica Donovan, has worked as a cancer nurse for almost 20 years and has occupied formal leadership positions in cancer services. Monica is now a lecturer in adult nursing in the School of Nursing and Midwifery, Queen’s University Belfast, and co‐ordinates a leadership module for nurses and other healthcare professionals.

10.2 Leadership

Leadership is a highly desirable and highly valued commodity in all industries (Northouse 2019), yet it is one of the most difficult concepts to define due to its complex nature. Northouse (2019) also argues that attempting to define the concept of leadership is similar to trying to define concepts such as democracy, love and peace. Individuals intuitively know the meaning of such words; however, they can mean different things to different people. Many years ago, having completed a review of the leadership research literature, Stogdill (1974, p. 7) claimed there were as ‘many definitions of leadership as those who have tried to define it’. Kouzes and Posner (2012) describe leadership as a set of skills and abilities that a person embodies; however, Daft (2015) believes leadership is more than a set of skills: it is a set of powerful personal qualities such as integrity, humility, courage and enthusiasm. Such definitions represent leadership as a generic concept; however, leadership is context‐specific and needs to be understood in terms of its professional and organisational contexts (Turnbull‐James 2011). In nursing, those in advanced nursing practice roles are increasingly identified as leaders who have progressed into areas of higher‐level practice, improving care quality and outcomes (Leggat et al. 2015; Thompson et al. 2019; Evans et al. 2020).

10.3 Self‐Recognition of the Clinical Nurse Specialist as a Leader

In the last decade, there has been a growing expectation that all nurses should be leaders (Nursing and Midwifery Council 2018). Anecdotal evidence suggests that CNSs do not always recognise themselves as leaders and often fail to appreciate the enhanced skill set developed in their careers before embarking on the CNS role. This view is perhaps predetermined by the lack of self‐recognition of nurses as leaders in general. Historically, nurses have been taught to follow, not lead; and until recently, the concept of nursing leadership has largely been associated with nurse executives and formal leadership roles (AL‐Dossary 2017). Research has predominantly focused on first‐line managers/executives and has explored attributes, traits, competencies, roles and styles, and impact (Austin et al. 2003). AL‐Dossary (2017) further highlight that nursing leadership has rarely been associated with bedside nursing practice.

Few studies have explored nurses’ self‐perceptions of leadership; however, one study by Booher et al. (2021) explored the perception of leadership with clinical nurses at the bedside in relation to patient care and outcomes. All participants in this study identified qualities they admired in leaders, such as integrity, compassion, good communication, vision, caring and self‐awareness. The authors report that almost 50% 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. Booher et al. (2021) concluded that nurses assume a formal title is required to be a leader. This lack of self‐recognition of leadership in nursing can help to explain why some nurses who progress to an advanced level do not consider themselves leaders.

It is essential that CNSs recognise themselves as leaders. Daft (2015, p. 6) believes that ‘to see our own opportunities for leadership and recognize the leadership of people we interact with every day, we must stop equating leadership with greatness and public visibility’. Understanding the difference between formal and informal leadership roles is a first step in recognising the leadership potential of the CNS. Formal leaders such as managers and lead nurses gain authority by formal appointment. Northouse (2019) describes this as ‘assigned leadership’, where leadership is based on the position occupied in an organisation. Furthermore, leadership is often associated and confused with management, contributing to its vagueness. In contrast, registered nurses at the bedside attain authority informally from acceptance and support by followers who trust them, a phenomenon described as ‘emergent leadership’ (de Souza and Klein 1995) or ‘informal leadership’. The emergent leader can be the most influential member of a group or an organisation, regardless of the individual’s title.

CNSs have an informal leadership role that is no less important in achieving successful patient outcomes than those in formal leadership positions. The level of recognition as a leader may depend on the level of experience of those who occupy the CNS role. Nurses need to accept that leadership is a core activity of their role at all levels – once this is acknowledged, the transition to advanced roles will be easier (Wood 2021). Furthermore, they need to acknowledge their role as leaders to themselves, patients, other healthcare professionals and healthcare executives (Larsson and Sahlsten 2016).