Nursing Research and Practice

Volume 2016, Article ID 1797014, 8 pages

http://dx.doi.org/10.1155/2016/1797014
Research Article
The Staff Nurse Clinical Leader at the Bedside: Swedish
Registered Nurses’ Perceptions
Inga E. Larsson1 and Monika J. M. Sahlsten2
1Department of Health Sciences, University West, 461 86 Trollhättan, Sweden
2Department of Health and Education, University of Skövde, 541 28 Skövde, Sweden
Received 25 July 2016; Accepted 14 November 2016
Academic Editor: Michelle Aebersold
Copyright © 2016 Inga E. Larsson and Monika J. M. Sahlsten. This is an open access article distributed
under the Creative Commons Attribution License, which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Abstract
Registered nurses at the bedside are accountable for and oversee completion of patient care as well as
directly leading and managing the provision of safe patient care. These nurses have an informal leadership
role that is not associated with any given position. Leadership is a complex and multifaceted concept and its
meaning is unclear, especially in the staff nurse context. The aim was to describe registered nurses’
perceptions of what it entails to be the leader at the bedside in inpatient physical care. A phenomenographic
approach was employed. Interviews were performed with Swedish registered nurses (). Five descriptive
categories were identified: demonstrating clinical knowledge, establishing a good atmosphere of
collaboration, consciously structuring the work in order to ensure patients’ best possible nursing care,
customized presence in the practical work with patients according to predetermined prerequisites, and
monitoring coworkers’ professional practice. Registered nurses informal role as leader necessitates a social
process of deliberate effort to attain and maintain leader status and authority. Participants used deliberate
communicative approaches and interactive procedures. Leader principles grounded in the core values of the
nursing profession that ensure nursing values and person-centered attributes were a key aspect.
1. Introduction
Registered nurses at the bedside are accountable for and oversee completion of patient care as well as
directly leading and managing the provision of safe patient care [1]. These nurses have an informal
leadership role that is not associated with any given position. The nurse’s leader role is not prescribed or
scripted; rather, it is negotiated among the actors involved and therefore subject to more or less well-
articulated expectations from others. Even patients expect a registered nurse to be the leader of the nursing
team that provides their care [2]. With diminishing resources, deficiencies in quality of care, and an
increasing number of medical injuries, effective leadership has become essential, which is a challenge for
professional nurses. Quality initiatives require leadership by front-line registered nurses [3]. Accordingly,
nurses need research-based knowledge of how to implement appropriate leadership. However, leadership is
a complex and multifaceted concept [4] and its meaning continues to be unclear, especially in the staff nurse
context [1]. Each nurse may have his/her own experience and understanding of leadership and how to
exercise it. Accordingly, nurses’ perceptions of being a leader at the bedside are important knowledge for
the nursing profession.
Leadership is complex and often associated with management, coaching, or mentoring, which all contribute
to vagueness when it comes to implementation [5]. Research has predominantly focused on first-line
managers/executives and has explored attributes, traits, competencies, roles and styles, and impact [6].
Nursing leadership has traditionally been linked with transactional leadership, not compatible with
professional core values [7]. Transformational leadership has been recommended for registered nurses at the
bedside [8, 9] but also Kouzes and Posner’s [10] leadership, authentic leadership [11], and emotionally
intelligent leadership [12, 13].
Formal leaders such as managers/head nurses gain authority by formal appointment [14]. In contrast,
registered nurses at the bedside attain authority informally from acceptance and support by followers who
trust in them. The maintenance of leadership is then dependent on intrateam relationships based on leaders’
behaviors and followers’ perceptions of these [15].
The concept of nursing leadership is used interchangeably with nursing management and literature is
comprehensive and developed to support nurses with management responsibilities [5]. Research and
literature in this field have been accepted as transferable and are used to acquire understanding of clinical
leadership in terms of leading at the bedside. Clinical leadership is often used interchangeably and
inappropriately or alongside nursing management and nursing leadership [16, 17]. Clinical leadership has
been used to identify leadership qualities of staff nurses at the bedside and differentiate staff nurse clinical
leadership (SNCL) from leadership in formal administrative roles [18, 19]. According to Stanley [17],
clinical nurse leaders are positive clinical role models with high-level clinical competence and knowledge.
They are effective communicators, remain open and approachable, visible and accessible in practice, and
empowered decision-makers, and display nursing core values and beliefs through their actions. These
characteristics have resulted in the theory of congruent leadership [17].
When it comes to leadership for registered nurses at the bedside or more recently staff nurse clinical leaders
(SNCL), there is still a shortage of empirical studies. Research is needed in order to develop evidence-based
knowledge. In this study, we define staff nurse clinical leaders (SNCL) as registered nurses (RN), with a
bachelor degree in nursing, who are directly involved in providing nursing care at the bedside and who exert
significant influence on assistant nurses (AN), although no formal authority has been vested in them. The
aim of this study was to describe registered nurses’ perceptions of what it entails to be the leader at the
bedside in inpatient physical care.
2. Materials and Method
This study is part of a larger project concerning staff nurses’ clinical leadership (SNCL) in nursing care and
the perspective of both nurses and head nurses. It is limited to inpatient physical care and is based on
interviews with experienced nurses. The study has a descriptive, qualitative, and phenomenographic
approach. This is appropriate for mapping qualitatively different ways through which people experience,
conceptualise, perceive, and understand various aspects of a phenomenon around them [20]. The goal is to
identify and describe the various ways in which people experience the phenomenon [21]. The relative
strength of phenomenographic studies lies in their emphasis on variation between peoples’ various ways of
experiencing and conceiving the world around them [22]. Accordingly, the outcome categories from a
phenomenographic analysis constitute peoples’ various ways of thinking about their experiences [22].
Marton [20] made a distinction between research undertakings belonging to either the first-order
perspective, what something is, or the second-order perspective, how something is perceived to be. The
second-order perspective is the essential one in phenomenography. The result is a description on a collective
level of the logical relationship between descriptive categories and conceptions [23]. It contributes with
structural and content aspects of how phenomena are experienced in different situations.
The selection of nurses was purposeful and the intention was to have interested participants able to
contribute with a scope of perceptions. Marton [20] means that motivation to participate in the investigation
is crucial. Fifteen registered nurses were recruited from inpatient physical care in three central hospitals in
Sweden. They worked on different wards: general surgical, gynaecological, ear, nose, and throat, stomach
and intestinal, kidney and dialysis, neurological, heart failure, and rehabilitation wards. The head nurse of
the wards was contacted by telephone by the first author (Inga E. Larsson) and given information. All
nurses on the wards were sent written information regarding aim and procedure by e-mail. Fifteen nurses
agreed to participate. After written informed consent to participate had been obtained, the participant chose
where and when to meet for an interview. The participants included three men and twelve women, seven
from surgical wards and eight from medical wards. The age range was 22–54 years (mean 42) and they had
worked as registered nurses for 2–15 years (mean 7) and had a bachelor degree (13) or a master degree (2).
None of the participants had management education.
Collection of data was made by means of open interviews and carried out as a dialogue as recommended by
Marton [23]. All interviews were held adjacent to the wards in a place where there would be no interruption
in order to provide a relaxed environment. The interviews were conducted in an open and friendly
atmosphere by the first author (Inga E. Larsson) and lasted 45–90 minutes. All interviews began with two
questions: (1) what does it mean to you to be the leader at the bedside? And (2) what do you do as the leader
at the bedside? Follow-up questions used were as follows: What do you mean by…? Can you describe an
explicit situation for what you mean? And Can you provide further details? These questions were posed in
order to clarify the meaning, deepen understanding of the answers, and ensure that the participant had been
correctly understood. Each interview was audiotaped and transcribed verbatim in its entirety by the first
author (Inga E. Larsson).
Ethical approval for the study was given by the Ethics Review Board at University West (number 2016:7).
The Declaration of Helsinki was adhered to [24]. The participants were informed that participation was
voluntary and could be halted at any time without explanation, and they were assured of confidentiality. All
participants gave their written consent after receiving verbal and written information.
The phenomenographic analysis focuses on similarities and differences between individual statements and
based on this the conceptions are grouped in nonoverlapping descriptive categories [23]. Since descriptive
categories relate conceptions to each other, they also relate to statements and the whole text [20]. The
analysis followed the phenomenographic approach described by Marton [23]. The data material was read
repeatedly as open-mindedly as possible to gain an overall sense of the content. Statements in accordance
with the aim of the study were identified. These statements were compared in order to find similarities and
differences, identifying distinct expressed ways of understanding or experiencing the phenomena. Each
statement was labelled and then grouped together as emerging conceptions. To obtain an overall map of
possible links between similarities and differences, the conceptions were compared and grouped into
preliminary descriptive categories. The focus now changed from relations between the conceptions to
relations between the preliminary descriptive categories. The system of conceptions and descriptive
categories was scrutinized and checked against statements and the whole data material. The researchers
performed the analysis independently and then compared and discussed the results until consensus was
reached. By switching focus between the whole and the parts, five established descriptive categories and 12
conceptions finally emerged (Table 1). The 15 interviews included 354 statements.
Table 1: The results describe registered nurses’ perceptions of what it entails to be the
leader at the bedside in inpatient physical care.
3. Results
3.1. Demonstrating Clinical Knowledge
This descriptive category contains two conceptions: handling clinical duties securely and being underpinned
with scientific sources.
3.1.1. Handling Clinical Duties Securely
This conception concerns the fact that nurses deliberately demonstrate secure handling to coworkers in both
medical care and how they act in acute situations safeguarding patient safety. Nurses’ experience and
knowledge of the work in the unit develop over time and lead to greater safety at every stage and also
enhance structuring of daily work. With increased knowledge, nurses’ authority is strengthened. “When I
demonstrate my knowledge, they see that I’m skilled and confident. I notice that they listen more to what I
say. I want to do everything right so that they see that I can manage the situation, that there’s order and
structure, so they look up to me. Sure, there are things I don’t know, but I can find out.”
3.1.2. Being Underpinned with Scientific Sources
This conception is about nurses making use of scientific sources to justify decisions and measures and to
demonstrate relevant knowledge. This is regarded as creating a solid basis and ensuring that nursing
measures are carried out correctly and in a way that safeguards patient safety. By searching for regulations
on Internet and in steering documents, evidence is also used, for example, regarding safety of personnel
when there is a risk of infection. This is regarded as strengthening trust in the nurse’s knowledge. In
development and quality enhancement of nursing care, research is used as an argument for changes. “It’s
difficult to tell an assistant nurse who has worked for 30 years that you’re doing it wrong. First, you have to
make it clear that she has competence, but that the procedure is different now due to new research. For
example, that inserting an indwelling catheter has been replaced by intermittent catheterization and bladder
training. This change increased the assistant nurses’ workload. Then I had to underpin this changed routine
with research, gave repeated information, explained why and discussed patiently.”
3.2. Establishing a Good Atmosphere of Collaboration
This descriptive category comprises three conceptions: mutual respect, courage to be honest, and involving
others by encouraging reflection.
3.2.1. Mutual Respect
This conception refers to nurses being sensitive to AN’s verbal and nonverbal signals so they feel seen,
heard, and valuable. This also includes listening long enough and taking into consideration what they say.
Nurses listen to opinions expressed by others but also pay attention to their own feelings, experiences, and
ideas. They explain that everybody should show each other respect regardless of the number of years in the
profession, age, or where the person was born. Coworkers need to show understanding for each other’s
work and not just do as they feel fit. “I don’t want to say to somebody: do that and that; instead,
everybody’s opinions are important and we reach an agreement. If somebody else suggests that we could do
it better this way, then I listen and change my mind if I feel that it’s better.”
3.2.2. Courage to Be Honest
This conception is about nurses wanting to have open and frank communication characterised by
genuineness so that everybody can present their views. This presupposes that nurses can be themselves and
stand for what they say and that words and actions are congruent. The largest challenge facing a leader is to
be able to fearlessly give and accept feedback. This necessitates an open atmosphere and that everybody
dares and feels free to express their opinion. Nurses need to be aware that what they feel comfortable with
could be challenging for an AN. Criticism needs to be a natural part of collaboration and adapted
individually. Nurses may sometimes choose to criticise indirectly because they are uncertain as to how the
AN will react. This is exemplified by removing the problem from the AN and discussing it on a general
level and from the patient perspective. “I have to say when something isn’t good, otherwise the assistant
nurse has no chance of improving. Nobody is perfect, everybody can make a mistake and we need to talk
about it. If I want to have an open atmosphere, it’s important to be able to admit my own mistakes too.
When something in the interaction doesn’t feel right, I might say: the atmosphere feels weird, how does it
feel to you?”
3.2.3. Involving Others by Encouraging Reflection
This conception concerns nurses asking questions that require reflection instead of automatically just giving
an answer. Open questions are used such as what, when, how, where, and who. This, in turn, results in new
questions that are regarded as motivating ANs to increase their responsibility for their actions and
promoting development of knowledge. Discussions inspire everybody on the team to find alternative
solutions: “In the same way as I mentor nursing students, I ask questions to encourage reflection, for
example, based on Gibbs’ model of reflection instead of just saying how something should be done. It’s also
important to show what decisions are based on; you can read that or you’ll find it here. Assistant nurses who
question are a positive thing, I think. It can lead to discussions that stimulate reflection and contribute to all
of us acquiring more knowledge.”
3.3. Consciously Structuring the Work in Order to Ensure Patients’ Best Possible Nursing Care
This descriptive category comprises three conceptions: providing coworkers with a complete picture of the
patient’s situation, assigning and giving specific instructions for the work, and ensuring that patients’ needs
are met in front of routines.
3.3.1. Providing Coworkers with a Complete Picture of the Patient’s Situation
This conception concerns nurses’ coordination of the patient’s care and giving a well-founded and complete
description of their patients to coworkers involved. By means of dialogue, nurses try to find out how
patients are feeling, their understanding of the situation, and expectations regarding their own care.
Information about the patient is also gathered from coworkers and relatives. The nurse as leader is seen as
the spider in the web who coordinates the patient’s care by knowing everything. “I need to have control
over everything being planned and having to be done. I must have read everything in patients’ records and
know everything about my patients and quickly get a clear picture so that I can give this information to
everybody on the team; assistant nurses, physiotherapist, counsellor, physician, the patient and relatives.”
3.3.2. Assigning and Giving Specific Instructions for the Work
This conception deals with nurses’ assignment of duties to ANs based on an assessment of their level of
knowledge. A shift often begins with the nurse gathering ANs for a brief review of who does what of the
duties planned and assignments are usually done in an open dialogue. Nurses sometimes assign duties on
the basis of their own plan for the day, including both others and their own work. After the medical ward
round, nurse and ANs meet once again for a review of what they will do. The plan is followed up during the
day. When ANs’ duties involve doing something special with the patient, the nurse explains why and how it
should be done so that they understand the context. It is felt that just giving orders does not work. Some
ANs need more guidance and others less when they know what to do. Nurses need to be very clear. “I
communicate, analyze and reflect on what works. When I said this, it didn’t work. Then I specify in
practical terms what has to be done and later I ask: have you done it, otherwise do it now. Sometimes, I
remind her in advance and sometimes I write a note for her to fill in and hand back to me, otherwise I know
it won’t be done. /…/ It works when everybody knows what they all have to do and we have a continuous
dialogue.”
3.3.3. Ensuring That Patients’ Needs Are Met in front of Routines
This conception concerns nurses’ planning and evaluation of the nursing care which is built from patient’s
needs. In nursing documentation, patients’ problems and/or needs that have been observed by nurses are
noted. Neither routines nor the nurse’s or ANs’ own wishes are allowed to steer the work; instead, it is the
patient’s needs, clarified in the nursing documentation. “Our work must be structured so that everybody has
the same goal and do their duties with focus on the patient and not just follow routines. For example,
everybody should be washed before breakfast. I might hear from assistant nurses that first the ordering of
supplies must be ready. When priority is given to routines and patients’ needs come last, you have to tackle
this problem and expand understanding by discussing it from different perspectives and talking about the
consequences.”
3.4. Customized Presence in the Practical Work with Patients according to Predetermined Prerequisites
This descriptive category contains two conceptions: being approachable to staff and patients and consulted
when changes occur in a patient’s condition.
3.4.1. Being Approachable to Staff and Patients
This conception concerns nurses showing that they are approachable to ANs and patients. Being visible and
“out” with ANs in practical care work is considered to be crucial for the ability to be in control and for
monitoring quality of care. Working together strengthens solidarity with ANs as the nurse then understands
the work situation. Not being involved too much in practical work with patients and thus neglecting work
that only nurses can carry out are a balancing act. “I can’t lead the work if I’m not with my patients. I
usually have medicine trolley and computer with me and I’m always sensitive to what is going on around
the patients.”
3.4.2. Being Consulted When Changes Occur in a Patient’s Condition
This conception concerns the fact that nurses should immediately be contacted by the ANs when something
deviates from what is normal for the patient. Instead of their own observations of patients, nurses often need
to rely on second-hand information from ANs. This is a consequence of an overstretched and heavy work
situation with too many patients per nurse. The nurse does not have time to be with each patient as long as
what is actually necessary. This requires prioritisation of actions that only a nurse has competence and
obligation to carry out, such as medical-technical and acute measures. This places demands on being able to
organize one’s own work efficiently but also on being a problem-solver who can quickly identify other
alternatives. “I can’t be everywhere. I have to be told directly if, for example, a patient is suffering from a
cold sweat, is pale or says that he isn’t feeling well so that I can do something about it. When I have too
many patients, I have to reprioritise and do what I’m first and foremost is required to do as a nurse. I then
have to see to it and trust that other tasks are carried out by the assistant nurses.”
3.5. Monitoring Coworkers’ Professional Practice
This descriptive category comprises two conceptions: keeping an eye on the interaction between assistant
nurses and patient and keeping an eye on new staff.
3.5.1. Keeping an Eye on the Interaction between Assistant Nurses and Patient
This conception is about nurses observing ANs’ interaction in their encounters with patients. This can be
initiated by an AN having behaved unpleasantly towards a patient or complaints from close relatives. It can
also be a consequence of AN having talked over the head of a patient and asked the nurse instead of talking
directly to the patient. Nurses also observe to make sure that nobody aggravates or exploits the weak
position a patient is in. Keeping an eye on interactions can take the form of direct observation of how a task
is performed or indirect observation by standing in the corridor outside a room and listening to how an AN
treats patients. “I feel responsible for how assistant nurses behave. When I suspect that an assistant nurse is
not actively present and attentive to a patient or doesn’t reflect on how a measure feels to him, I tackle the
problem. When, for example, we wash a patient together, I look first at how she’s doing it and then I think
aloud on purpose. I don’t tell the assistant nurse how to do her job; instead, I ask the patient: is it OK like
this, does it hurt, how can we do to make it feel better. The way I talk affects the care we give together. I
lead by trying to influence how we think in interactions with patients in our daily work.”
3.5.2. Keeping an Eye on New Staff
This conception is about nurses keeping an eye on persons who have just joined the unit so that patients’
safety is not endangered as a result of insufficient knowledge. Getting to know and assessing a new AN’s
level of knowledge can be achieved by performing a task together. The AN is given opportunity to change a
wound dressing so that the nurse can be certain that the measure is based on insight, for example, wearing
apron and gloves and doing everything correctly. “I keep an eye on all new assistant nurses and sometimes I
have to ask for an explanation of what she’s doing. I always make it clear to new staff members that they
must ask if there is something they are uncertain about or don’t know. Assistant nurses and even registered
nurses can be dangerous if they doesn’t ask and makes a mistake.”
4. Discussion
This study provided a structure of descriptive categories and conceptions of registered nurses’ perceptions
of what it entails to be the leader at the bedside in inpatient physical care. The findings confirm and add to
previous work on what it entails to be nurse leader at the bedside. However, our findings highlight these
nurses’ perceptions of approach and procedures and clarify elements and process, which few researchers
have elaborated earlier. One explanation may be that most of the research has investigated formal leadership
practices such as those of managers and head nurses. Formal leadership models, for example,
transformational leadership, have been claimed to be transferable to nurses leading at the bedside. Our
participants’ leader principles seem to be grounded in the core values of the nursing profession that ensure
nursing values and person-centered attributes ahead of those associated with the dominant groups of
managers and physicians (cf. [17]). These are foremost loyal to the organization and its ideology of New
Public Management and economism, which often conflict with nurses’ professional community values and
beliefs about patient care [25]. A leader needs to assume responsibility for caring as the subject matter and
give direction towards patients’ vulnerability and suffering (cf. [26]). Leadership can then be interpreted as
empowerment to focus on patients’ interests as the guiding principle.
Our findings point to a social process of deliberate effort to attain and maintain trust, leader status, and
authority, in line with Chávez and Yoder [1]. Since nurses have an informal leadership role they need to
acknowledge their role as leaders both to themselves and to coworkers or somebody else will take the lead.
The findings also point to a deep sense of professional responsibility, but it is up to the coworkers to decide
whether the leadership is experienced as “responsible leadership” or not. This leadership involves nearness
and sensitivity, distance, understanding, and reflection, as noted by Foss et al. [26]. Our findings also
indicate that a nurse leader adheres to the same core values in relation to both patients and coworkers.
Demonstrating clinical knowledge points to necessity of attaining status by achieving authority as a leader.
As nurses have an informal leadership position, trust in them is essential. This is in line with Stanley [19]
who claims that ANs gain confidence in nurses as leaders when they have skills to demonstrate clinical
knowledge such as knowledge of nursing and knowledge linked to the specific area of practice. The ability
to lead is based on a solid and up-to-date understanding of the basis of professional nursing, in line with
Sahlsten et al. [27]. Understanding forms how nurses develop their professional autonomy, which can lead
to different ways of thinking. Accordingly, nurses in the unit need theoretical knowledge to discuss and
reach a consensus on the meaning of professional responsibility to lead at the bedside.
Establishing a good atmosphere of collaboration clarifies the significance of a dialogue and the leader’s
responsibility for creating a good climate of honesty and authenticity that makes it possible to build
confidence in the nurse as a role model. This is recognized as one of the elements in congruent leadership
[17]. If the nurse and AN have confidence in each other, it is easier to be honest and they can demand more
of each other. In a secure but also challenging collaboration, the nurse can test new ideas and way of leading
in order to develop courage and knowledge of both parties. A prerequisite is to reflect together in order to
utilise the AN’s potential for providing care. This can be traced to “reflection in action,” a conscious
reflection during the course of the action, followed by “reflection on action” after the action in order to raise
awareness of reflected knowledge [28]. As leader, a nurse also needs to be perceptive and confirming so that
each individual coworker feels valuable and appreciated and is able to develop in his/her work. This is in
line with Bondas [29] who claims that a trustful atmosphere requires human love visible in mutual response,
tolerance, and respect for the individual.
Consciously structuring the work in order to ensure patients’ best possible nursing care places high demands
on the nurse as leader as it involves being an effective coordinator and communicator and assumes the
responsibility to be in control. Being an effective communicator requires excellent listening skills and
ability to clearly articulate and share clinical information, observations, and opinions, also pointed to by
Stanley [19]. Our participants display values and beliefs through their actions and stimulate ANs to see and
deepen their understanding of clinical situations from different perspectives. Sometimes, instead of verbal
criticism, a nurse makes indirect remarks to stimulate reflection. Congruence with professional values,
empathy, and nonjudgementalism are qualities Rogers [30] identified as prerequisites for leading, teaching,
and counselling, activities involved when a nurse leads coworkers.
Customized presence in the practical work with patients according to predetermined prerequisites shows
that some participants can be available to coworkers and patients during the day and others are consulted in
the event of changes in the patient’s condition. This clarifies that nurses adapt their way of leading in
accordance with the prerequisites a nurse has to relate to here and now. This is in line with situational
leadership theory based on formal leadership practices [31]. Even though none of the participants mentions
any theoretical basis for their leadership, this model can still be identified. They seem to act as participating
leaders, a low task and high relationship style that passes on day-to-day decisions such as task allocation to
the followers (cf. [31]). Why nurses do not mention any theoretical model for leadership may depend on
lack of clarity regarding their leader position as nurses both during their nursing education and from their
organization. Registered nurses may seldom been recognized as the leader at the bedside in hospitals.
Accordingly, nurses maybe do not see themselves as the leader. Another explanation may be that research
has not focused on nurses’ informal leader position.
To lead the nursing care is a question of organizing one’s own and ANs’ work while adapting to each
person’s competence level and ability to take responsibility. A nurse needs to learn about and become
involved in the AN’s continued development. The main responsibility for allocating and organizing
resources and for development of coworkers’ competence lies with the first-line manager of the unit.
However, everybody has a responsibility, which means that coworkers need to be reminded that they are
part of the work environment. Previous research has shown that both nurses [27] and patients [32, 33]
emphasise the importance of a person-centered organization where patients have their own nurse during
their hospital stay. When nurses have too many patients, they are dependent on second-hand information
from ANs instead of being present and quickly initiate actions. Aiken et al. [34] have shown that too many
patients per nurse increases mortality, number of infections, and medical injuries. This causes suffering and
unnecessary costs, which could instead be used to increase the number of nurses.
Monitoring coworkers’ professional practice does not seem to have emerged so clearly in previous studies
of nurses’ leadership at the bedside. Here, nurses assume leadership accountability for patient safety in
order to protect them from violations and abuse of power or insufficient knowledge that could pose a risk. If
patient’s integrity and autonomy are not respected, the nurse is obligated in her capacity as leader to deal
with the problem [35]. This is also in line with Bondas [29] who states that there is no tolerance for
violations of human dignity. Patients are the group with least power and influence and are at the bottom of
the power hierarchy in the health care sector [33]. Our results show that nurses monitor the interaction
between ANs and patients so that the asymmetry is not exploited or reinforced. The nurse is a key person
and which kind of leadership he/she performs is crucial for the situation whether a patient is guaranteed
legal right to participate in their own care or not [36]. Accordingly, the patient’s perspective on their own
situation constitutes the basis and core of leading person-centered nursing care.
Our findings are based on these participants () and their ability to describe conceptions and experiences.
The descriptions are related to a group level rather than to the individual participants. The findings describe
the qualitatively different ways the participants experience the situation. When 13 interviews had been
conducted, earlier data were replicated and nothing new was added. The participants contributed a broad,
rich, and detailed variation of experience-based data. Two researchers independently performed an analysis
and compared structures of descriptive categories and conceptions. According to Marton [23], there should
be at least a two-thirds agreement when comparing analyses of two independent and competent researchers
and in our case consensus was reached. The credibility of the findings mainly concerns the relationships
among the categories and the data and is thus strengthened by direct quotations (cf. [23]).
The findings of this study should be interpreted in light of a few limitations. First, this study is limited to
physical inpatient care and the reader has to decide if the findings are transferable to their own context.
Obviously, other nurses and settings need to be explored. Second, several factors may influence a nurse in
being a leader and studies are lacking of hindrances/barriers nurses experience as well as what promotes
their leadership. Third, as nurses adapt their way of leading in accordance with the prerequisites they have
to relate to, nurse staffing levels influences need to be investigated. Fourth, the perspectives of head nurses,
ANs, and physicians are lacking in this study and would be essential to obtain in order to develop an in-
depth understanding of issues surrounding being a leader at the bedside.
Competing Interests
The authors declare that there is no conflict of interests regarding the publication of this paper.
Authors’ Contributions
Inga E. Larsson and Monika J. M. Sahlsten were responsible for study conception and design, data
collection and analysis, drafting of manuscript, and critical revision for important intellectual content.
Acknowledgments
The authors would like to acknowledge the Department of Health Sciences, University West, Trollhättan, as
well as the city of Trollhättan for financial support. Their grateful thanks go to the participants in the study
who openly shared their thoughts and experiences.
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SUMMARY

This study provided a structure of being a leader at the bedside in inpatient

physical care based on Swedish registered nurses’ perceptions. Leader principles
grounded in the core values of the nursing profession that ensure nursing values and
person-centered attributes were a key aspect. Our results highlight a social process of
deliberate effort to attain and maintain leader status and authority. Deliberate
communicative approaches and interactive procedures were identified as five
descriptive categories: demonstrating clinical knowledge, establishing a good
atmosphere of collaboration, consciously structuring the work in order to ensure
patients’ best possible nursing care, customized presence in the practical work with
patients according to predetermined prerequisites, and monitoring coworkers’
professional practice. As the leadership role is influenced by predetermined
prerequisites in the context, further studies are essential.

The findings from this study are essential in teaching nurse students what it
means to lead at the bedside. It can also provide guidance in drafting of a job
description for SNCL. Accordingly, the findings can contribute to a common
understanding of the phenomenon among nurses and differentiate it from leading in
general whatever professional area, to lead as a head nurse, and, as such, form a basis
for discussions and further research.

REFLECTION

As a student nurse, it is important to experience the struggle in the nursing ward

specially in the Philippine setting to imply value and provide the highest standard of
holistic care. It is imperative to communicate and work collaboratively with the
health care team to reach the common goal--- wellness of the client.