ALR

Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=imhn20

Issues in Mental Health Nursing

ISSN: 0161-2840 (Print) 1096-4673 (Online) Journal homepage: https://www.tandfonline.com/loi/imhn20

Intentional Modelling: A Process for Clinical Leadership Development in Mental Health Nursing

Gary Ennis, Brenda Happell & Kerry Reid-Searl

To cite this article: Gary Ennis, Brenda Happell & Kerry Reid-Searl (2016) Intentional Modelling: A Process for Clinical Leadership Development in Mental Health Nursing, Issues in Mental Health Nursing, 37:5, 353-359, DOI: 10.3109/01612840.2016.1158336

To link to this article: https://doi.org/10.3109/01612840.2016.1158336

Published online: 22 Apr 2016.

Submit your article to this journal

Article views: 2305

View related articles

View Crossmark data

Citing articles: 1 View citing articles

Issues in Mental Health Nursing, 37:353–359, 2016 Copyright © Taylor & Francis Group, LLC ISSN: 0161-2840 print / 1096-4673 online DOI: 10.3109/01612840.2016.1158336

Intentional Modelling: A Process for Clinical Leadership Development in Mental Health Nursing

Gary Ennis, RN, B Sci (Prac Dev), Cert Ed University of Canberra, Synergy: Nursing and Midwifery Research Centre, Faculty of Health, Melbourne, Australia and ACT Health, North Western Mental Health, Melbourne, Australia

Brenda Happell, RN, RPN, BA (Hons), Dip Ed, B Ed, M Ed, PhD University of Canberra, Synergy: Nursing and Midwifery Research Centre, Faculty of Health, Melbourne, Australia

Kerry Reid-Searl, PhD, MClin Ed, BHlth Sc, RN, RM Central Queensland University, School of Nursing and Midwifery, Division of Higher Education, Rockhampton, Queensland, Australia

Clinical leadership is becoming more relevant for nurses, as the positive impact that it can have on the quality of care and outcomes for consumers is better understood and more clearly articulated in the literature. As clinical leadership continues to become more relevant, the need to gain an understanding of how clinical leaders in nursing develop will become increasingly important. While the attributes associated with effective clinical leadership are recog- nized in current literature there remains a paucity of research on how clinical leaders develop these attributes. This study utilized a grounded theory methodology to generate new insights into the ex- periences of peer identified clinical leaders in mental health nursing and the process of developing clinical leadership skills. Participants in this study were nurses working in a mental health setting who were identified as clinical leaders by their peers as opposed to iden- tifying them by their role or organizational position. A process of intentional modeling emerged as the substantive theory identified in this study. Intentional modeling was described by participants in this study as a process that enabled them to purposefully iden- tify models that assisted them in developing the characteristics of effective clinical leaders as well as allowing them to model these characteristics to others. Reflection on practice is an important contributor to intentional modelling. Intentional modelling could be developed as a framework for promoting knowledge and skill development in the area of clinical leadership.

INTRODUCTION Leadership skills are viewed by many healthcare agencies

as essential for nurses (Anonson et al., 2014; Brady Germain

Address correspondence to Brenda Happell, Synergy: Nurs- ing and Midwifery Research Centre, University of Canberra, Fac- ulty of Health, and ACT Health Research, Building 6, Level 3, Canberra Hospital, P.O. Box 11, Woden 2606, Australia. E-mail: [email protected]

& Cummings, 2010; Buckner et al., 2014; Wilmoth & Shapiro, 2014) with reports such as The Review of Australian Govern- ment Health Workforce Programs in 2013 continuing to high- light the importance of investing in nursing leadership (Mason, 2013).

Clinical leadership has emerged as a type of leadership that enables nurses to support ongoing nursing workforce needs and contribute to improved outcomes for consumers (Ennis, Happell, & Reid-Searl, 2015b; Fealy et al., 2011) but continues to struggle to be integrated into the wider nursing profession (Ennis, Happell, & Reid-Searl, 2015b). This may be due to the difficulties that most nurses have in conceptualizing leadership as a clinical skill that is distinct and separate from nursing man- agement roles. Nurse clinicians have historically seen leadership through this management lens and relevant only to nurse unit managers or to nurses in similar roles (Carlin & Duffy, 2013). Clinical leadership in nursing relates to the quality and effec- tiveness of care that is delivered to consumers, can have a direct positive impact on the environment of care and quality of health outcomes (Davidson, Elliot, & Daly, 2006; Fealy et al., 2011) and for the purpose of this article does not relate to managerial responsibilities.

In mental health nursing clinical leaders can have a positive impact in the recruitment and retention of staff (Seed, Torkelson, & Karshmer, 2009), an area where mental health nursing has historically struggled (D. Scott & Happell, 2012), making it a valuable tool in broader nursing workforce strategies that focus on both recruitment and retention rates of nurses. While aca- demic preparation for mental health undergraduate placements is important (Happell, 2009) the experience students gain on clinical placement plays a significant part in any future decision about choosing mental health nursing as a career option (D.

353

354 G. ENNIS ET AL.

Scott & Happell, 2012). Undergraduate nurses report improved experiences when working with a nurse who displays the at- tributes associated with effective clinical leaders (Zilembo & Monterosso, 2008), suggesting that effective clinical leadership can have an important role to play in recruitment strategies.

Although there is much evidence available on leadership within the context of management roles a review of the cur- rent available literature highlighted a paucity of research on leadership programs that had content specifically aimed at de- veloping clinical leaders in nursing. This may be related to the lack of research around how clinical leaders develop the skills and attributes that enable them to fulfill that role. Nurses deliv- ering clinical care can have difficulty in separating leadership and management roles as the terms leadership and management are often used interchangeably (Carlin & Duffy, 2013; Holm & Severinsson, 2010). In addition, clinical leaders can be difficult to detect and are frequently only identifiable as clinical leaders by their peers. Effective clinical leaders are considered to have a number of attributes by their peers. These include enabling professional development; effective communication; remaining calm in a crisis; positive role modeling and implementing ev- idence based care (Cleary, Horsfall, Muthulakshmi, & Hunt, 2013; Ennis, Happell, & Reid-Searl, 2015a).

One model of developing skills and competence that most nurses will be familiar with is role modeling (Nouri, Ebadi, Al- hani, & Ahmadizadeh, 2013). Nursing, given its focus on prac- tical skill and competence development, has traditionally used approaches such as role modeling in the education and devel- opment of nurses (Carlin & Duffy, 2013; Davis, 2013; Felstead, 2013). While its support of the professional development of ju- nior nursing staff is well understood (Cleary et al., 2013; Nouri, et al., 2014; Klunkin et al., 2011) there remains a lack of ev- idence on the impact of role modeling on the development of nurse leaders.

Studies have recognized some of the attributes associated with effective role modeling for nurse educators and nurse lead- ers (Anonson et al., 2014; Baernholdt & Cottingham, 2010; Fealy et al., 2011; Salmela, Eriksson, & Fagerstrom, 2011; Wang, Chontawan, & Nantsupawat, 2011); however, they gener- ally provide little detail about how these attributes are developed. While role modeling is recognized as a core strategy to assist new nurses in developing clinical skills and competencies in the early stages of their career its applicability to clinical leadership development is not clear. In contrast to the evidence base avail- able on developing the more familiar middle management type leadership roles in healthcare, there are scant details on what is required to develop the attributes and characteristics of effective clinical leaders in nursing.

This article discusses the findings from a study that examined the process of clinical leadership development from the perspec- tive of peer identified clinical leaders in mental health nursing. Intentional role modeling emerged as a substantive theory in this grounded theory study.

METHODOLOGY

Design As there is a paucity of research on how clinical leaders

are developed in mental health nursing, Grounded Theory was chosen as the most appropriate methodology to guide this study and facilitate gaining understanding of the development of clini- cal leadership skills. Grounded theory is particularly appropriate as it facilitates development of new knowledge or insights re- garding a topic that has minimal existing evidence or research and seeks a theoretical explanation for the knowledge and in- sights uncovered (Charmaz, 2014; Creswell, 2007; Strauss & Corbin, 1998).

Ethics Ethical approval for the study was obtained from both the

mental health service where the research was conducted and the University Human Research Ethics Committee representing the research team. All participation in the study was voluntary with each participant giving formal, written consent. Consistent with the National Statement of Ethical Research (National Health and Medical Research Council, 2007), this formal consent included providing the participants with a participant information and consent form that outlined important considerations such as how privacy and confidentially would be maintained and their right to withdraw from the study if they chose to do so.

Setting The site of the study was in a public mental health service

in Victoria, Australia. This site was chosen as suitable because nurses work in mental health across a number of care settings including community teams, mental health telephone triage, a crisis team, and adult and aged acute inpatient units. In addi- tion, the site was of sufficient size to increase the likelihood of engaging an adequate number of participants in the study.

Participants This study was conducted in two phases. During the first

phase, participants were asked to identify any current peers that they believed were effective clinical leaders. The second phase involved interviewing those identified as clinical leaders with a view to gaining an understanding of how they developed the attributes and characteristics that enabled them to be recognized as clinical leaders by their peers.

The selection criteria for the participating group of nurses included peer identification as a clinical leader and currently working in a mental health setting at the study site. The partici- pants were identified as having the attributes and characteristics that are associated with clinical leadership that included calm- ness in a crisis, good communication skills and positive role modeling (Ennis et al., 2015a, 2015b).

PROCESS FOR CLINICAL LEADERSHIP DEVELOPMENT 355

Procedure The peer identified clinical leaders were contacted and pro-

vided an overview of the study. The first author subsequently arranged to meet with those who agreed to participate and ex- plained the study; time involved and obtained their consent if they agreed to participate. A private interview room was made available to conduct the interviews, ensuring that the chance of interruptions and distractions during the interviews were min- imized. Collection of data involved individual semi-structured interviews that were audio recorded (with consent of partici- pants). These audio recordings were transcribed verbatim.

Data Analysis A fundamental component of grounded theory is the proce-

dure of constant comparative data analysis. For this study data analysis began after the first interview and this iterative process of data collection followed by analysis and further data collec- tion continued until the final data was collected and saturation was achieved. Consistent with a grounded theory methodology this analysis influences subsequent data collection and includes additional questions that assist in the development of any emer- gent theory (Charmaz, 2014; Strauss & Corbin, 1998). The anal- ysis of data moves through a number of levels. The first level known as open coding includes examining and analysing data line by line from transcripts. At this point the study data were broken down through a process of line by line coding. These codes are then given conceptual labels using key words from the data collected (Charmaz, 2014; Strauss & Corbin, 1998).

The next level of analysis was axial coding where the data was reviewed and categorized, using a conditional relationship guide (K. W. Scott & Howell, 2008). The conditional relationship guide helped to establish relationships between subcategories and categories (K. W. Scott & Howell, 2008). The final level of coding was selective coding and involved identifying a central or core category and developing an understanding of how this core category relates to other categories (Charmaz, 2014; Creswell, 2007; Strauss & Corbin, 1998).

In keeping with grounded theory methodology memo writing and diagramming were used throughout the various levels of coding, assisting in the development of categories and ensuring that the emergent substantive theory was grounded in the data (Strauss & Corbin, 1998; Wertz et al., 2011).

FINDINGS Intentional modeling in relation to clinical leadership is the

core category that emerged from the data in this study. Inten- tional modeling is described by participants as a three stage process. In the first stage participants described intentionally observing the clinical leadership characteristics and attributes they want to develop. The second stage was described as a pro- cess of reflecting on what they have observed and deciding how it could be adopted into their own practice. The third stage oc- curs both in formal learning situations and informally in day

to day clinical practice and involves participants intentionally modeling these characteristics to others.

The peer identified clinical leaders that participated in this study described the experiences and processes that enabled them to develop the characteristics and attributes that allowed others to see them as effective clinical leaders. Identifying positive role models at an early stage in their nursing career was impor- tant. The clinical leader participants described how intentionally modeling the actions and behaviors of others that they identi- fied as clinical leaders influenced their own development as a clinical leader.

Participants observed and identified attributes and character- istics that they wanted to exemplify and adjusted/adapted for their own use. The following quote reflects this:

. . .along your way over the years, you certainly identify with people that you think, God, this guy’s switched on, or I really like the way—you know. I think you can often grab those things as you build a sort of kit bag of your own skills and strategies that you might need to pull out.

Identifying the nurses who displayed the characteristics and attributes that they wanted to develop was an important part of intentional modeling.

So, very from the beginning, I could pick who I wanted to aspire to, because of their practices, and their philosophy of how—their caring sense of humor, very caring, professional, hardworking, genuine.

The attributes and characteristics that were seen as important were identified by this participant who stated,

The friendliness, the confidence in themselves, they’re good decision makers and safe, very, very safe clinicians.

Another participant considers the part that observing and watching others has played in their development as a clinical leader.

I think that’s how we learn and I can think of some great nurses. Watching others who have done that successfully, and kind of say, “Oh, I like the way they do that.”

The importance of observing how others work is critical.

I’ve learnt those skills by – a lot of it, by watching other senior psych nurses, of how they do things.

One participant describes developing an approach to work- ing with distressed consumers based on their experiences of watching or observing others handling these types of situations:

If you’ve got someone who is paranoid, who doesn’t want to look at you, who is very agitated. . . I’ll just. . .[say] look, I know you don’t want to talk to me, it’s understandable, it’s obviously very stressful for you. . . .do the very, low grade, sort of, low stress, sort of way. And, I think, that’s something that I have observed in other clinicians when I was training. I loved watching that. I love that.

Identifying effective role models was part of the process. Participants in this study who were identified as effective clinical

356 G. ENNIS ET AL.

leaders then developed their own strategies and approaches. They took what was meaningful for them and made it relevant for their practice. They were able to pick out what was useful for them and, importantly, adopt or adapt it for their own use. They did not mimic or completely copy the actions of others if not compatible with their own style. As one participant explained,

Over the years you always see—well you just, and this goes back years ago to somebody who you looked up to and you thought, my God they do that so easily, and you try it. . . . ‘ve seen people who are so amazingly good at doing something but they do it in a way that I wouldn’t be comfortable with, so you can try different people’s skills out in a way but you still have to—it has to still sit good with you, because you can’t pretend to be somebody you’re not.

Again, the observation and identification of the approach or intervention that was thought to be useful or good practice was only part of the process of purposefully modeling. As described by the following participant, incorporating the clinical learning into practice and making it your own was the next important step for peer identified clinical leaders in this study:

I can think of some great nurses. One who is astoundingly good in the really acute, heated situations, amazingly good, and she’s calm and she talks and talks and before you know it, the patient’s taking the medication and it’s all good, and so you think, oh, I’d love to be able to do that. So I must admit, yeah, I take that on board and I’ll integrate that with my style.

Including and developing what they learned into practice was important for the peer identified clinical leaders, as described by one participant who stated that,

The opportunity to practice, given the opportunity to practice is a big thing. The gains that I’ve had was with opportunity [to practice] and people having confidence in me.

All participants described similar experiences when it came to adapting or using the approaches and skills they have iden- tified as useful for them. They all purposefully adapted and developed the characteristics and attributes that they observed in others to suit their own style. They now find themselves in a position of intentionally portraying or modeling a way of deliv- ering care. The intentional component of this is described by the peer identified clinical leaders as using particular approaches or clinical interventions to maximize the potential for a positive outcome for consumers as well as simultaneously modeling the characteristics and attributes that they have developed in clinical leadership to other staff.

One participant describes a clinical scenario where they in- tentionally approach a consumer who is presenting as aggressive in a confident manner, even though internally they are feeling far from confident.

If somebody’s really aggro I—I look quite comfortable with that to the point that I’ve got people behind me very comfortable with me doing the talking, but the person is so aggro, I’m screaming in my head would somebody grab him before he decks me, but because I look comfortable it—it continues really. And I come across as being very confident in that area.

Another participant reinforces how they, as a clinical leader, are very aware of how they present themselves, even if it is not how they are actually feeling internally.

You’ve got to stay very calm, in your tone of voice. And, if you’re doing an Mental Status Examination (MSE), how you would present yourself; everything is opposite to how you actually feel. Because you’re fighting that urge to not have your voice wobble [laughs] and not to say something stupid and not to give them false information.

When discussing why others may see them as a clinical leader another participant outlines how they feel it is important to actively demonstrate some of the attributes and characteristics they use in their day to day clinical practice. Again, the example is around modeling a sense of confidence and certainty to others.

I think, portraying to people around me, that I’ve got it under control, I know how to source it, and I can do it in a way, that, there’s no stress and it’s all right. And, even though it is a stressful situation, we look at it and prioritise. And, I suppose, I have those definitions in my head and I’ve learnt those skills by—a lot of it, by watching other senior psych nurses. . .how they do things.

When reflecting on how they work with staff that may be less experienced this participant intentionally creates a space for others to observe them modeling clinical interventions.

Yeah. What I’ll often do is ask them, “Do you feel comfortable in doing this?” [if they say] “No,” I’ll always say, “Come and watch me do it and learn from others.” Yeah, support them. It’s a scary process, and giving them support while they learn their skills and it builds their confidence, safely, and I don’t see anything wrong with that.

One participant takes this notion of intentional modeling to include clinical scenarios where the approach or interaction is deliberately selected by the clinical leader based on their clinical knowledge of the consumer. To the casual observer the interaction or engagement appears low key when in fact the clinical has planned to adopt a particular approach.

I think we’re chameleons. I think—I’m different with every person I meet. Sometimes, I bowl up and, “How’re doing?” And others, I’ll be very respectful and it just depends.

DISCUSSION Nursing leadership development has mainly focused on

nurses in middle management positions or those with formal leadership roles with minimal attention given to the develop- ment of clinical leaders (Hampel, Procter, & Deuter, 2010). The findings of this study indicate the development of the character- istics and attributes required for effective clinical leaders may require a different approach and need an evidence base distinctly different to that for other leadership and management roles. En- couraging the development of clinical leadership skills requires an understanding of how these skills are developed. The peer identified clinical leaders that participated in this study not only reflect the attributes and characteristics of effective clinical lead- ers that are identified in the literature (Ennis et al., 2015b) but

PROCESS FOR CLINICAL LEADERSHIP DEVELOPMENT 357

also have provided valuable insights into how they developed these characteristics and attributes.

A process of intentional modeling emerged as a substan- tive theory in this research. Although the concept of intentional modeling may be new for some nurses most will be familiar with more traditional approaches to modeling such as role mod- eling. Role modeling is well supported in the literature as an important way to develop clinical skills and competencies, es- pecially in clinical practice (Davis, 2013; Nouri, Ebadi, Alhani, & Rejeh, 2014). Approaches to role modeling generally focus on the behaviours to be modeled and how others can imitate them (Armstrong, 2008; Nouri et al., 2014), suggesting the ex- pert, or modeler, has control over what the learner or novice will see or experience as part of the modeling process. This traditional approach gives little control to the learner in select- ing or identifying the behaviors to be modeled, the learner in this context is not an active participant. While this current ap- proach to role modeling has great value in developing clinical skills (Davis, 2013; Felstead, 2013) its impact on other areas of nursing development such as professionalism and clinical leadership development is less clear. Intentional modeling as described in this study extends beyond the concept of role- modeling. It describes a process whereby the emerging clinical leader is active in the modeling process. Intentional modeling is a new concept that describes a process whereby the clinical leadership characteristics and attributes that are worthy of mod- eling are observed, reflected on, adapted by the clinician into their practice and then modeled to others. It is deeply ingrained in clinical practice and therefore very relevant for clinical leadership roles.

In explaining the process of intentional modeling, clinical leaders described the importance of reflection, although they did not always use this term explicitly. Reflection has been de- fined as “the ability to examine one’s actions and experiences with the outcome of developing their practice and enhancing clinical knowledge” (Caldwell & Grobbel, 2013, p. 319). The use of reflective practice in developing nursing practice is well accepted in many approaches to nursing education (Barbour, 2013; Caldwell & Grobbel, 2013; Cleary, Horsfall, Happell, & Hunt, 2013) and while a number of studies have identified its potential use in developing nursing leadership skills (Bondas, 2010; Cathcart, Greenspan, & Quin, 2010; Jasper, 2010), its im- portance in the development of clinical leaders in mental health nursing has not previously been identified. This may in part be due to some of the broader challenges associated with reflec- tive practice (Barbour, 2013; Parrish & Crookes, 2014; Sumner, 2010) and how relevant nursing staff perceive it for day to day clinical practice. The process of intentional modeling may pro- vide a meaningful exemplar of how relevant and useful reflective practice can be for clinical practice and skill development.

Understanding how the process of intentional modeling in- fluences the development of clinical leaders in mental health nursing is important as this enables the profession to consider if and how this process can be replicated for other nurses. Although

research and evidence continues to emerge that legitimizes and reinforces the importance of clinical leadership (Baernholdt & Cottingham, 2010; Ennis et al., 2015b; Fealy et al., 2011; Seed et al., 2009), there is minimal evidence currently available on which to build programs or approaches specifically aimed at developing future clinical leaders in nursing (Supamanee, Krairiksh, & Sunghakhumfu, 2011).

The finding that intentional modeling contributes substan- tially to developing attributes and characteristics required for clinical leadership is a significant contribution to the next stage in clinical leadership skill development for mental health nurs- ing. Intentional modeling may provide a framework to further understand the attributes of effective clinical leaders, and ulti- mately facilitate a process for developing these attributes. No- tably, this study broadens the ongoing conversation around clin- ical leadership by focusing on the ‘clinical’, possibly making it more relevant to nurses delivering direct care and clearly distinguishing from management roles. It extends beyond un- derstanding what makes a good clinical leader and the impact that they have, to include a focus on options or approaches that may provide a basis for future clinical leadership development.

Limitations Limitations of this study are essentially the limitations of

qualitative research. As the aim of these methods is to facilitate understanding, the number of participants that can be involved is limited, and therefore cannot necessarily be assumed to rep- resent clinical leaders in mental health nursing more broadly. Furthermore, conducting the study in one geographical location may further impact the generalizability of these findings.

CONCLUSIONS Clinical leadership is viewed by many nurses as highly

relevant because of its strong links to the delivery of direct, evidenced-based care to consumers. Understanding what char- acteristics and attributes are required to be an effective clinical leader is important but can only ever be the first step. This arti- cle brings new insights regarding the way clinicians in mental health nursing use a process or framework of intentional model- ing to develop their leadership attributes. Intentional modeling may offer an alternative approach to that of traditional leader- ship or management roles, to provide emerging clinical lead- ers a deeper understanding of the characteristics and attributes they should develop to fulfill their leadership potential within the clinical setting. While this article contributes new evidence and will promote discussion around clinical leadership devel- opment in mental health nursing, further research is required. Given the challenges of embedding a culture of reflection into clinical practice, it may be worthwhile understanding how the process of intentional modeling could be used as a framework for encouraging reflective practice to support emerging clinical leadership.

358 G. ENNIS ET AL.

ACKNOWLEDGMENTS The authors acknowledge the participants who gave freely

of their time to participate in this research. Thanks also to the staff that facilitated access to participants and supported the importance of the research. Particular thanks to the senior nurse, Ms. Shirley Jennings.

Declaration of Interest: The authors report no conflict of interest. The authors alone are responsible for the content and writing of this paper.

REFERENCES Anonson, J., Walker, M. E., Arries, E., Mapose, S., Telford, P., & Berry, L.

(2014). Qualities of exemplary nurse leaders: Perspectives of frontline nurses. Journal of Nursing Management, 22, 127–126. doi: 10.1111/jonm.12092

Armstrong, N. (2008). Role modelling in the clinical workplace. British Journal of Nursing, 16(9), 596–603.

Baernholdt, M., & Cottingham, S. (2010). The clinical nurse leader - new nursing role with global implications International Nursing Review, 58, 74–78.

Barbour, J. (2013). The making of a butterfly: Reflective practice in nursing education. International Journal of Human Caring, 17(3), 7–12.

Bondas, T. (2010). Nursing leadership from the perspective of clinical group supervision: A paradoxical practice. Journal of Nursing Management, 18, 447–486. doi: 10.1111/j.1365-2834.2010.01085.x

Brady Germain, P., & Cummings, G. (2010). The influence of nursing leadership on nurse performance: A systematic literature review. Journal of Nursing Management, 18(4), 425–439. doi: 10.1111/j.1365-2834.2010.01100.x

Buckner, E. B., Anderson, D. J., Garzon, N., Hafsteinsdottir, T. B., Lai, C. K. Y., & Roshan, R. (2014). Perspectives on global nursing leadership: In- ternational experineces from the field. International Nursing Review, 61, 463–471.

Caldwell, L., & Grobbel, C. (2013). The importance of reflective practice in nursing. International Journal of Caring Sciences, 6(3), 319–326.

Carlin, A., & Duffy, K. (2013). Newly qualified staff’s perceptions of senior charge nurse roles. Nursing Management, 20(7), 24–30.

Cathcart, E., Greenspan, M., & Quin, M. (2010). The making of a nurse manager: the role of experiential learning in leadership development. Journal of Nursing Management, 18, 440–447. doi: 10.1111/j.1365-2834.2010.01082.x

Charmaz, K. (2014). Constructing grounded theory (2nd ed.). Thousand Oaks, CA: Sage.

Cleary, M., Horsfall, J., Happell, B., & Hunt, G. (2013). Reflective com- ponents in undergraduate mental health nursing curricula: Some issues for consideration. Issues in Mental Health Nursing, 34, 69–74. doi: 10.3109/01612840.2012.722171

Cleary, M., Horsfall, J., Muthulakshmi, P., & Hunt, G. (2013). Recent graudate nurse views of nursing, work and leadership. Journal of Clinical Nursing, 22, 2904–2911. doi: 10.1111/jocn.12230

Creswell, J. W. (2007). Qualitative Inquiry and Research Design (2nd ed.). Thousand Oaks, CA: Sage.

Davidson, P. M., Elliot, D., & Daly, J. (2006). Clinical leadership in contempo- rary clinical practice: implications for nursing in Australia. Journal of Nursing Management, 14, 180–187.

Davis, J. (2013). Modelling as a strategy for learning and teaching in nursing education. Singapore Nursing Journal, 40(3), 5–10.

Ennis, G., Happell, B., & Reid-Searl, K. (2015a). Clinical leadership in mental health nursing: The importance of a calm and confident approach. Perspec- tives in Psychiatric Care, 51(1), 57–62. doi: 10.1111/ppc.12070

Ennis, G., Happell, B., & Reid-Searl, K. (2015b). Enabling professional development in mental health nursing: The role of clinical leader- ship. Journal of Psychiatric and Mental Health Nursing. doi: 10.1111/ jpm.12221

Fealy, G., McNamara, M., Casey, M., Geraghty, R., Butler, M., Halligan, P. . .., Johnson, M. (2011). Barriers to clinical leadership development: Findings from a national survey. Journal of Clinical Nursing, 20, 2023–2032. doi: 10.1111/j.1365-2702.2010.03599.x

Felstead, I. (2013). Role modelling and students’ professional development. British Journal of Nursing, 22(4), 223–227.

Hampel, S., Procter, N., & Deuter, K. (2010). A model of succession planning for mental health nurse practitioners. International Journal of Mental Health Nursing, 19, 278–286. doi: 10.1111/j.1447-0349.2010.00668.x

Happell, B. (2009). Influencing undergraduate nursing students’ attitudes to- wards mental health nursing: Acknowleding the role of theory. Issues in Menatl Health Nursing, 30(1), 39–46. doi: 10.1080/01612840802557113

Holm, A. L., & Severinsson, E. (2010). The role of mental health nursing lead- ership. Journal of Nursing Management, 18, 463–471. doi: 10.1111/j.365- 2834.2010.01089.x

Klunklin, A., Sawasdisingha, P., Viseskul, N., Funashima, N., Kameoka, T., Nomoto, Y., & Nakayama, T. (2011). Role model behaviors of nursing fac- ulty members in Thailand. Nursing and Health Sciences, 13, 84–87. doi: 10.1111/j.1442-2018.2011.00585.x

Jasper, M. (2010). Guest Editorial: The role of reflective leadership, supervision as well as emotional intelligence in nursing and midwifery. Journal of Nursing Management, 18, 351–354. doi: 10.1111/j.1365-2834.2010.1111.x

Mason, J. (2013). Review of Australian government health workforce programs. Australian Government. Retrieved from https://www.health. gov.au/internet/main/publishing.nsf/Content/D26858F4B68834EACA257B F0001A8DDC/$File/Review%20of%20Health%20Workforce%20programs. pdf.

National Health and Medical Research Council. (2007). National statement on ethical conduct in human research. Canberra, Australia: National Health and Medical Research Council.

Nouri, J. M., Ebadi, A., Alhani, F., & Ahmadizadeh, M. J. (2013). Qualitative study of humanization-based nursing education focused on role modeling by instructors. Nursing and Health Sciences, 15, 137–143. doi: 10.1111/j.1442- 2018.2012.00732.x

Nouri, J. M., Ebadi, A., Alhani, F., & Rejeh, N. (2014). Experiences of role model instructors and nursing students about facilitator factors or role modeling process: A qualitative research. Iranian Journal of Nursing and Midewifery Research, 19(3), 248–254.

Parrish, D., & Crookes, K. (2014). Desigining and implementing reflective practice programs - Key principles and considerations. Nurse Education in Practice, 14, 265–270.

Salmela, S., Eriksson, K., & Fagerstrom, L. (2011). Leading change: A three- dimensional model of nurse leaders’ main tasks and roles during a change process. Journal of Advanced Nursing, 68(2), 423–433. doi: 10.1111/j.1365- 2648.2011.05802.x

Scott, D., & Happell, B. (2012). Utilization and perceptions of primary health care services in Australian adults with mental illness. Population Health Management, 16(3), 208–213. doi: 10.1089/pop.2012.0018

Scott, K. W., & Howell, D. (2008). Clarifying analysis and interpretation in grounded theory: Using a conditional relationship guide and reflec- tive coding matrix. International Journal of Qualitative Methods, 7(2), 1–15.

Seed, M., Torkelson, D., & Karshmer, J. (2009). The clinical nurse leader: Helping psychiatric mental health nurses transform their practice. Jour- nal of the American Psychiatric Nurses Association, 15(2), 120–125. doi: 10.1177/1078390309333063

Strauss, A., & Corbin, J. (1998). Basics of qualitative research: Techniques and procedures for developing grounded theory (2nd ed.). Thousand Oaks, CA: Sage.

Sumner, J. (2010). Reflection and moral maturity in a nurse’s caring practice: A critical perspective. Nursing Philosophy, 11, 159–169.

Supamanee, T., Krairiksh, M., & Sunghakhumfu, L. (2011). Preliminary clin- ical nursing leadership competency model: A qualitative study from Thai- land. Nursing and Health Sciences, 13, 433–439. doi: 10.1111/j.1442- 2018.2011.00649.x

PROCESS FOR CLINICAL LEADERSHIP DEVELOPMENT 359

Wang, X., Chontawan, R., & Nantsupawat, R. (2011). Transformational lead- ership: Effect on the satisfaction of registered nurses in a hospital in China. Journal of Advanced Nursing, 68(2), 444–451. doi: 10.1111/j.1365- 2648.2011.05762.x

Wertz, F. J., Charmaz, K., McMullem, L. M., Josselson, R., Anderson, R., & McSpadden, E. (2011). Five ways of doing qualitative analysis. New York, NY: The Guilford Press.

Wilmoth, M., & Shapiro, S. (2014). The intentional development of nurses as leaders. The Journal of Nursing Administration, 44(6), 333–338. doi: 10.1097/NNA.00000000000000078

Zilembo, M., & Monterosso, L. (2008). Nursing students’ perceptions of desir- able leadership qualities in nurse preceptors: A descriptive study. Contempo- rary Nurse, 27(2), 194–206.