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The clinical nurse educator as leader

Article in Nurse education in practice · July 2012

DOI: 10.1016/j.nepr.2012.07.006 · Source: PubMed

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Contents lists available at SciVerse ScienceDirect

Nurse Education in Practice

journal homepage: www.elsevier.com/nepr

The clinical nurse educator as leader

Theresa Adelman-Mullally*,1, Cindy K. Mulder 1, Deborah E. McCarter-Spalding 1, Debra A. Hagler 1,
Kathleen B. Gaberson 1, Mary Beth Hanner 1, Marilyn H. Oermann 1, Elizabeth T. Speakman 1,
Patricia S. Yoder-Wise 1, Patricia K. Young 1
Bradley University, Department of Nursing, 1501 West Bradley Ave., Peoria, IL 61625, USA

a r t i c l e i n f o a b s t r a c t

Article history: The National League for Nursing recognizes leadership as an important aspect of the educator role. The
Accepted 8 July 2012 purpose of this article is to describe leadership in the context of clinical nursing education and how
clinical nurse educators enact leadership. The article identifies particular nursing practice skills and
Keywords: strengths that clinicians bring to nursing education that enhance leadership knowledge, skills, and
Clinical nurse educator abilities. After review of several leadership models, we identified five overarching themes that
Leadership
demonstrate how clinical nurse educators exemplify the various models including role modeling,
Nursing education leadership
providing vision, helping students to learn, challenging the system or status quo, and seeking relational
Nurse educator role
integrity. We explicate the themes with examples affirming the leadership potential of clinical nurse
educators, and suggest ways in which nursing faculty members and administrators might draw on the
leadership capital of clinical nurse educators.
Ó 2012 Elsevier Ltd. All rights reserved.

The clinical nurse educator as leader hire adjunct or part-time clinical faculty members to supplement
the full-time faculty for teaching in clinical settings. Clinical faculty
Nurse educators are expected to function as change agents and members have most or all of their teaching obligations with clinical
leaders, and to use leadership skills in preparing graduates for ever- courses and are expected to demonstrate competence as clinical
changing, complex healthcare environments (Halstead, 2007, p. practitioners and educators (Emerson, 2007). The role of the clin-
116). Both academic leaders and experienced clinicians are core ical educator can be compared to the role of “coach” (Emerson,
elements of the well-prepared faculty team required to achieve and 2007, p. 156). Essentially, the clinical educator guides student
sustain excellence in nursing educational programs (NLN, 2006). learning within the highly contextualized clinical setting (Gaberson
Clinical nurse educators who practice in healthcare and also and Oermann, 2010, p. 67).
guide clinical learning for students contribute greatly to the faculty As a group of current and emerging nursing education leaders,
team; experienced clinicians with knowledge, skills, and a deep funded through the NLN/Johnson & Johnson Faculty Leadership and
understanding of contemporary nursing practice have great Mentoring Program, we carried out a review of leadership literature
potential as educational leaders. The purpose of this article is to within and outside nursing and reflected on nursing education
describe leadership in the context of clinical nursing education, leadership during a year-long series of discussions. Mentor/proté-
including how clinical nurse educators can, and often do, enact gée dyads met by phone or electronic mail one or more times each
leadership. We identify particular leadership skills and strengths month to conduct individual literature searches for current lead-
that nurse clinicians bring from clinical practice to academic ership theory and analysis of evidence, then reported back to the
settings. large group monthly for discussion and synthesis. Dyads chose
In the United States, many academic settings have clinical-track theories that appeared highly congruent with clinical nursing
appointments as well as tenure-track appointments. Nursing education for additional review, and the group used their extensive
education programs without a separate clinical faculty track may collective experience as nursing leaders as a lens for more detailed
analyses.
Two of the large group discussions took place face-to-face over
the year within the context of a meeting or a national conference,
* Corresponding author. Tel.: þ1 309 369 2127.
and the rest were held as monthly 1e2 h phone conference calls.
E-mail address: [email protected] (T. Adelman-Mullally).
1
NLN/Johnson and Johnson Faculty Leadership and Mentoring Program Written transcripts of the meetings were valuable for successive
2008e2009. discussions and analysis.

1471-5953/$ e see front matter Ó 2012 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.nepr.2012.07.006
30 T. Adelman-Mullally et al. / Nurse Education in Practice 13 (2013) 29e34

The group progressed from wide exploration of leadership Clinical faculty members can encourage staff members to discuss
theories to identification of five overarching themes that demon- their rationale for how a procedure is performed as a way of helping
strate ways in which clinical nurse educators exemplify leadership: students to learn the clinical decision making required in the
role modeling, providing vision, helping students to learn, chal- professional role (Gaberson and Oermann, 2010, p. 45). This
lenging the system or status quo, and seeking relational integrity. In approach extends the role modeling beyond the clinical faculty
this article, we explicate these themes with examples affirming the member, facilitates teaching with nursing staff members as
leadership contribution and potential of clinical nurse educators. resources for teaching students, and provides an example of the
value of teamwork among providers. Staff nurses and faculty
Role modeling members working together enhance student learning as well as
staff and student satisfaction.
Leadership in the clinical faculty role can be demonstrated by Participation in the larger professional community is another
the conscious decision to be a role model for students. In the value that can be modeled. As students observe their clinical
Transformational Leadership model (Bass, 1999; Burns, 1978), this educator being part of practice decisions on an institution-wide or
role modeling is described as “idealized influence”. As experienced unit practice committee, or in a national organization, they begin to
nurses, clinical faculty members are well-acquainted with the understand how this leadership aspect of the professional role is
complexities of patient care, which extend beyond the perfor- actualized.
mance of technological skills to the domains of patient teaching,
counseling, monitoring, clinical judgment, ability to work as part of Providing vision
a healthcare team, and ensuring the quality of patient care (Benner,
2001). Essential elements of this expertise can be communicated A critical characteristic of an effective leader is developing and
to students by role modeling (Henderson, 2001; Walker et al., sharing a vision of the preferred future (Bass, 1999; Kouzes and
2011). Students learn from role models, whether the learning Posner, 2007). Inspiring others and leading change are attributes
gained from their example is intended or unintended (Gaberson of effective leaders that are crucial in preparing nursing students
and Oermann, 2010, p. 29). Providing leadership in the clinical for professional practice. In nursing education the preferred future
nursing role is an intentional choice to serve as a role model for encompasses many facets such as what nursing is, what a nurse
nursing students. could become, how patients should be cared for, what a clinical
At a basic level, role modeling includes teaching students by environment could be, and the goals for the semester. Nurse
observation of the faculty member performing a task or an inter- educators help students see the larger picture of the profession of
vention, which they then will be expected to perform. Clinical nursing versus only focusing on the tasks of nursing. Clinical faculty
educators model many care measures using their expertise to members not only nurture and mentor nursing students but also
demonstrate those procedures and activities. Beyond this, however, influence their coworkers to do the same by communicating
is modeling of the thought process underlying clinical decision students’ visions of “becoming a nurse”. These principles are sup-
making. As experienced nurses, clinical educators can think ported by the Transformational Leadership model and Kouzes and
through possible decisions in a patient situation before deter- Posner’s conceptualization of leadership. Transformational Lead-
mining the best approach to use with a patient. Often, experienced ership contends that the leader finds the way and leads others
nurses arrive at decisions based on intuition (Benner et al., 1996). As along that path (Burns, 1978) whereas Kouzes and Posner (2007)
role models, educators can demonstrate the decision-making identified this aspect of leadership practice as “inspiring a shared
process with students by speaking their thought processes aloud, vision”.
making the intuitive process evident to the student. Thinking aloud Clinical nurse educators help students to “envision goals”,
with students makes the decision-making process more apparent a characteristic of leadership described by Gardner (1989).
to the student and allows for discussion about possible options and According to Gardner, leaders point others in the right direction
how decisions are made (Price, 2005). and help group members negotiate tension between short- and
Many opportunities for leadership by role modeling are present long-term goals. Clinical educators exemplify this skill by envi-
when teaching professional responsibilities such as work behav- sioning the future, inspiring a commitment to the possibilities, and
iors, ways of interacting with patients and staff members, ethical enlisting others in a common vision. They support students to
behaviors, and advocacy, among others. For example, clinical achieve their professional goals.
educators may model appropriate ways to deal with a safety issue While it is true that nursing students must learn many skills
or medical error by their responses when students make related to caring for patients, professional nursing is more than
errorsdacknowledging the errors and responding by being theory and technical skills. Experienced nurses need to help
reflective rather than punitive. This models ethical behavior as well students see nursing in its complexity, merging theory and
as how nurses should respond to quality and safety issues in the knowledge with the relationship with a patient. Clinical educators
clinical setting, a lesson often easier to learn in context rather than are well positioned to demonstrate the complexities of nursing
in the classroom. Clinical faculty members may model how to practice because they often bridge the clinical and educational
question a physician’s order, using appropriate evidence and worlds. The clinical faculty member who is a leader should have
respectful communication, while functioning as a patient advo- a clear vision of professional nursing and how it is enacted at the
cate. Leadership in communicating such professional values has bedsidedin real patient care settings.
been described by Kouzes and Posner (2007) as “modeling the Clinical nurse educators move students beyond doing “academic
way”. exercises” and help them see how the learning activity will enable
Opportunities for leadership through role modeling can also them to develop as nurses. Because they often are participants in
extend to collaboration with other staff members. Perry (2009) practice changes, they can help students and colleagues alike to be
reported that clinical nurses who are considered to be excellent aware of new ideas and practices, and to evaluate how those
role models attended to the “little things” for patients, made changes might (or might not) move toward the envisioned future.
connections purposefully, and affirmed others. Students observing Both nursing faculty members and students can be over-
nurses often note differences in how the students learned a proce- whelmed by the many tasks that must be accomplished during
dure in school and how it is performed in real healthcare settings. a clinical learning activity. However, to prepare future nurse
 T. Adelman-Mullally et al. / Nurse Education in Practice 13 (2013) 29e34 31

leaders, part of what must be accomplished is inspiring a shared Planning and setting priorities is a skill that students must learn
vision of both the daily and long-term goals of the clinical experi- to be successful in nursing practice. Students can observe how
ence. What does the clinical group want to accomplish collectively? a clinical faculty member moves through the day to ensure that
What should the group do to make that vision come to life? each student has the opportunity for discussing his or her activities
Focusing on those questions throughout the semester will and seeking necessary guidance. They also see this skill played out
encourage students to develop a sense of looking to the future and when the educator asks questions such as, “How are you priori-
charting a course. tizing what the patient needs, and what you will do for the
Students need to explore not only the reality of the current patient?” Keeping the system functioning can be seen as the clinical
system of patient care but also imagine the possibilities of what faculty member intervenes when a student is responding too
a better system would look like. For example, in an acute care slowly to meet patient needs or when tension exists between a staff
facility, discussion in conferences or written journals could center member and the student. Exercising political judgment may be less
on envisioning how the system could be improved. What would an apparent and more diplomatically covert unless the clinical faculty
ideal hospital unit look like? What changes would be necessary for member explains the action and how it is carried out in the
this unit to become the most desirable workplace for new nurses? healthcare environment with a spirit of advocacy. This political
Inviting experienced nurses to participate with students in judgment skill, commonly referred to as “working the system”,
a brainstorming discussion about their visions for transforming allows the clinical faculty member to select assignments that
nursing practice could open new possibilities for change for both support student learning, deflect those staff members upset with
students and nurses. a student, and intervene when students face situations beyond
Another strategy to assist students to look to the future is to their skill level (Jowett and McMullan, 2007).
encourage them to think about who they can become as nurses. Finally, the clinical educator who is performing Gardner’s (1990)
Students can reflect on what they would like their colleagues to say leadership task of serving as a symbol can help students envision
about them when they retire. How did they make a difference in what it looks like to be a professional nurse. Through words and
others’ lives? What would they want others to list as their major actions, clinical faculty members portray professional nursing to
accomplishments? For what do they want to be remembered? novice learners. Thus, choosing words and actions that convey the
These types of visioning experiences are examples of ways to help responsibility, accountability, and opportunity of the profession
students to see beyond the moment, reflect on what could be, and enhances the meaning of “nurse” to the students and patients with
envision a preferred future as a nurse and leader. whom they interact.
Faculty members in clinical teaching roles also have the
Helping students to learn opportunity to empower students to become agents of positive
social change (Zungolo, 2009) at an individual level through patient
Expert clinical nurses who become faculty members guide advocacy, by facilitating change in a unit or community, or by
students to learn in an experiential way that is often far more participating in the political process for health policy change. When
memorable than what can be achieved in the classroom. Anderson a student practices leadership skills in solving healthcare problems
(2009) identified the results of a descriptive explanatory study under the guidance of an expert clinical nurse, both the student and
exploring the role transition from clinical nurse expert to novice society benefit from that available expertise.
academic. A key characteristic identified was integrating expertise,
providing a real-life perspective for viewing content and skills. The Challenging the status quo
clinical expert’s ability to provide numerous examples of patients’
experiences and professional nurses’ problem-solving abilities Another important aspect of leadership is challenging the
enriches the students’ learning, especially in relation to complex system or status quo to bring about desired change. Both healthcare
concepts. Clinical educators as leaders help students learn to act in and nursing education environments are undergoing rapid,
patient care situations. Enabling others to act is a practice of leaders continuous change that creates ambiguity and unpredictability.
identified by Kouzes and Posner (2007). Facing these challenges, leaders recognize when the old ways of
Benner (2001), in fact, identified one of the domains for doing things and typical solutions to problems are no longer
conceptualizing the role of nurses as “effective management of working, and have the confidence and courage to propose new
rapidly changing situations” (p. 111). This domain refers to nurses approaches.
using good clinical judgment while acting in the moment during Transformational leaders use authority and power to reject old
life-threatening situations. To students who are new to an acute care models of thinking and acting when they are no longer effective,
clinical setting, for example, differentiating between normal and create space for new perspectives and solutions (Bass, 1999).
intensity and life-threatening crisis is a moot point. Rather, at first all Transformational leaders use intellectual stimulation to inspire
challenges in a high acuity environment seem overwhelming; creative new approaches to challenges and innovative solutions to
students look to clinical faculty members to help them notice the problems. For instance, the clinical educator holds the potential to
salient aspects of the situation, identify patterns in patient transform nursing units using the intellectual capital and energy of
responses, and explore how the culture of the nursing unit may students to identify and overcome outmoded nursing practices,
influence care decisions (Tanner, 2006). When a faculty member is a function described by Gardner (1989) as renewing. Renewing
an established clinical and systems expert, the nature of the support challenges the “trance of non-renewal” (p. 24) in which the power
available from that teacher allows students to focus on learning. of inertia and the anxiety of change prevent real change from
Gardner (1990), in his classic work On Leadership, identified occurring. While many nursing faculty members and clinical unit
managing as one of 9 tasks of leadership. The clinical faculty nurses would espouse in principle the value of change, they resist
member who manages the learning environment and supports real change because it threatens the familiar, established way of
students in their learning is a skilled leader. Gardner’s managing doing things. The leader must recognize this resistance and ques-
task is divided further into five areas. While each of those areas tion the status quo as the first step toward breaking out of this
relates to clinical leadership by faculty members, three of the areas trance.
provide exceptional views of what established clinicians operating Leaders must not only take the risk of challenging a process that
in faculty roles can accomplish. is no longer working, they must create an environment in which
32 T. Adelman-Mullally et al. / Nurse Education in Practice 13 (2013) 29e34

their followers feel safe to take such risks. Kouzes and Posner license to think critically, trust their intuition, and grow personally
(2007) described this leadership practice as challenging the and professionally” (Speakman, 2009, p. 44).
process. One aspect of a safe environment is the leader modeling The role of the clinical nurse faculty member is to coach the
the way by demonstrating risk-taking behaviors, e.g., by starting practice of new learning in a “human laboratory”. Benner et al.
small and taking one step at a time. Additionally, the leader can (2009) identified coaching as nursing education’s signature
reduce the perceived cost of failure by emphasizing the benefits of pedagogy. The student who is coached, inspired, and motivated
learning from errors while at the same time assuring students that gains a sense of trust and builds a repertoire of knowledge and
patient safety will be protected. This can be accomplished as clin- skills that will support their learning and praxis in the future. This
ical educators encourage students to mentally rehearse skills before positive educatorestudent relationship provides encouragement
performing them, provide time and privacy for students to think by recognizing and appreciating individual contributions and
aloud with instructors and peers, and provide opportunities to celebrating the values and victories that create community spirit,
practice psychomotor and clinical reasoning skills in simulation described by Kouzes and Posner (2007) as encouraging the heart.
before moving into actual patient care settings. For instance, clinical educators can encourage the heart by helping
Challenging the status quo can be demonstrated by both students to reflect on how they made a difference in patients’
academic and clinical faculty members. Academic faculty members lives. Brookfield (1990) claimed that “underlying all significant
who are “insiders” to the educational system can challenge that learning is the affective glue binding educational relationships
system to create needed change in a nursing education program. together” (p. 163).
However, they may need to rely on expert clinicians to keep them Gardner (1990) acknowledged that establishing trust and
abreast of changes in the clinical environment and nursing practice loyalty are pivotal components to the act of leadership. Similarly,
that will require change in nursing education. Expert clinicians who Kouzes and Posner (2007) noted that leaders build trust; facilitate
are clinical teachers can identify current issues and trends that relationships; foster collaboration; and enhance others’ self-
affect a nursing curriculum, and can bring them to the attention of determination, competence, and confidence to enable others to
academic faculty members who have the authority and responsi- act. Specifically teacher involvement with students is needed for
bility to introduce curricular change. An important implication is engaged reasoning, perceptual acuity, and connecting in situations
that academic and clinical faculty members must be partners with (Benner et al., 1996). Clinical educators as leaders must create
one another to provide the most effective leadership for students in a learning environment that supports experimentation and forges
all learning environments. This partnership might challenge learning and critical thinking. It is in this leadership role that
traditions of the academic hierarchy by a greater involvement of teachers are called on to manage and assess students in a milieu
clinical faculty members who are often part-time. that is highly charged for both students and staff. This feat is truly
Clinical teachers demonstrate leadership by challenging the a balancing act and has a significant impact on the education of the
status quo in the clinical setting, advocating for students, nursing student. When students learn to trust, they become
communicating their student learning goals to staff members, and inspired to seek new knowledge and experiment-in-action. Clinical
creating an environment in which students feel safe to learn while educators bring with them skills from clinical practice for devel-
at the same time safeguarding patients from harm (Jowett and oping trusting relationships with patients that lend themselves to
McMullan, 2007). The clinical teacher also can challenge the relating with students.
status quo in the clinical setting by sharing new evidence for “Fairness is treating everyone equitably, not necessarily treating
practice, theories, and understandings of nursing practice gained them the same” (Guinier et al., 1997, p. 21). If it is appropriate to
from experience and knowledge in the academic setting. teach students that no two patients are alike, then is it not
Challenging the system to bring about needed change by important as nurse educators to acknowledge that no two students
making well thought-out suggestions for change is courageous but are alike? Past learning and personal experiences frame what and
prudent risk-taking, not risky behavior. When questioning the how students view the world and themselves as learners. Clinical
status quo and challenging the system are taken to the extreme, educators, while bridging theory to practice and supporting
a faculty member may become an “academic cowboy” (Saunders, experimentation-in-action in the clinical setting, also must attend
1999), ignoring the faculty’s collective responsibility for the to the uniqueness of each student. This task is not just daunting, it is
curriculum in favor of his or her own “creative ideas and uncon- heroic. Clinical educators are the leaders and advocates of the
ventional approaches to learning” (p. 30). Because clinical nursing education program, and as liaisons they have to envision
teaching takes place behind closed doors and may be invisible to the possibility of each learner in the reality of the practice. As such
other faculty members, there may be a greater risk of this it is evident that “the success of nursing as a profession in facing the
happening among clinical nurse educators. The clinical educator challenges ahead will hinge on our ability to proactively recruit,
as leader promotes ongoing communication among academic and develop, and mentor future nurse leaders” (Sherman, 2007, p. 295).
clinical faculty members to preserve the integrity of the Nurse educators use clinical practice settings to create experi-
curriculum. ential learning for students, whereby students gain clinical fore-
thought and wisdom (Speakman, 2000). Learning a skill and
Relational integrity language that are unfamiliar is a challenge to most learners. For the
nursing student, learning a skill or procedure one day and then
The nurse educator in the clinical environment must establish practicing it in the clinical setting the next day can be and often is
relational integrity through trusting relationships that motivate overwhelming. It is important for clinical educators not only to
and inspire students to learn and think. According to Kouzes and lead, but also to support the student’s inquiry and experiment-in-
Posner (2007), leadership is a relationship with credibility as its action to promote the wisdom of nursing practice. Nursing
foundation. A trusting relationship between the clinical educator students are asked to meld scientific knowledge with reflective
and the student is powerful, allowing students to gain autonomy nursing knowledge to learn to use clinical wisdom to understand
that enhances the acquisition of new learning experiences, partic- a patient’s condition (Benner et al., 1999). The clinical educator as
ularly in a learning environment that is by nature highly emotive the conduit leads students to an awakening or understanding that
and charged. Hence, empowerment is central to the achievement of becomes the basis of how they practice nursing. It is in this bidi-
learning outcomes. “Students who feel empowered are given rectional communication, the clinical dialog that shares one’s
 T. Adelman-Mullally et al. / Nurse Education in Practice 13 (2013) 29e34 33

knowing and expertise, that students begin to see themselves as Gardner’s tasks of leadership (pp. 11e22).
part of the profession of nursing.
Tasks/functions of leadership Description
What remains interesting is that “the paradox of learning
Envisioning goals Provide direction, solutions, and focus
a really new competence is this: that a student cannot at first
Affirming values Reflect group beliefs as they evolve
understand what he needs to learn, can learn it only educating Motivating Create group synergy to achieve
himself, and can educate himself only by beginning to do what he a common goal
does not yet understand” (Schön, 1987, p. 93). Without previous Managing Planning/Priority Setting;
knowledge or experience, how do students become responsible for Organizing/Institution Building;
Keeping the System Functioning;
their own learning in the clinical environment? Simply, clinical
Agenda Setting/Decision Making;
faculty members create an educational milieu, develop a relation- and Exercising Political Judgment
ship with students that allows students to be authors of their own Achieving Build a sense of community and trust
reality, guide learning by coaching, and celebrate students’ workable unity
Explaining Communicate clearly, anticipate
progress.
communication needs
Therefore, it is sufficient to say that transformative clinical Serving as a symbol Portray the collective identity
nursing opportunities are crafted, not created; are genuine, not to the group
contrived; and are ways in which faculty members share with Representing Serve as a symbol of the group
students what is unique to the domain of nursing. A student’s the group to external constituents
Renewing Modify the direction of the
learning transformation will not only have an impact on learning in
organization while holding
the present but on future learning endeavors as well. true to the purpose and values

Implications

This review of leadership concepts in the context of clinical Acknowledgment

nursing education provides an opportunity to appreciate leadership
as demonstrated through the clinical nurse educator role. Clinical We would like to acknowledge the contributions of Theresa L.
leaders embody the leadership qualities described by Richards and Puckett as a member of the project team.
Engle (1986) including articulating vision, embodying values, and Presentation of this work: The South Dakota Nursing Education
creating the environment and relationship within which learning Deans and Directors Conference 2009, NLN Education Summit
opportunities and activities can be presented and mastered. 2009, and the NETNEP 3rd International Nurse Education Confer-
Leaders inspire change, promote unity, accept responsibility, and ence 2010.
demonstrate the ability to motivate, validate, and empower others
(Adams, 2009).
Clinical experts bring leadership skills from practice to their role
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