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Strong leadership capabilities are essential for effective health services, yet definitions of leadership remain contested. Despite the acknowledged contextual specificity of leadership styles, most leadership theories draw heavily from Western conceptualizations. This cultural bias may attenuate the effectiveness of programmes intended to transform healthcare practice in Sub-Saharan Africa, where few empirical studies on health leadership have been conducted. This paper examines how effective leadership by doctors was perceived by stakeholders in one particular context, Sierra Leone. Drawing together extensive experience of in-country healthcare provision with a series of in-depth interviews with 27 Sierra Leonean doctors, we extended a grounded-theory approach to come to grips with the reach and relevance of contemporary leadership models in capturing the local experiences and relevance of leadership. We found that participants conceptualized leadership according to established leadership models, such as transformational and relational theories. However, participants also pointed to distinctive challenges attendant to healthcare provision in Sierra Leone that required specific leadership capabilities. Context-specific factors included health system breakdown, politicization in the health sector and lack of accountability, placing importance on skills such as persistence, role modelling and taking initiative. Participants also described pressure to behave in ways they deemed antithetical to their personal and professional values and also necessary in order to continue a career in the public sector. The challenge of navigating such ethical dilemmas was a defining feature of leadership in Sierra Leone. Our research demonstrates that while international leadership models were relevant in this context, there is strong emphasis on contingent or situational leadership theories. We further contribute to policy and practice by informing design of leadership development programmes and the establishment of a more enabling environment for medical leadership by governments and international donors.

As we witness an alarming change in the delivery of healthcare worldwide, there is a need for transformational leadership that can inspire and empower healthcare professionals, and patients alike. Due to the lack of economic, infrastructural and human resources especially in developing countries, the organisation and delivery of healthcare services is even more challenging. Hence, the focus of leadership development in resource-limited environments should be to facilitate knowledge building, interprofessional collaboration, empowerment and inclusion.In this paper, we use two exemplary cases to illustrate the impact of, and the challenges facing leadership capacity building in non-Western contexts with special reference to India and Curaçao. These cases demonstrate that there is a place for validated medical leadership models in developing countries with promising outcomes for the collective health status of communities at large. Such models, however, need to be contextualised to fit the individual country's economic and sociopolitical context. Also, the stakeholders should be prepared to create healthy professional cultures that embrace respect (for self and others) and focus on effective communication practices within their local environments.

Background: This is a critical reflection in relation to the nine months I spent on the Clinical Leadership Programme organised by a large NHS acute trust in England, underpinned by practice development methodology. The programme aimed to support 23 consultant clinicians from different medical specialties in their leadership development. Aims: To develop insights into my personal development as a transformational leader from exploring the concepts and tools introduced in the programme in relation to my role as a clinical lead for anaesthetics services across the trust. Conclusions: From my reflection, I now have a clear understanding of what leadership is, how it relates to management and that a good leader is often a good manager too. In addition, I have concluded that investing time in developing self-awareness in terms of my leadership behaviours has clarified my leadership role and also how to be a transformational leader in everyday practice. Additionally, using the headings person-centred care, safe care, effective care and effective workplace culture, I have been able to reflect and review some of my achievements as follows: Person-centred care: I visited the home of a patient with learning difficulties to enable them to access the hospital from the community Safe care: I have enabled a reduction in the number of ‘never’ events by promoting the stop before you block (SB4UB) programme in my anaesthesia department Effective care: I facilitated the enrolment of major elective surgical patients into the Enhanced Recovery Programme Effective workplace culture: I have zero tolerance to incidences of bullying and harassment Implications for practice: • Good leaders have the skills to develop with their teams shared priorities and purposes that guide everyday actions • Good leaders and good managers are needed to enable teams of people to work together • Successful leaders sometimes make changes that may be unpopular • Anyone, regardless of position or discipline, can develop transformational leadership behaviours

Background: Leadership development impacts on quality of care and workplace cultures for staff. Clinical Leadership embracing transformational and other collective leadership approaches are key enablers to developing effective workplace cultures at the micro-systems level. Following the development of a shared purpose and values framework, an internal, inter-professional clinical leadership programme was set up to grow a critical community of transformational leaders across one NHS organisation in England. This programme had previously been unsuccessful in engaging medical doctors. Aims and Objectives: This paper shares how a dedicated practice development based clinical leadership programme set out to support medical doctors across one organisation with their leadership journey, equipping them to become both transformational and collective leaders and facilitators with the skills to begin to develop and sustain effective workplace cultures, that are person centred, safe and effective. Methods: Practice development methodology with its collaborative, inclusive and participative approach for developing person centred cultures combined with clinical leadership strategies, formed the basis of the programme which emphasised the use of active and action learning drawing on the workplace as the main resource for learning, development and improvement. Self-assessment and co-creation of insights about clinical leadership together with collaborative analysis of evaluation data led to the syntheses of insights through the use of reflection and action planning. Findings/Results: Findings are presented at two levels: 1) Five individual authentic reflections by authors to illustrate their leadership journeys which also demonstrate how a range of tools were used and their impact from reflections. Insights and learning include recognition of the benefits of peer support and networking; development of a disciplined approach to learning and self-management; 2) A collaborative reflection and critique that embraced the feeling of a sense of team ethos and community cohesion, for the first time in a safe environment; as well as, a sense of collective shared purpose and values. Conclusions: We conclude that the programme helped to identify the impact of leadership on workplace cultures and to begin to embed ways of working that are collaborative, inclusive, participative and celebratory. This unique approach by one organisation to leadership development has enabled a journey of self-transformation for medical clinical leaders to commence. Practical implications arising from our learning: • An internal model grows clinical leadership capacity across the organisation through peer support and networking and collective leadership. • Investing in a safe confidential space for clinical leads and other staff groups is a strategy for leadership development practice. • There is need to develop more skilled critical companions to support leadership, improvement and development activities • Clinical leadership development, informed by practice development methodology, demonstrates potential for enabling transformative and collective leadership for achieving person-centred cultures in the workplace. Keywords: Clinical leadership, collective leadership, critical companionship, micro-systems, transformational leadership, workplace culture

peer-reviewed Aim To explore the differences in perceived importance and actual performance of clinical leadership for all grades of nurses and midwives engaged in clinical practice. Background Clinical leadership is central to the provision of person‐centred care. However, little is known about how nurses and midwives perceive this in practice. Methods Data were collected on a sample of nurses and midwives in the Republic of Ireland, using a cross‐sectional study design (n = 324). The clinical leadership needs analysis instrument was used to measure perceived importance and performance of clinical leadership in practice. Grades of nurses/midwives included; staff, manager, advanced practitioner and senior manager. Results Senior managers were more likely to report significantly higher scores than staff grades for perceived importance of Technology & Care Initiatives (p < .01) and Financial & Service Management (p = .02). Performance of Staff & Care Delivery was significantly higher for senior managers than staff grades [F(5,309) = 6.06 p < .01]. Conclusion There was a mismatch between the perceived importance and actual performance of clinical leadership in practice between different grades of staff. Implications for Nursing Management Leadership training for all grades and mentoring of staff grades can promote the building of confidence and empower staff in leading clinical practice.

Leadership is a role that nurses are expected to fulfil, regardless of their job title and experience. Nurses are required to lead and manage care as soon as they have completed their training. However, the development of leadership skills and the associated learning can be challenging, especially for less experienced nurses and those at the beginning of their careers. This article examines the importance of effective leadership for nurses, patients and healthcare organisations, and outlines some of the theories of leadership such as transformational leadership. It also details how nurses can develop their leadership skills, for example through self-awareness, critical reflection and role modelling.

The Health and Social Care Act 2012 heralded wide reaching reforms intended to place clinicians at the heart of the health service. For NHS general dental practice, the conduits for this clinical leadership are the NHS England local professional networks. In Greater Manchester, the local professional network has developed and piloted a clinician led quality improvement project: 'Healthy Gums DO Matter, a Practitioner's Toolkit'. Used as a case study, the project highlighted the following facilitators to clinical leadership in dentistry: supportive environment; mentoring and transformational leadership; alignment of project goals with national policy; funding allowance; cross-boundary collaboration; determination; altruism; and support from wider academic and specialist colleagues. Barriers to clinical leadership identified were: the hierarchical nature of healthcare, territorialism and competing clinical commitments.

Patrick A., Laschinger H.K.S., Wong C. & Finegan J. (2011) Journal of Nursing Management19, 449–460 Developing and testing a new measure of staff nurse clinical leadership: the clinical leadership survey Aim To test the psychometric properties of a newly developed measure of staff nurse clinical leadership derived from Kouzes and Posner’s model of transformational leadership. Background While nurses have been recognized for their essential role in keeping patients safe, there has been little empirical research that has examined clinical leadership at the staff nurse level. Methods A non-experimental survey design was used to test the psychometric properties of the clinical leadership survey (CLS). Four hundred and eighty registered nurses (RNs) providing direct patient care in Ontario acute care hospitals returned useable questionnaires. Results Confirmatory factor analysis provided preliminary evidence for the construct validity for the new measure of staff nurse clinical leadership. Structural empowerment fully mediated the relationship between nursing leadership and staff nurse clinical leadership. Conclusion The results provide encouraging evidence for the construct validity of the CLS. Implications for nursing management Nursing administrators must create empowering work environments to ensure staff nurses have access to work structures which enable them to enact clinical leadership behaviours while providing direct patient care.

Putting ideas for management improvement into practice is one of the core tenets of the RCN's clinical leadership programme It's a transformational experience,' says RCN interim head of education Anne Corrin. 'The change is personal and professional.'

Who are the clinical nurse leaders? What are the qualities and characteristics of clinical nurse leaders? Why are they seen as clinical leaders and what might their experiences of clinical leadership be? This paper outlines a research project that sought to explore these questions. The research involved surveying registered/qualified nurses from D to H grade ( n= 830) who staffed 36 clinical areas in one acute NHS Trust in the English Midlands. Only 188 questionnaires were returned, but the data proved a rich source of information about clinical leadership, the attributes of clinical leaders and who might be recognised as a clinical leader. F-grade sisters were seen as strongly associated with the role. The questionnaire was followed by interviews with 42 qualified nurses from D to H grade on four clinical areas in the same NHS Trust, and these were followed by eight further interviews with nurses identified from the interviews as clinical nurse leaders. The results demonstrate that clinical leaders appeared to be present at all nursing levels and in considerable numbers, but they were often not the most senior nurses and their approach to clinical leadership was based upon a foundation of care that was fundamental to their values and beliefs or view of nursing and care. The study also indicated that the type of clinical area had an influence on who might be seen as a clinical leader. The attributes of clinical leaders appeared to be clinical competence, clinical knowledge, approachability, motivation, empowerment, decision-making, effective communication, being a role model and visibility.

Aims and objectives To determine whether a formal mentoring programme assists nurse practitioner candidates to develop competence in the clinical leadership competencies required in their advanced practice roles. Background Nurse practitioner candidates are required to show evidence of defined clinical leadership competencies when they apply for endorsement within the Australian health care system. Aiming to assist the candidates with the development or enhancement of these leadership skills, 18 nurse practitioner candidates participated in a mentoring programme that matched them with senior nurse mentors. Design A pre-postlongitudinal intervention study. Method Eighteen nurse practitioner candidates and 17 senior nurses participated in a voluntary mentoring programme that incorporated coaching and action learning over 18 months in 2012 and 2013. Participants completed a pen and paper questionnaire to document baseline measures of self-reported leadership practices prior to commencement of the programme and again at the end of the programme. Results The mentors and the nurse practitioner candidates qualitatively evaluated the programme as successful and quantitative data illustrated significant improvement in self-reported leadership practices among the nurse practitioner candidates. In particular, the nurse practitioner candidates reported greater competence in the transformational aspects of leadership, which is directly related to the nurse practitioner candidate clinical leadership standard. Conclusions A formal, structured mentoring programme based on principles of action learning was successful in assisting Australian advanced practice nurses enhance their clinical leadership skills in preparation for formal endorsement as a nurse practitioner and for success in their advanced practice role. Relevance to clinical practice Mentoring can assist nurses to transition to new roles and develop knowledge and skills in clinical leadership essential for advanced practice roles. Nurse managers should make greater use of mentoring programmes to support nurses in their transition to new roles.

*Clinical process redesign has enabled significant improvements in the delivery of health care services in emergency departments and elective surgery programs in New South Wales and at Flinders Medical Centre in South Australia, with tangible benefits for patients and staff. *The principles used in clinical process redesign are not new; they have been applied in other industries with significant gains for many years, but have only recently been introduced into health care systems. *Through experience with clinical process redesign, we have learnt much about the factors critical to the success of implementing and sustaining this process in the health care setting. *The key elements for success are leadership by senior executives, clinical leadership, team-based problem solving, a focus on the patient journey, access to data, ambitious targets, strong performance management, and a process for maintaining improvement.