Are nurses prepared for clinical leadership in the intensive care units?

Nurse-clinical leadership is attributed to bedside nurses who, from an informal authority, exert a significant influence on other professionals in the team to achieve shared clinical goals.¹ From this position they can identify areas for improvement, motivate other members of the care team to act on patient care and lead initiatives for change to correct problems in the environment in which they work. They can also identify the key issues related to organisational structures, workflows, policies and procedures for the delivery of optimal patient care.² The most obvious consequence of this type of leadership impacts positively on both clinical practice, professional practice environment, safety and quality of patient care, as well as on the job satisfaction and retention of the professionals themselves.³

In order to promote clinical leadership in nurses, it is important to bear in mind that its development may vary depending on the context in which it is exercised.^4,5 In Intensive Care Units (ICU), where patients are in a critical state and require complex and specialised care, there is a need for nurse leaders at the bedside, with analytical skills, a sense of control, competence and autonomy, and who can provide an agile and effective response.^3–7 Among the key competencies that ICU nurses must develop to exercise this leadership are two-way and effective communication, both with professionals from the same or different disciplines, as well as with the patient and family.^5,8–10 The influence they exert on others increases when they gain their respect and confidence by demonstrating their knowledge of problem solving and ethical issues, especially in critical situations where they need to make confident and sensitive decisions.^9–11 Through their example, the confidence they provide by passing on their knowledge also empowers team members to pursue new ideas, encouraging growth and intellectual development, and fostering a sense of belonging.⁹ They must also be able to provide emotional support to team members by knowing the professionals and possessing an adequate emotional intelligence that enables them to recognise, understand and control their own and others' emotions.¹¹

In this regard, the question arises: are ICU nurses prepared to provide clinical leadership?

ICU nurses face situations on a daily basis that require appropriate communication skills, both with critical patients and their families, as well as with the interprofessional team in which they play an indispensable role,¹² due, in part, to their knowledge of the patient. As previously mentioned, the ICU nurse must know how to communicate at different levels and, for this, it is also necessary for them to possess adequate emotional intelligence. Both of these 'soft' competencies, together with those more technical and specific to intensive care, pave the way for the exercise of this type of informal leadership. This fact has been further highlighted during the COVID-19 pandemic, where the media has also echoed the need for nurses trained in the care of critical patients.^13,14

The evidence found shows that, despite the importance of ICU nurses being leaders at the bedside, most do not have adequate training to do so.^5,14,15 There are numerous occasions when ICU nurses express concern about the lack of tools to deal with difficult conversations with the patient, express their opinion or communicate with other professionals.¹⁶ The lack of communication skills and emotional intelligence have an impact on teamwork and, therefore, on patient care and safety.¹⁷ In fact, already in the literature, the lack of communication skills and emotional intelligence in ICU nurses has had an impact on teamwork and, therefore, on patient care and safety. In fact, the Institute of Medicine's 2011 report on the future of nursing highlighted the need for: (1) highly educated nurses to respond to the changing needs of patients; (2) an education system to develop advanced competencies; (3) lifelong learning opportunities; and (4) nurses with the necessary competencies to contribute to the quality of care.¹⁸ Along these lines, countries such as the United Kingdom and the United States have regulated the training of ICU nurses in the acquisition of technical and/or 'soft' skills to meet standards for critical patient care and to facilitate, for example, the development and implementation of improvement projects in the units.^19,20 In this way, nurses' talents can be fully harnessed to achieve the highest levels of quality and safety in health care.

In this way, nurses' talents can be fully harnessed to achieve the highest standards of quality and safety in health care.

Spain, like other countries in Europe, lacks a compulsory system for the training of nurses for intensive care. Those who do train do so on a voluntary basis, partly on the assumption that they have a professional and ethical obligation to seek professional development opportunities.²¹ As nurses are increasingly expected to act as leaders in the health care system in general, health care institutions should improve nurses' training and enhance professional development opportunities. The Clínica Universidad de Navarra, for example, offers a variety of specialised care qualifications each year as an alternative to existing social care programmes, with the aim of providing nurses with more advanced training to enable them to develop leadership in critical care.²² This type of training could serve as a starting point for the design of more ambitious comprehensive programmes that manage, from leadership, to develop the full potential of intensive care nurses for the benefit of critical patients and the healthcare system.

In view of this challenge, and taking into account the above, the following steps are suggested in order to promote the clinical leadership of nurses in the ICU:

• 1

  Train nurses in competencies in which we are less prepared, such as communication and emotional intelligence, through workshops, podcasts, or simulation.²³

• 2

  Promote the active participation of nurses in decision-making, through committees, working groups, proposing projects to improve daily practice in the units, or having a voice in multidisciplinary and interprofessional team rounds.

• 3

  Giving visibility to what we do inside and outside the organisation, through the media, forums, schools and associations. Nurses can be agents of change in intensive care units. It is necessary to make visible that we have this competence, that we can contribute that specificity to which our discipline and others contribute.

• 4

  Establish synergies at different levels: clinical-academic; public-private; between units and services (ICU-hospitalisation-ambulatory). To raise our voice, we must work collaboratively and learn from each other, and adopt measures to achieve organisational changes.

Funding

No funding was received for the preparation of this study.

Conflict of interests

There are no conflicts of interest.