SEMINAR PAPER 4

| |Received: 17 January 2020    Revised: 25 February 2021    Accepted: 1 March 2021

DOI: 10.1111/jpm.12751

ORIGINAL ARTICLE

Nurses' leadership in psychiatric care—A­ qualitative interview
study of nurses' experience of leadership in an adult psychiatric
inpatient care setting

Kajsa Sundberg1,2  | Cecilia Vistrand1,3  | Karin Sjöström1  | Karin Örmon1

1Department of Care Science, Faculty of Accessible Summary
Health and Society, Malmö University, What is known on the subject?
Malmö, Sweden • Previous studies on leadership in psychiatric care have focussed on a diversity of
2Malmö Addiction Center, Malmö, Sweden
3Division of Forensic Psychiatry, Malmö, staff and on different healthcare settings.
Sweden • Nurses in both Sweden and internationally, working with patients newly diag-

Correspondence nosed with psychosis and addiction, describe an overwhelming workload.
Karin Örmon, Department of Care • Existing research points out that experience and leadership training are the
Science, Faculty of Health and Society,
Malmö University, Malmö, Sweden. most important factors to exert a good nursing leadership. In Sweden, require-
Email: [email protected] ments for leadership exists already from the first day of a nurse's career.
• The relationship and communication between nurses in psychiatric care and
members of the staff is decisive for whether the leadership will work.
What the paper adds to existing knowledge
• The study adds knowledge regarding the challenges leading the nursing care for
patients diagnosed with psychosis and addiction.
• Ambivalence in the leadership role is prominent among nurses in psychiatric
care and feelings of responsibility and meaningfulness are mixed with feelings
of powerlessness and uncertainty.
• Swedish psychiatric nurses lack mandate to lead psychiatric nursing care. This
may increase the feelings of uncertainty in their leadership role.
What are the implications for practice?
• A mandate to lead as well as a leadership guidance in communication and team-
building will enhance the leadership, especially among newly graduated nurses.
• Heightened awareness within the healthcare organization about nurse's experi-
ence of difficulties in leading the psychiatric nursing care of the most severe
psychiatric illnesses could increase the right prerequisites for leadership.

Abstract
Introduction: Research shows that psychiatric nursing care puts additional demands
on the nurse as a leader due to the psychological complexity of care. Experience and
leadership training are most important to exert leadership. In Sweden, demands for

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
© 2021 The Authors. Journal of Psychiatric and Mental Health Nursing published by John Wiley & Sons Ltd.

|J Psychiatr Ment Health Nurs. 2021;00:1–12. wileyonlinelibrary.com/journal/jpm    1

|2      SUNDBERG et al.

leadership exist already at the beginning of a nursing career, and in psychiatry, it may
lead to an overwhelming workload.
Aim/Question: The aim of the present study is to highlight nurses' experiences of
leading the psychiatric nursing care in an adult psychiatric context.
Method: A qualitative interview study of eleven registered nurses within psychiatric
inpatient care. Content analysis was used for analysis.
Results: Leading with combined feelings of both meaningfulness and uncertainty
were the theme arising from the result.
Discussion: Findings from Swedish and international studies stress special demands
on leadership in psychiatric care. The result shows that nurses perceived an ambiva-
lence of their leadership in terms of both meaningfulness and uncertainty.
Implications for Practice: An official mandate to lead as well as leadership guidance
in communication and teambuilding will enhance leadership, especially among newly
graduated nurses. Heightened awareness within healthcare organizations about diffi-
culties in leading psychiatric nursing care could increase the possibility to create right
prerequisites for leadership.

KEYWORDS
inpatient psychiatric care, interview study, leadership, nurse, psychiatric nursing care

1  |  INTRODUCTION Warshawsky and Cramer (2019), nurses perceive that experience as a
nurse and leadership training are the core components of leadership
According to the ICN (International Council of Nurses), nurses should competence. In contrast, a study by Gerrish (2000) shows that newly
participate fully as members of the healthcare team and supervise graduated nurses in medical and surgical wards experience difficul-
and train nursing and healthcare auxiliaries. Furthermore, in a position ties in the transition from education to being a registered nurse, with
statement about evidence-­based safe nurse staffing, the ICN states regard to supervisory tasks. However, even experienced nurses may
that the nurses' work as leaders is very important (Duffield et al., feel that their leadership competence is inadequate and may, accord-
2007). The goals of nurse leadership are to ensure that the members ing to Josefsson and Hansson (2011), have difficulties in leading.
of the staff are working towards the same goal, to communicate in a
straightforward way and to enhance teamwork. Furthermore, patient Literature about psychiatric nursing leadership focusses on nurs-
satisfaction increases when the nurse has a clearly defined leadership ing practice, continuity of care, technology and innovation, stigma
role (Ennis et al., 2013; Holm & Severinsson, 2010). and patient partnership (Mildon et al., 2017). In psychiatric nursing
care, nurses are expected to participate in the direct psychiatric
Experienced leadership has been studied among nurses in gen- nursing care, show responsibility and expertise as well as being ac-
eral, and some of the studies performed stress that nurses in gen- cessible to co-­workers and patients. Other qualities in nursing care
eral and in a variety of healthcare contexts experience difficulties that are deemed important by mental health staff are to be able to
in leading (Gerrish, 2000; Karlsson et al., 2009; Solbakken et al., create trust, shape a safe environment and make decisions as leader
2018; Berg, and Hallberg, 2000). In a study by Casey et al. (2011), it of nursing care (Karlsson et al., 2009). However, a study by Glantz
emerges that nurses and midwives feel a great responsibility for the et al. (2019) describes how nurses working at a psychiatric clinic
quality of the care but have trouble defining their leadership role. If spend most of their time with medication management. The second
nurses are not confident in their leadership role, this will affect the most common activity was communicating with staff and other pro-
co-­workers negatively, which may in turn have a negative effect on fessionals about patient-­related information and planning the care
patient care (Sellgren et al., 2006). It also emerges from several stud- of the patients. Working close to patients was only the third most
ies that nurses experience difficulties in connection with decision-­ common activity for a nurse in a psychiatric context.
making regarding patients, partly because it is beyond their remit
and partly due to a lack of competence (Casey et al., 2011; Gerrish, Working in a psychiatric care settings is at times considered chal-
2000; Karlsson et al., 2009). lenging (Molin et al., 2016). These challenges have also been found
by Odeyemi et al. (2018), who described an overwhelming workload
The nurse is a role model and must lead the care judiciously among nurses working with patients newly diagnosed with psychosis
and competently, which entails reflection on ethical issues together and with a lack of clinical supervision. Nurses also felt abandoned in
with their co-w­ orkers (Gustafsson & Stenberg, 2017). According to situations where patients were threatening towards co-­workers, other

SUNDBERG et al. |      3

patients or towards themselves (Ross & Goldner, 2009). A challenging 2015). Nurses sometimes perceive it as contradictory to have a
work environment combined with feelings of abandonment could be great deal of responsibility but limited possibilities to influence the
the hindrance in preventing newly graduated nurses to fully adopt a overall nursing care (Berg & Hallberg, 2000). All in all, there are high
leadership role. Psychiatric care puts special demands on the nurse demands on the nurse's ability to lead and shape the nursing care,
as a leader because of the forceful psychological interactions that which will put further burden on the nurse as leader.
may take place. Nurses must analyse these interactions and lead the
staff towards optimal care in complex and difficult situations that may Gabrielsson et al. (2016) stress the importance that leaders of
be both emotionally challenging and dangerous (Mildon et al., 2017). psychiatric nursing care act as “ethical safe-­guards” and role models
Swedish nurses lead staff continuously. Since there is a lack of special- and take responsibility for the psychiatric nursing care. Leadership
ist nurses, even younger untrained nurses without specialist training qualities such as interacting with others, being team-o­ riented and
must lead the psychiatric nursing care. This is challenging, especially have the ability to teach and coach members of the team were con-
for novices, since psychiatric and mental health nurses in Sweden are sidered central for clinical improvement within psychiatric nursing
expected to lead psychiatric nursing from their first day at work. The care (Cleary et al., 2010). Ennis et al. (2015) describe clinical leaders
authors stress that these expectations are on an organizational and of psychiatric nursing care as effective role models especially for
on an individual level. The psychiatric context implies special demands newly graduated nurses. They are viewed as approachable, willing to
on leadership, such as nurses ability to teach and coach others (Cleary share knowledge and identify learning opportunities for colleagues.
et al., 2010), as well as being role models and leading the psychiatric Their ability to be calm and confident in emergency situations is also
care (Gabrielsson et al., 2016; Mildon et al., 2017). The relationship considered important leader attributes within psychiatric nursing
between the psychiatric and mental health nurse and members of the care. Hence, does a study by Molin et al. (2016) describe everyday
staff, and how the communication between them takes place, is de- work at a psychiatric in patient clinic were obstacles such as resigna-
cisive for whether the leadership will work or not (Ennis et al., 2015). tion prevented the staff from putting their ideals into practice.
The deeper experience of how nurses experience their leadership in
psychiatric care is, however, not fully explored. Previous Swedish research, describing leadership within psychi-
atric care, has been conducted in a variety of healthcare contexts
Cleary et al. (2010) state that, in a psychiatric context, transfor- and with a mix of professionals participating in interviews, such as
mative leadership fits well in a changing environment since it inspires nurses and nurses assistants (Gabrielsson et al., 2016) and nurses,
and motivates and, furthermore, encourages innovative thinking ward managers and physicians (Molin et al., 2016). This differs from
and promotes a supportive climate for an individual's developmen- our study, which focus solely on the experiences of nurses in psychi-
tal needs (Jambawo, 2018). To maximize the performance and re- atric nursing care. The present study results contributes to the body
sults of both staff teams and individuals, thereby enhancing health of knowledge regarding the challenges in leading psychiatric nursing
and recovery for patients, transformative leadership is described care, but solely from a nurses' perspective and within the area of
as effective (Poghosyan & Bernhardt, 2018). Promoting safety as a adult psychosis and addiction care. The aim of the present study is to
leader, for other healthcare members as well as patients, is another explore nurses' experiences of leadership in the psychiatric nursing
imperative in the mental healthcare setting. In a study by Gustafsson care in a psychiatric inpatient context.
and Stenberg (2017), psychiatric and mental health nurses state that
they also have an ethical responsibility when acting as leaders to 2  |  METHOD
protect both the staff and the patients, by having a non-­permissive
attitude to unethical behaviour, and to report if staff members are A qualitative interview study with an inductive approach was used,
found wanting in their psychiatric care. and content analysis according to Berg (2009) was conducted in
order to answer the aim of the study. The study was designed to
Ethical theories are seen as the basis of transformative leadership capture nurses' subjective experiences of leadership in psychiatric
and are hence of importance (Treviño et al., 2003). Ethical leadership nursing care.
encompasses three dimensions: to support, to provide and to protect
(Jambawo, 2018). Support is about being able to be supportive of the 2.1  |  Participants
staff, to receive and handle other people's feelings and to show care
and affirmation. Providing means that the leader, through evidence-­ Inclusion criteria for participation were registered nurse working in
based efforts, creates the structure for a good culture of care. adult inpatient psychiatric care and experienced in leading psychi-
Protecting means that the leader must protect the professionals as atric nursing care. Exclusion criteria were not defined. The nurses
well as those cared for (Jambawo, 2018). Barkhordari-S­ harifabad who participated in the study were employed at a public psychiat-
and Mirjalili (2020) describe how ethical leadership may lead to both ric clinic in an urban area in southern Sweden. They worked within
nurses' and patient satisfaction, as well as “inner satisfaction of the adult psychosis and addiction care. The authors informed the
leader.” Even though Brown et al. (2005) mention that ethical leader- nurses about the study at staff meetings at the psychiatric clinic,
ship increases confidence in the leader, an increase in responsibility and information regarding the study was also sent to the nurses
will be the result since an ethical leader must take responsibility for
colleagues and patients (Sayers, Lopez, Howard, Escott, and Cleary,

|4      SUNDBERG et al.

by the manager of the ward. Nurses who were interested in par- correspondence proved to be satisfactory, though a number of
ticipating informed the authors of this on location or by e-mail. adjustments were made. Initially, questions regarding psychiatric
There were eleven wards, where approximately 70 nurses worked. nursing care were asked in order for the informant to be intro-
Among these, there were both nurses with a graduate nursing ed- duced into the subject. The questions were semi-s­ tructured ac-
ucation and nurses with a specialist education within psychiatric cording to Berg (2009), which entailed predetermined questions
nursing care, and all of them were asked to participate in the study. or topics, but also a freedom to probe further. The questions in
Two to four nurses were present at each working shift. The nurse the interview guide were as follows: “Can you tell us about how
who worked the day before was assigned the leadership role. All you lead psychiatric nursing care?”, “Can you tell us about a situ-
the nurses were, however, responsible for providing the psychi- ation that has been challenging for you as a leader of psychiatric
atric nursing care. Eleven nurses finally participated. Their work- nursing care?” and “Can you tell us about a situation where you
ing hours varied between daytime, evening and night work. The experienced your leadership as well managed?” The informants
nurses had undergone their nursing education between the years could choose the time and place for the interviews, and all the
1990 and 2018. Five of the participants were specialist nurses in interviews were performed in a separate room at the hospital.
psychiatric care, working as psychiatric and mental health nurses Sociodemographic questions regarding gender, age, education
within psychiatric care for between 6 and 20  years (Table 1). In and experiences working within psychiatric nursing care initiated
Sweden, psychiatric nursing is an advanced level post-r­ egistration the interview. The interviews were conducted during 3 weeks in
specialization. March 2019. The median duration of the interviews was 29  min,
and most of the material corresponded to the aim.
2.2  |  Ethical considerations
During the interviews, one of the authors was active in asking
The ethical principles of the Declaration of Helsinki (World the questions based on the interview guide and the other author
Medical Association, 2018) were taken into account during the listened actively, in order to ensure that the aim was answered,
course of the study. The information requirement was fulfilled by and asked follow-u­ p questions towards the end of the interview.
the participants getting both written and verbal information about When verbal and written consent had been given by the infor-
the study as well as information about the ethical principles of the mants, the interviews were audio-­recorded. After 11 interviews,
Declaration of Helsinki (World Medical Association, 2018). This the decision was made that additional interviews would not con-
code for research is in accordance with the bioethics of the Human tribute to further valuable and unique data. The audio-r­ ecorded
Rights Act and emphasizes the right of confidentiality regarding interviews were then divided equally among the authors and tran-
participants and the right to end participation of studies at any scribed verbatim.
time. These bioethical standpoints were among others assured of
and were of great importance since no ethical approval was de- 2.4  |  Data analysis
manded in this kind of study under the Swedish Act concerning
the Ethical Review of Research Involving Humans. Confidentiality According to Berg (2009), the purpose of content analysis is to make
regarding participants in the study was assured. The authors of a detailed review and interpretation of the text that corresponds to
the study had no relationships with the participants that could the aim of the study. All the recorded interviews were listened to
pressure them to participate. parallel to reading the transcripts. Each author individually selected
meaning units, which are the segments of the transcripts that cor-
2.3  |  Data collection respond to the study aim in all the interview texts (Berg, 2009). The
choice of meaning units was discussed until consensus was reached
A pilot interview was conducted in order to ensure that the in- and joint meaning units were selected. The meaning units were
terview questions corresponded to the aim of the study. The then condensed, which according to Berg (2009) means that they
are shortened without losing important information. Subsequently,
TA B L E 1  Demographic data of the study participants (N = 11) the meaning units were coded and subcategories were created,
which Berg (2009) refers to as axial coding. The subcategories were
Female 7 initially created separately and then discussed until consensus was
obtained. Subcategories that resembled each other were analysed
Male 4 before creating a category with a higher level of abstraction. During
Age 26–­64 the process of analysis, pre-u­ nderstanding was bracketed through
Work experience within psychiatric care 2 months–­29 years the authors taking a step back and maintaining an attitude of open-
Bachelor of science in nursing (BSN) 6 ness and curiosity to the material and to what emerged in the analy-
Master of science in nursing (MSN) 5 sis. The ambition was to slow down the process of analysis, in order
not to make any hasty decisions about categories and the theme
(Table 2).

SUNDBERG et al. |      5

Theme 2.5  |  Rigour
Leading with combined feelings
In order to ensure rigour in the findings, we aimed for trustworthi-
of meaningfulness and ness in accordance with standard criteria for qualitative research
uncertainty (Graneheim & Lundman, 2004). The fact that two of the authors
participated in all interviews, reflected after each interview and
Category transcribed all recorded material, and thus became familiar with the
Feelings of control material, increases the reliability of the study. Transferability was
strengthened by the variety of participants, a clear description of
facilitates the the data collection and analysis process as well as a clear presenta-
leadership tion of the result together with relevant quotations. Three of the au-
thors are psychiatric and mental health nurses, and one researcher is
Subcategory a psychiatrist. The authors have all worked in a variety of psychiatric
Knowing one's staff care settings and are experienced in leadership, which has been ben-
eficial for the process of analysis.
Code
I have an idea of who 3  |  RESULTS

is most suitable for The aim of the study was to explore nurses' experiences of leading
which task psychiatric nursing care in an adult psychiatric context. The analysed
material resulted in ten subcategories, four categories and a theme
TA B L E 2  From meaning unit to theme according to Berg's (2009) content analysis Condensation (see Table 3). The result will be presented below; the theme and cat-
I have an idea that, if I select someone egories are shown in bold italic headlines, and the subsequent sub-
categories are introduced in italics in the body of the text. When the
to have a talk that person, if it's not informants refer to nursing assistants or aides, they use the overall
a contact person, is more suitable. I term “staff” and this is therefore the term used in the result.
believe that I have an idea at the back of
my mind when I distribute who is most 3.1  |  Leading with combined feelings of
suitable meaningfulness and uncertainty

Meaning unit Being a leader meant being the hub of the wheel. It was often chal-
I probably have an idea sometimes lenging and difficult to be both a leader and a colleague. The focal
point of the leadership was to guide the clinical work and be the per-
that, if I select someone to have a son who was responsible for the nursing care provided. One benefit
talk that I think that that person was that the nurse as a leader had a superior position, but the focus
maybe, if it's not a contact person, was the nursing care and the patients, not the staff. Although, being
that that person is perhaps more a leader meant being a coach to the staff. As a leader the nurse had
suitable. I believe I do, I think I have the overview of the patients and the psychiatric nursing care, which
an idea at the back of my mind was fulfilling. The main obstacle, however, was that the nurses were
when I distribute, uh, who is most not always given a clear mandate to lead, which was experienced as
suitable challenging.

I like to lead and I feel that I'm, sort of, good at it. I
enjoy teaching, teaching new staff how to do, for
example. It's also when the whole team is, when it's
harmonious and everyone knows and sees the psychi-
atric nursing care. It can also be hard to reach [them],
that is, they don't listen. You don't get help when you
ask for it, that's something that I feel is difficult, it's
like talking to a wall.

(Informant 11)

|6      SUNDBERG et al.

TA B L E 3  Subcategories, categories and theme Feelings of uncertainty when
leading
Theme
Feeling a lack of clarity
Leading with combined feelings of meaningfulness and uncertainty regarding who leads

Categories Being a novice in the
leadership role
Leading with feelings of Feelings of control facilitates the Feeling powerless in one's leadership
responsibility leadership
Frustration over unmotivated staff
Subcategories A feeling of inadequacy
The difficulty of not being accepted
Being the one who has an Knowing one's staff
overview as a leader

Confident to lead when A supportive structure
necessary

Being a supportive leader

3.2  |  Leading with feelings of responsibility negatively affected by their work, why a supportive leadership role
was-f­ elt to be important.
Leading the psychiatric nursing care was considered to be important
by the nurses. They expressed how it was essential to have knowl- I'm often the one who has to intervene and point out
edge in psychiatric nursing care, take responsibility and lead when and support the staff in solving situations, which can
needed. The leadership role was seen as important, meaningful and sometimes involve instruction when the staff are in-
rewarding. experienced and don't understand that the patients
behave in a certain way and need a certain care.
Being the one who has an overview was important. It was essential
to have the overarching responsibility for giving the patients good (Informant 1)
psychiatric nursing care, for the coordination with other agencies
and for running the daily work in the ward. It emerged that having 3.3  |  Feelings of control facilitate the leadership
the key function and an overarching responsibility for the function-
ing of the ward was the foundation for leading the psychiatric nurs- A supportive structure, and staff who followed the routines, facili-
ing care. tated the leadership, as well as providing a sense of meaningfulness.
By having knowledge about the staff's competence, and having trust
Then I really have to gauge, scan, and prioritize. That's in the staff, the nurses felt in control of their leadership.
what it's all about all the time: what's most important,
what fires should we put out? Knowing one's staff was highly important for being able to lead
the psychiatric nursing care. By knowing which staff members who
(Informant 7) were suitable for different work tasks, a sense of confidence was
created with regard to delegate a task to the right person. There was
Being confident to lead when necessary was also described as a considerable awareness in every decision made by the nurse with
important in the narratives. This experience was rendered through respect to delegation.
descriptions of the importance of having the courage to lead when
the team had different opinions about what was to be done. I know how the staff think, how to adapt my leader-
Depending on the knowledge of the staff, direct exhortations, ship, or how the staff will react. We all have different
as well as careful descriptions of how to perform the psychiatric knowledge in the group, someone a great deal and
nursing care, were sometimes required. The staff seemed to find someone perhaps a little, that's why it becomes im-
it troublesome that the required nursing care was not always spe- portant how well I know the group. For example, here
cifically psychiatric, which could entail a risk of the care not being I may hand over, I know that the risk of suicide will be
performed correctly. In those situations, the leader needed to be handled correctly.
courageous in order to stand up for all the needs of the patient
and guide the staff. (Informant 2)

Being a supportive leader was considered crucial when the staff A supportive structure was described as essential for feeling confi-
did not have enough knowledge. The experience was that patients dent in one's leadership role. Experiences emerged to the effect that
cared for in the wards often had complex needs of care, which the structure could be a support both in performing and in leading the
placed high demands on the nurses‘ leadership in psychiatric care, psychiatric nursing care. The structure made it possible for the staff to
since knowledge was sometimes lacking in the staff and hence since take responsibility themselves, and the nurse felt that leading the psy-
the staff were in need of support. Working with patients with men- chiatric nursing care was facilitated. Routines and guidelines increased
tal illness was also described as taxing and the staff at times were

SUNDBERG et al. |      7

the participation of the staff as well as their awareness of the tasks and help out, which made the nurses feel invisible as leaders. Feelings of
goals of the care. By means of the structure in the wards, the leader- not being liked by the staff emerged, and it was difficult to implement
ship of the psychiatric nursing care was perceived as efficient and a suggestions for the psychiatric nursing care, which created uncer-
sense of confidence arose. tainty in leading psychiatric nursing care in the ward. The staff were
described as sometimes opposing decisions and not agreeing to what
Most things are written down, what to do, and peo- was decided on.
ple are very good at taking responsibility themselves
here. We have our medical records, so it's very easy. You notice that people turn their backs on you a little
There's seldom anyone who doesn't know what their or don't answer. That's not fun and some people are
tasks are. so, a little bit in their own rut, so to speak. They've
been there for many years and claim to know how to
(Informant 9) do things, and don't share and keep it to themselves.

3.4  |  Feeling powerless in one's leadership (Informant 6)

A feeling of powerlessness in leading the psychiatric nursing care was The nurses experienced feelings of powerlessness with regard to
experienced when there was little ambition on the part of the staff leading the psychiatric nursing care, especially when members of the
to perform care. Dislike from the staff, lack of time, and the feeling staff perceived themselves to be experts at psychiatric nursing care
of not being listened to, exacerbated the feelings of powerlessness. and wanted to perform the work in a certain way, thereby hindering
the nurse to lead the psychiatric nursing care.
The result showed a feeling of frustration over unmotivated staff.
A feeling of powerlessness and irritation arose when the nurse was 3.5  |  Feelings of uncertainty when leading
to exercise leadership of the psychiatric nursing care over staff who
were not perceived to be interested in their work. Finding one's leadership role was considered challenging, and there
was uncertainty as to the leadership assignment. The nurse's feel-
Unwillingness is also a difficulty, when it's pure un- ings of ambiguity regarding the leadership role also led to feelings
willingness. There's no willingness to work, people of uncertainty.
who are just sitting there, who don't want to be there,
that's almost the worst thing, because you can't do Feeling a lack of clarity regarding who leads the psychiatric nursing
anything more about that. Those who are lazy you care was common. Several nurses taking on the leadership role at
can still get going somehow, they can after all be lazy the same time created disarray and lack of clarity. Some nurses did
and interested. But those who are completely unin- not get any opportunity at all to lead the psychiatric nursing care,
terested in the care or in people, they are difficult. as there were other persons, such as other staff members and non-­
medical trained managers, who took the leadership role. Difficulties
(Informant 3) arose when there was competition between nurses, that is, when a
nurse was to lead the psychiatric nursing care in a team where there
When there was not enough time to be able to lead the psychi- was another nurse. Furthermore, uncertainty arose when the work
atric nursing care, a feeling of inadequacy emerged. It was important situation was disorganized and no one took a clear responsibility for
to participate actively in the nursing care in order to be able to lead. the leadership.
Knowing the patient's needs, as well as knowledge about and time with
the patients, were necessary factors but took time off the leadership I become nervous when the person who's supposed
tasks. Even so, taking an active part in the daily tasks gave the nurses to lead doesn't clearly take on the role of a leader,
the mandate they needed to lead. then I become confused and want to take over so that
someone leads. Then things can become a bit disor-
I'm responsible for six patients and it doesn't work, I ganised, but, well, what do I do then? I don't know.
don't keep track of them at all, I must say, and that's
too bad. The others in the staff deal with most things (Informant 4)
there, at least I think so, but it's sad that there isn't
a lot of time to talk with the patients and follow up Being a novice in the leadership role was described as an obstacle
and know the planning, and how then can I lead any when the nurses were to lead the psychiatric nursing care. The result
psychiatric nursing care? also showed that being new in the ward entailed considerable insecu-
rity, as well as difficulties becoming one of the group. Coming straight
(Informant 8) from nursing education, equipped with new knowledge, and meeting
the experienced staff in the ward, was a huge challenge. Relating to the
The difficulty of not being accepted as a leader also emerged. There leadership role was something that took a great deal of effort on the
were members of the staff who did not listen or who did not want to

|8      SUNDBERG et al.

part of the new nurse, as there were staff members who had worked that empathy was a support for the cognitive part of the leadership
for a long time and knew how things should be done. by facilitating communication, and thereby improving problem solv-
ing and decisions, and furthermore, increasing staff performances.
You come straight from school and meet people who
have perhaps worked all their lives, yes, perhaps 20 or The value of being informed about staff's level of knowledge and
30 years. Who know the daily and nightly routines, so personal suitability, in order to be able to make optimal use of their
that if you come from school it's not always very easy competence in psychiatric care, was also expressed by the nurses.
to take on the leadership role directly. Knowing what the staff's strengths and weaknesses were, as well as
whether the staff's education and experience were adequate for the
(Informant 2) task, made the nurses in the present study feel confident. Similar re-
sults have been confirmed in other studies and are not explicit within
There was also a wish to practise the leadership role and a desire psychiatric nursing care (Cameron et al., 2012; Linton & Farell, 2009;
for more leadership training in order to be able to lead the psychiatric Solbakken et al., 2018). It is not only within a psychiatric context that
nursing care in the wards. There were, furthermore, hopes of more nurses feel confident when they are able to trust the staff; similar
support from the managers, as it was difficult for many of the nurses to results have been arrived at in the somatic nursing care (Linton &
perceive themselves as leaders of the psychiatric nursing care. Farell, 2009). Furthermore, Burns's (2009) study, focusing on expe-
riences within general practices, sheds light on the fact that experi-
4  |  DISCUSSION OF RESULTS encing a sense of confidence in one's leadership role is completely
dependent on whom the work is done with, which is in accordance
The result shows that the nurses described their leadership in both with the results of the present study.
terms of meaningfulness and uncertainty. In the present study,
nurses agreed that concern for the well-b­ eing of the staff and aware- 4.1  |  The meaningful leadership
ness of the importance of confirming others' work efforts were nec-
essary in order to be a supportive leader of the psychiatric nursing However, while the study result showed feelings of inadequacy
care. In a study based on results from a variety of healthcare set- and uncertainty with regard to psychiatric nursing care leadership,
tings, Solbakken et al. (2018) point to similar aspects of nurses' ex- there were also experiences of a meaningful leadership. It emerged
periences of exercising meaningful leadership. By showing the staff that the nurses considered themselves needed and important in the
appreciation for their performance, and by supporting and coaching ward, and that they felt that they had competence, were supportive
the staff, as well as being responsible for their well-b­ eing, the nurses of staff and took on responsibility and leadership roles when nec-
experienced meaningfulness (Solbakken et al., 2018). essary. The experience of being a supportive leader could involve
teaching as well as confirming and encouraging the staff in difficult
Other factors presented in the result were experienced as neg- situations. In international studies, similar results have emerged re-
ative, making leadership difficult. Nurses stressed a lack of time garding the importance of leadership, which indicates that it is not
as one variable that severely influenced leadership. Participation only in a Swedish care context that nurses in general consider lead-
in psychiatric nursing care suffers since other duties occupy their ership to be important (Cameron et al., 2012; Stanley, 2006; Villaruel
working hours and, as a result, a sense of inadequacy arises with & Peragallo, 2004).
regard to being a role model and a leader. This is in accordance with
theories of charismatic and transformative leadership, since one im- 4.2  |  Feelings of frustration
portant factor for a positive outcome according to these theories is
the leader's own engagement in and skills with respect to the main In contrast, the result also shows feelings of frustration. In the
task (Behling & McFillen, 1996), in this study the caring for patients narratives, there are descriptions of weariness regarding the lead-
with mental ill-­health. If nurses have difficulties engaging in their ership when the staff were experienced as uninterested in their
work and proving their competence as professionals in psychiatric work tasks. Feelings of powerlessness and irritation arise when
care, it will be difficult to engage the staff as a leaders (Behling & staff who are passive or have a negative attitude to their tasks,
McFillen, 1996). Descriptions of similar problems are found in inter- yet have to be led in psychiatric care. Similar problems are de-
national studies, where the importance of finding time to communi- scribed in a study by Oh and Gastmans (2015), which deals with
cate with patients and staff is emphasized (Cioffi & Ferguson, 2009; moral frustration in the leader when the staff did not carry out
de Melo & Schiindwein, 2011). In a study by Håkansson et al. (2014), their work tasks properly, and when the staff did not behave in
lack of time is also referred to as a contributing factor in experienc- an ethically correct way. Moral frustration constitutes a risk for
ing leadership-­related stress. Empathy and support are indeed im- leaders in that it might make them engage in a more repressive
portant factors in psychiatric nursing care leadership. However, staff way that is contradictory to transformative and ethical leadership.
achievements with regard to provide evidence-­based care indicate a Collins (2001) showed that organizations that performed badly for
cognitive awareness of the leadership exercised by the nurses. These
findings are supported by the study of Kellet et al. (2006), who found

SUNDBERG et al. |      9

15 years in a row performed successfully after a change in leader- 4.4  |  Lacking a mandate to lead
ship. The study also showed that the new leaders of these success-
ful organizations were more humble and showed more endurance. Nurses experience difficulties to lead since they have no official
Endurance is a personal quality that is valuable both in caring for mandate to do so, which is highlighted in the result. This stands in
patients and in leadership in psychiatric care. However, the need stark contrast to the demands of professional medical expertise and
for endurance in leadership stresses the need for time and experi- supervision that the nurse must live up to. It was difficult to be ac-
ence, something which may be difficult to achieve for all nurses, cepted as leaders, and a feeling of not being liked created a sense of
given the great burden of administrative tasks, but especially for powerlessness when the nurse had to lead the psychiatric nursing
young nurses starting their career. care. This is supported by the findings of Solbakken et al. (2018),
which showed that nurses felt that different categories of staff tried
4.3  |  Unexperienced and newly educated nurses to take over their leadership, which resulted in feelings of being ig-
nored and not accepted as a leader.
In this study, it was felt as a huge challenge for nurses to come
straight from their nursing education into working life. Nurses who A further reason why nurses in psychiatric care could experience
were new in their leadership role said that they experienced a great uncertainty with regard to their leadership was an unclear assignment
deal of stress initially, but as they became more experienced they by management, and yet an expectation of the nurse to lead hence, a
also became more confident. Other studies are supportive of these confusion regarding leadership role evolved. This phenomenon has
findings and highlight the importance of experience with respect been well studied and described by Katz and Kahn (1978) as role
to leadership (Lau et al., 2014; Warshawsky & Cramer, 2019). This overload, role conflict and role confusion. The interviews revealed
is also supported by Gerrish's (2000) study, which shows, with re- that nurses did not get the opportunity to lead the psychiatric nurs-
gard to supervisory tasks, that recently graduated nurses that newly ing care when there were other persons, such as staff members and
graduated nurses in medical and surgical wards experience difficul- non-m­ edically trained managers, who took over the leadership role.
ties in the transition from education to becoming a registered nurse. Similar results can be seen in the survey by Josefsson and Hansson
Moreover, studies show that nurses state that they are often ques- (2011), conducted within municipal services, describing how one
tioned as leaders, as other staff have reservations about the nurse's third of the nurses did not experience any leadership responsibil-
competence (Rudolfsson & Flenser, 2012; Solbakken et al., 2018). ity and how one fifth perceived that they had been criticized for in-
The need for support in the leadership role is obvious, and a study adequate leadership. According to Josefsson and Hansson (2011),
by Ekström and Idvall (2015) demonstrates that recently graduated there is a risk connected to employees not being allowed to use their
nurses perceive the leadership role as difficult if they are not sup- competences which may diminish the nurses' willingness to increase
ported and are expected to lead others before they themselves have their competence. On the other hand, the possibility of shared lead-
the competence to perform psychiatric nursing care. At the same ership and delegation may be seen as an opportunity to diminish
time, the interviews showed that despite having experience, nurses the workload among leaders, although it may be difficult for those
could feel a lack of confidence in their leadership since other as- leaders who are young or insecure. Two organizational psychological
pects, e.g. personal factors, influenced the feeling of confidence. general studies about roles in teams show that there are benefits
This is in accordance with a study by Josefsson and Hansson (2011) (Bales & Slater, 1955; Wang et al., 2014) in sharing leadership with
that shows similar problems and points to the fact that even expe- or delegating tasks to other members of staff, because it may be
rienced nurses perceive their leadership skills to be inadequate and seen as an adaptation to the high demands and exposure that come
have difficulties seeing themselves as leaders of nursing care. The with leadership today, and may also increase effectiveness in teams.
nurses in the present study felt that they had too little education and Delegation, as a way to share the burden of leadership, may increase
experience to be able to lead the psychiatric nursing care. Similar the willingness among members of staff to take responsibility and to
problems are highlighted in several international studies (Ekström acquire knowledge. In this context, supervision on how to deal with
& Idvall, 2015; Gerrish, 2000; Saccomano & Pinto-­Zipp, 2011; delegation and shared leading functions may be of great importance
Warshawsky & Cramer, 2019), emphasizing the need for leadership to leaders.
supervision. Supervision should be mandatory and organized, which
is especially important for young nurse leaders. Being supported in 4.5  |  What the study adds to existing research
analysing group processes and in finding ways to stimulate and em-
power your staff is one way through which your leadership could be Previous research describing leadership within psychiatric care has
strengthened by supervision Tobias et al., 2016). Tobias et al. (2016) been conducted in a variety of healthcare context and with a mix of
also mention that there are some studies to support the evidence for professionals (Cleary et al., 2010; Karlsson et al., 2009; Mildon et al.,
the benefit of supervision, but the general opinion is that psycho- 2017). This study contributes to a deeper understanding regard-
logical support when being a new leader is more important on both ing psychiatric nursing care leadership, but solely from the nurses'
an organizational and a personal level. perspective when caring for patients diagnosed with psychosis and
addiction. The result of this study illuminates nurses' feelings of

|10      SUNDBERG et al.

ambivalence in leading the psychiatric nursing care, feelings that in- ACKNOWLEDGEMENTS
clude a range of emotional experiences. A consciousness about the The authors wish to gratefully thank the participating nurses who
difficulties in leading emerged and a concern about the many pitfalls generously shared their experiences with us.
in leadership. One important factor is that nurses experience that
the mandate to lead is not evident in the organization. This obscurity CONFLICT OF INTEREST
may increase the feeling of insecurity in leadership. Younger nurses The authors report no conflict of interest.
perceive the lack of experience as negative for their leadership,
though this study shows that even experienced nurses may feel the AUTHOR CONTRIBUTION
same. Even so, the participants in this study also describe their work All authors (KS1, CV, KS2 and KÖ) together formulated the aim and
as leaders as meaningful, not only in relation to staff but also in rela- design of the study, KS1 and CV collected the data, and all authors
tion to patients and their relatives, as well as finding it challenging. participated in the analysis and interpretation of the data. All au-
thors wrote the paper.

5  |  LIMITATIONS ETHICAL APPROVAL
The ethical principles of the Declaration of Helsinki (World Medical
A sample of eleven nurses may be considered small; however, every Association, 2018) were taken into account in the course of the study.
individual narrative was considered to be unique and representa- The information requirement was fulfilled by the participants get-
tive for the study aim. Nurses in forensic psychiatric care were not ting both written and verbal information about the aim of the study.
represented, which may be seen as a limitation. Another limitation Under the Swedish Act concerning the Ethical Review of Research
may be the inclusion of nurses with only minor experience of lead- Involving Humans, the study did not require ethical approval.
ing psychiatric care. However, the participating nurses believed that
their experience was sufficient for participation in this study. The DATA AVAIL ABILIT Y STATEMENT
participants cared for patients diagnosed with psychosis and addic- The data sets generated and/or analysed during the current study
tion, which could, due to the specific unique context, be a limitation are not publicly available due to ethical considerations, but are avail-
regarding transferability. able from the corresponding author on reasonable request.

6  |  IMPLICATIONS FOR PR ACTICE ORCID

The result enhances the need for support and training with regard Kajsa Sundberg  https://orcid.org/0000-0003-0585-7807
to leadership, especially among newly graduated nurses. An organi-
zational mandate to lead, as well as leadership guidance in commu- Cecilia Vistrand  https://orcid.org/0000-0002-9467-4027
nication and teambuilding, are important for the psychiatric nurse's
leadership. Furthermore, heightened awareness within healthcare Karin Sjöström  https://orcid.org/0000-0002-7466-5086
organizations, regarding nurse's experience of leading psychiatric
nursing care, could increase the possibilities to create the right pre- Karin Örmon  https://orcid.org/0000-0002-0228-1358
requisites for the psychiatric and mental health nurse's leadership.
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