ORIGINAL ARTICLE

Development of a leadership role in a secure environment

Shobha Rani, MSc, MA, HDip Nursing (Ed) RGN, RPN, RNT1 , Michael Brennan, RPN, RNT, Dip Social Studies,
Cert Management Studies, Dip Addiction, MEd2 , and David Timmons, PG Dip FBS, RMN, CertM, ENB99,
MSc in Mental Health1
1 Training & Development Department, National Forensic Mental Health Service, Dublin, Ireland
2 School of Nursing & Midwifery, Trinity College, Dublin 2, Ireland

Keywords
Clinical supervision; forensic nursing; leadership
development; leadership skills; training needs;
training program; work-based learning.
Correspondence
Michael Brennan, RPN, RNT, Dip Social Studies,
Cert Management Studies, Dip Addiction, MEd.
School of Nursing & Midwifery, 24 D’Olier
Street, Trinity College, Dublin 2, Ireland.
Tel +353 1 8963950/086 0247433;
E-mail: brennami@tcd.ie
Received: May 15, 2008; accepted: February 26,
2009
doi: 10.1111/j.1939-3938.2010.01073.x
Abstract
The ever-changing demands of recruitment and retention, both nationally and
at a local level, have resulted in many staff with little or no experience in
managing a unit in a secure setting. This study aimed to elicit the views of a
cross-section of unit-based staff and middle management, on their experiences
of leadership and taking charge of a shift/unit. A qualitative descriptive de-
sign was adapted for this study. The data were collected using focus group
interviews guided by semistructured interview schedules. Twenty-one sub-
jects participated in three focus groups. The data were analyzed using Co-
laizzi’s (1978) framework. Five themes emerged from the data analysis. These
are: Perceived practical skills deficit, perceived difference in experience, train-
ing program, leadership skills, and teaching learning methods. Implications:
The themes generated will provide a framework to develop a training pro-
gram, which will prepare staff to take on a leadership role within a unit,
if required.

In Ireland, nursing has undergone tremendous
changes, where the role of the nurse has changed from
the traditional caregiver to a nurse leader. According to
Goertz-Koerner (1998), leadership is pertinent to deal-
ing with change and functioning as a change agent. It is
also increasingly recognized that management is an in-
tegral part of the staff nurse’s role (Parkin, 1992) while
it is evident from both practice and research that clinical
leadership is a major factor in influencing the quality of
patient care (Cook & Leathard, 2004). Furthermore, the
development of managerial skills in nurses is thought to
make them more effective multidisciplinary team mem-
bers, increase effectiveness, and helps with the planning
and evaluation of care (McDermott, 1992). However, the
literature has also identified a paucity of preparation for
this significant role (Cook & Leathard, 2004). This study
sets out to elicit the views of a cross-section of unit-based
staff and middle management on their experiences of
leadership and taking charge of a shift/unit in a secure
hospital.
National forensic mental health service
in Ireland
Central Mental Hospital (CMH) was established in 1850,
under Section 8 of The Lunatic Asylums (Ireland) Act,
1821, to provide for the detention in custody of “persons
indicted and acquitted on the grounds of insanity at the
time of commission of the crime” (Robins, 1986, p. 103).
The hospital provides national forensic mental health ser-
vice for a population of approximately 4.2 million and the
13 prisons throughout Ireland. The hospital has 100 beds,
which includes a seven-bedded community hostel.
The model of service delivery for the national foren-
sic mental health service is based on providing predomi-
nantly medium secure care with some high security and
low security also, all on one site (Kennedy, 2006). This
is the only mental health service in Ireland, which pro-
vides for the assessment, diagnosis, treatment, and reha-
bilitation for high-risk patients in conditions of therapeu-
tic security (Kennedy, 2002). Forensic psychiatric services

96 Journal of Forensic Nursing 6 (2010) 96–103 

c 2010 International Association of Forensic Nurses
S. Rani et al.
in Ireland are undergoing rapid changes in response to
national policy guidelines (Department of Health and
Children, 2006) and the introduction of Government of
Ireland (2001), Mental Health Act and Government of
Ireland (2006), Criminal Law (Insanity) Act. Based on
these recommendations, forensic psychiatric nurses pro-
vide person-centered care using a primary nursing model,
which is recovery-oriented and involves integrated care
plans. A core component of this is the provision of best
practice assessment and intervention, which predomi-
nantly involves risk assessment and risk management of
patients with challenging behaviors within a forensic set-
ting. As yet, there is no published literature on the role of
forensic psychiatric nurses in the Irish context.
The total number of ward-based staff is 155, approxi-
mately one-third of these are psychiatric nurses recruited
from overseas. Originally, care was provided by care offi-
cers1 who were not trained as nurses. In 1992, the hos-
pital adopted a policy to cease the recruitment of care of-
ficer grades. This grade of care officer was replaced by
registered psychiatric nurses. However, there still remains
a cohort of care officer grades working within the ser-
vice resulting in two categories of staff providing care
at the ward level, which will remain the case until all
care officers have terminated their contracts. Within this
framework there exist two career pathways; staff nurse
to Clinical Nurse Manager (CNM)-II and care officer to
Charge Care Officer. These are promotional grades, which
are determined by competency-based interviews. There is
an identified overlap in functions and responsibilities for
these groups. The main difference in the role of these two
grades is that only registered psychiatric nurses adminis-
ter medications and carry out specific nursing activities
whereas both grades are involved in documentation, ob-
servations, taking charge of the unit, and providing lead-
ership to junior colleagues. In-service training is provided
to both grades to ensure a high standard of documen-
tation, for example, Report Writing, Court Appearances,
Legislations. In some areas, nurses receive training on is-
sues pertinent to nurses only, for example, preceptorship
preparation training, medication management, and pri-
mary nursing.
Need for the study
The ever-changing demands of recruitment and reten-
tion, both nationally and at a local level, have resulted
in many staff with little or no experience in managing a
unit. Contributing factors to this phenomenon have been
a higher rate of turnover of staff, the retirement of a num-
1
A care officer is an employee of the Health Service Executive
working specifically at the CMH and works alongside nurses.
Development of a leadership role in a secure environment
ber of senior staff, the recruitment of nurses with less
than 2 years experience, and/or no forensic experience,
and an influx of overseas nurses with diverse cultural and
clinical experiences. The findings from previous studies
(Brennan, 2006; Malone, 2004) highlighted the changing
role of the CNM IIs in the East Coast Area Health Board
and the training needs of the complex workforce at the
CMH. Both of these studies indicated that poor prepara-
tion and lack of support for ongoing personal and pro-
fessional development were key factors, which resulted
in ward-based staff and first-line nurse managers experi-
encing difficulties in taking up a unit leadership role. It
is also clear from these studies that there is a need for
the development of training programs for future CNM-IIs
to ensure that they can fulfill this role within a foren-
sic mental health setting. Based on these factors, it was
deemed necessary to carry out this study.
Methods
Researchers carried out a descriptive qualitative study to
identify the training needs of staff nurses and care of-
ficers to develop their skills to become competent unit
managers. Milburn, Fraser, Secker, and Pavis (1995) state
that qualitative research is based on the assumption that
phenomena must be studied from the individuals’ per-
spective and in the context in which they happen. This
approach is broadly influenced by the interpretivists’
paradigm. Interpretivists hold the belief that human be-
ings actively construct the social world and that we are
continuously involved in making sense of or interpreting
our social environments (Milburn et al., 1995).
Data were collected using three focus groups. Focus
groups are a useful method to collect data from a sam-
ple with varied educational, cultural and positional back-
ground, and experience (Kreuger, 1994). The analy-
sis of the data was carried out using Colaizzi’s (1978)
framework.
A quota sample, which is a nonprobability sampling
technique, was adopted for this research study. The re-
searchers identified three strata, first, 23 managers, sec-
ond, 98 staff nurses, and third, 34 care officers. A pro-
portionate number of respondents were selected from
each stratum. The duty roster was utilized to compile the
sample (N = 21). Three focus groups were held to in-
clude staff from both of the shifts. One focus group was
held exclusively for the seven members from the man-
agement group to ensure that other participants would
not feel pressurized by the presence of management. The
other two focus groups consisted of a combination of
staff nurses and care officers; seven members in each
group. Staff nurses in the focus groups were either newly
97
Development of a leadership role in a secure environment
qualified2 or new nurses in the hospital, or nurses with
over 5 years of experience within forensic setting. The
focus group interviews were audiorecorded with the per-
mission of the participants. Each focus group lasted for
45 minutes. Field notes were also taken to compliment
recordings, to ensure accuracy, and to provide an audit
trail.
Researchers conducted the focus groups using a
semistructured interview schedule. The items for this in-
terview schedule were identified from the relevant liter-
ature, which included participants’ demographic details
and the other areas were preparation for taking a clini-
cal leadership role, skills required, training requirements,
and barriers and enablers to being an effective manager.
A nurse and a care officer participated in pilot interviews.
These interviews were conducted to test the audio equip-
ment and the suitability of the interview room.
Ethical approval
Ethical approval was gained locally from the hospital
ethics committee. Each participant was provided with a
written explanation of the purpose of the study, which
was verbally reiterated during the focus groups. The
voluntary nature of the study was also made explicit,
as was the guarantee of confidentiality. Informed con-
sent was obtained from the participants. In addition,
all data collected were used for no other purpose than
stated and were manually coded and transcribed by the
researchers.
Findings
The responses of the participants were analyzed using
Colaizzi’s (1978) framework for data analysis. The data
were transcribed from the audiotapes and read and reread
to understand the content. Significant statements were
extracted. Then meaning for each significant statement
was formulated. Common themes were identified for the
significant statements. This process was carried out by
each researcher individually to ensure accuracy. Further-
more, the themes extracted by each researcher were com-
pared. These themes were then organized into clusters
related to the research question and five key areas were
formulated:
r Practical skills deficits;
r Difference in experience “Three Generations;”
r Training program;
r Leadership skills; and
r Teaching and learning methods.
2
Newly qualified nurse has just successfully completed un-
dergraduate nursing program and registered with regulatory
body.
98
S. Rani et al.
Discussion
The five themes identified from this study will be used
as structure for the discussion. Each theme will be dis-
cussed from the perspectives of the three grades of staff
involved in this study, staff nurses, care officers, and
nurse managers.
Theme 1: Practical skills deficit
All the staff nurses expressed that there was a theory
practice gap. This view was more evident from newly
qualified nurses, who expressed that “what was learnt in
the preregistration nursing course was not easy to practice here
without having good background knowledge of the setting.”
Baillie (1999) reveals that attaining management skills
has always been a source of anxiety for newly qualified
staff nurses. Oermann and Moffitt–Wolfe (1997) shared
similar views that newly graduated nurses had a mod-
erate degree of stress during their initial period in the
hospital and perceived an initial practical skills deficit but
they learnt quickly with some training (Macleod-Clark,
Maben, & Jones, 1997).
Furthermore, the newly qualified nurses felt that they
were not sure of their decision-making ability. As one
of the nurses expressed, “. . . . . . At the end of the day, you
will be wondering if what you did was right or did I do any-
thing wrong.” It was clear from the newly qualified nurses
that they feared making a wrong decision on clinical mat-
ters. Macleod-Clark et al. (1997) report similar findings
that staff nurses considered their theoretical management
preparation to have been good but on qualifying, they
had felt unprepared for the practicalities of decision mak-
ing, organizing, and delegation. Oermann and Moffitt–
Wolfe (1997) stated that lacking experience as a nurse,
interacting with doctors and senior clinicians, new proce-
dures, and new situations causes a lot of stress for newly
qualified nurses.
The newly qualified staff nurses and those who are new
in the hospital (new nurses)3 also expressed that “. . . they
would rely on a senior staff member on the unit to make any de-
cision as they perceived themselves as having a lack of knowledge
of the patients’ condition, daily routines, policies and procedures
etc.” Charnley (1999) reports that newly qualified nurses
usually feel that they do not have sufficient skills to be
confident and competent in taking on a new role requir-
ing clinical leadership skills.
Interestingly, the complete opposite was reported by
the care officers in this study. All care officers in the
study suggested that they were capable of taking charge
3
New nurse is recently employed to the service but may have
had previous experience in other mental health services.
S. Rani et al.
of a unit effectively. Care officers working in this hos-
pital would have an average of 20 years experience in
their current roles. They perceived themselves as having
the practical skills required to handle critical incidents or
take charge of a unit based on their vast experience in the
field.
The managers in this study suggest that once staff
nurses are registered, they have a responsibility to take
charge of the unit but recognized that “. . . . . a newly qual-
ified nurse or a new staff nurse in the hospital may have diffi-
culty in taking charge of the unit within a few months as they
may not be well versed with the policies and procedures, daily
routines, patients conditions etc. However, they cannot decline
taking charge of a unit, if they are asked to.”
The managers also concurred that most of the care of-
ficers could take charge of the unit as they have been
in the hospital for many years. However, they also con-
tested that it is essential to have a theoretical knowledge
of leadership and management issues such as leader-
ship styles, conflict resolution, team building, etc. to
effectively handle certain sensitive issues. One of the
managers expressed “. . . . . care officers may handle a critical
incident on the unit or may carry out the daily routines but when
it comes to conflict resolution or team building or showing certain
management styles, they may lack information so it is good to go
for a management course or attend theory classes organised by
the training and development department in the hospital.”
Theme 2: Differences in experience—“three
generations”
The participants described the staff in CMH as belonging
to “three generations.”
The first generation are the group of care officers who
have more than 20 years of experience in the service,
they are perceived as being able to take charge of a unit
effectively as they have learnt these skills through obser-
vation over the years.
The second generation of staff are the cohort of staff
nurses who have been in the service for 5–10 years,
hence they are also perceived as being able to take
charge of a unit effectively as they have both the theo-
retical background on leadership and management skills
through their preregistration nurse training. They have
also gained considerable experience by working in the
hospital for several years.
The third generation of staff included those who are
newly qualified staff nurses and overseas nurses, who
have worked in the CMH for a short period of time, hence
they perceive themselves (or are perceived by others) as
not fully equipped to take charge of a unit even though
they have the theoretical background from their prereg-
Development of a leadership role in a secure environment
istration nursing course or experience as staff nurses or
nurse managers elsewhere.
It is evident from the analysis, that experience of work-
ing in a secure environment was considered an important
factor when taking charge of a unit as one of the partic-
ipant described “. . . . you may have plenty of experience else-
where but that is not going to help here as you need to know
the security aspects, what has to be done when things go wrong,
whom to contact and what to do.”
All of the care officers viewed experience as the most im-
portant factor to take charge. Furthermore, care officers
felt only after 5–10 years of experience one can take charge.
Whereas the staff nurses felt that one could take charge
after being in the hospital for minimum 10–12 months, how-
ever, he/she needs to be in the same ward for a length of time
to acquaint themselves with the ward routine, policies and pro-
cedures, patients condition, key persons to be identified in a crisis
situations, etc.
The management group also expressed that there is
a difference in experience among the staff but in con-
trast, considered the experience in nursing is the same
wherever one has worked previously. However, they also
considered it is essential to know the daily routines and
policies and procedures, etc. to run a unit smoothly. Sug-
gesting that there is a need for some experience in the
hospital to learn all the basics and get to know the key
persons. One of the participants strongly recommended
experience as a key element to take charge of the unit.
“. . . . . You cannot forget experience; it is only through experience
that one learns the skills. We have seen many incidents where a
newly qualified nurse or a new staff nurse in the hospital com-
pletely depend upon a senior care officer or a senior staff nurse
to handle a situation or to make any decision. So experience in
the hospital should be a requirement for anyone who is taking
charge.”
Theme 3: Training program
One of the newly qualified staff nurses explained “. . . I
have learnt the theory on management in my nursing course
but I think I cannot implement all those things here without
someone’s guidance on how to mange a ward in this setting. I
think I need to learn these skills in this setting to be an effective
nurse manager.”
One of the participants from the care officer group
stated that there was no need for formal training pro-
grams, however, he made a number of suggestions for
teaching clinical leadership skills to a newcomer in the
hospital. The participant also suggested that there should
be a structured training package but it should be delivered
in the unit by unit managers rather than teaching every-
thing in the classroom. Baillie (1999) identified similar
99
Development of a leadership role in a secure environment S. Rani et al.

views from staff nurses that nothing can prepare one for
Table 1 Comparison of views of study participants on clinical leadership
learning these skills, however; it would be useful if there
skills
was a list of skills identified on units where they could
be practiced. Similarly, the Framework for Nursing in Gen- Staff nurse and care officers’ views Views of management group
eral Practice (2005) suggests developing an information Knowledge of policies and Knowledge of policies and
pack with written material that could be used by new procedures procedures
staff. Knowledge of patients Knowledge of patients
All of the managers felt that there is a need for a train- Knowledge of the ward routines Knowledge of the ward routines
ing program, which should include both skills training Communication Communication
and theory classes. Furthermore, the managers expressed Management of human resources Good interaction with patients
Good personality Good personality
that they would support such a training program “if the
-Assertiveness -Assertiveness, confident
unit managers, rather than the training and development de- -Confident -Jovial disposition, competent
partment deliver it.” McMahon, Szczepanska, Hehir, and -Competent -Common sense, keen to learn
Flatt (2004) agree that if a scheme like that were to be -Accessible -Enthusiastic, creative
introduced, it would have to be with the wholehearted -Works autonomously
cooperation of the clinical staff. It would need to be run Conflict resolution Conflict resolution
on their terms and within their guidelines—not some Delegation Delegation
Decision making Decision making
scheme dreamt up by an academic and imposed from
Directing Time management
afar. Supervision skills
Thus, all the participants said that there was no
formal in-service training program available to learn
clinical leadership skills. Furthermore, the participants
felt that there was a need to develop a training pro-
Theme 4: Leadership skills
gram to help staff nurses and care officers to man-
age a ward effectively. They suggested the training The participants identified different leadership skills,
program should also enhance their personal and profes- which they would like to see in a unit manager. The
sional role in providing quality care. The Sainsbury Cen- skills recognized by the participants are listed in Table 1.
tre for Mental Health (2000) highlights the lack of time as All groups identified more or less similar clinical lead-
a key factor that results in services not providing train- ership skills to manage a unit effectively. There were
ing in risk assessment, and clinical supervision and staff only a few differences in their views such as the man-
development. agement group gave an extensive account of personal
The participants appreciated the current induction pro- qualities that makes a staff nurse or a care officer a bet-
gram for new staff nurses. However, they expressed that ter leader. Furthermore, they stressed the importance
“. . . it is not possible for anyone to understand everything in the of time management and interaction with the patients. Bail-
first few days, you can only take so much for a day and the hu- lie (1999) identified similar views from ward managers
man brain can retain only so much so the leadership aspects such as communication skills, assertiveness, being artic-
may not be worth teaching during the first induction period. ulate, questioning, working as a team member, prob-
They need to be here for a while to understand the hospital rou- lem solving, change management, time management and
tine and stuff like that. Therefore, consideration should be made medicolegal aspects being the positive skills of a leader.
when planning a training programme, perhaps such training Whereas, staff nurses and care officers gave an account
should be provided for staff nurse after 6–8 months of being in of human resource management and supervisory skills
the hospital. There is a need for such a probationary period to that a leader should possess. Gould, Kelly, and Maid-
ease the transition from student to staff nurse, especially now, well (2001) contradict this view by stating that clinical
when students spend less time on the wards than they used to.” nurse managers have disliked the human resource issues
Nurse training is about the acquisition of knowledge and as they spent a considerable amount of time in recruiting
skills, but it is also developmental—a process of growing staff. However, no one from the staff group mentioned
up. New nurses need time and space to shape their iden- the provision of direct patient care as a nurse managers’
tity as a nurse, with the support of senior colleagues (Mc responsibility. The researchers feel this could be because
Mahon et al., 2004). Loiseau, Kitchen, and Edgar (2003) staff nurses see themselves as being in a more responsible
expressed similar views that a 6 month’s time frame is position when they take charge of the unit, hence they
important to allow the graduates to solidify their skills in may perceive their role as more of a supervisor rather
the field. than a provider of direct patient care.

100
S. Rani et al.
Theme 5: Teaching-learning methods
All of the participants identified similar teaching-learning
methods for the training program. The methods such as
“Management days” were widely appreciated by all the
participants. Sayeed (1983) suggests that student nurses
and newly qualified nurses should be given opportunities
to run the ward under supervision so that they can prac-
tice prioritizing and organizing, but be given the chance
to discuss difficulties. “Shadowing” was another popular
method suggested by the participants to deliver a training
program. Baillie (1999) and Department of Health (2005)
revealed similar view of adopting a “shadowing” method
to learn the skills on the units. Furthermore, the shad-
owing of specific activities and events were considered as
more useful and of a higher value in learning experience
than a full-day shadowing.
“Mentoring,” “Precepting,” and “Role Modeling” were also
identified as other relevant methods of teaching and
learning. Many researchers have favored mentors and
preceptors as they are a very good source of informa-
tion for newly qualified staff (Baldwin & Blackburn,
1981; Genrich & Pappas, 1997; Gibbs, Gold, & Jenkins,
1987; Mills, 1983; Siler & Kleiner, 2001). Furthermore,
Oermann and Garvin (2002) and Ulrich (2003) identi-
fied the need for a consistent mentor who serves as a
role model to new graduates to help them cope with
the stresses they face on the commencement of practice.
Convey (1991) describes role modeling (setting a good
example) as the responsibility of leaders to stay focused
and lead by example. The downside, however, is men-
tors and preceptors may have personality clashes and in-
evitable relationship problems with new staff nurses as
well as a lack of time to commit, workload, and poor com-
munication skills, which may hinder the quality of infor-
mation provided by the mentors and preceptors (Depart-
ment of Health, 2005). Therefore, Reno (2005) suggests
a combination of online and in-house mentoring pro-
grams to make the teaching/learning more attractive and
beneficial.
“Simulation” method was also suggested to be helpful
for staff nurses and care officers to learn the clinical lead-
ership and management skills. Simulation exercises on
managing an incident, and conflict resolution helps to
prepare new staff nurses for management (Ross, 1988).
Similarly, the participants considered “Theoretical input”
on management styles and certain management skills are
essential along with clinical learning. Loiseau et al. (2003)
reported that a combination of classroom teaching and
clinical learning reduced nurse vacancy rates. Similarly,
Storey (1996) describes the management training pro-
gram as skills based, and competence must be achieved
in relation to managing services (e.g., monitoring qual-
Development of a leadership role in a secure environment
ity, health, and safety), managing people (for example,
clinical leadership, motivation) and managing informa-
tion (e.g., report preparation).
Hence, it is evident from the analysis that different
methods of teaching and learning such as management
days, shadowing, precepting, mentoring, role-modeling
may be adopted to learn the management skills on the
unit and a theoretical input on management style and
other clinical leadership skills will be beneficial to be a
ward manager.
Limitations of the study
The researchers acknowledge that this study did not con-
sider the educational qualifications of participants as part
of the study. Another limitation identified by the re-
searchers is that the study focused on exploring only core
clinical leadership skills to manage a secure unit. It is rec-
ommended that further research needs to be carried out
to identify unique issues relevant to clinical leadership
within a secure setting.
Conclusion and implications
This study has explored the perceived training needs of a
cross-section of staff to adopt a clinical leadership role and
manage a ward in the absence of an identified unit man-
ager and to further develop a training program to meet
those needs. It is clear from this study that the newly
qualified staff nurses and new nurses perceived them-
selves as having a deficit in skills that are required to
take charge of a unit due to a theory-practice gap, lack
of information on operational guidelines, and a lack of
experience on the unit. This implies that there is a re-
quirement to prepare operational guidelines for each unit
and to introduce a model of clinical supervision to sup-
port staff in decision making and developing their prac-
tice. A training program on clinical leadership skills is rec-
ommended to be developed for all staff in the service.
The researchers recommend delivering this training pro-
gram for unit-based staff after 8–10 months of working
within a secure unit using relevant theory and a men-
torship model. Hurst (2000) suggests that education pro-
grams for nurses should match the clinical areas in which
they work. Reviews need to be done of the range of skills
required to be competent practitioners in environments
where patients are highly dependent and sometimes ag-
gressive and violent. Punch and Horner (1991) suggest
that a training needs analysis can provide organizations
with the information necessary to provide appropriate
courses; this involves an agreement between an organi-
zation, education providers, and students. A consensus
will need to be reached among all parties concerned for
101
Development of a leadership role in a secure environment
the development and success of an education program for
this service.
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