1 INTRODUCTION

The Doctor of Philosophy (PhD) represents the highest level of education for a career in research and scholarship (American Association of Colleges of Nursing, 2010). PhD-prepared nurses have an important role in advancing nursing care in complex health care environments with ageing populations, a rise of chronic conditions and staff shortages (Berthelsen & Hølge-Hazelton, 2018). PhD-prepared nurses build inter- and intra-disciplinary networks to generate high-quality innovative, evidence-based knowledge and apply it meaningfully in clinical practice, education and policy development (Cashion et al., 2019; van Oostveen et al., 2017). PhD-prepared nurses have the potential to be leaders in the clinical setting by developing nursing practice, be clinical leaders and be clinical teachers for nurses and students (Dobrowolska et al., 2021).

Although many PhD-prepared nurses work in nursing faculties with roles in research and teaching, some continue to work in clinical settings (Andreassen & Christensen, 2018; Dobrowolska et al., 2021). Clinical academic careers for nurses are highly valuable as they support research on clinical relevant topics and implementation of evidence to support nursing care and clinical decision making by nurses (van Oostveen et al., 2017).

1.1 Background

The nursing profession highly depends on PhD-prepared nurses who generate and implement research findings into clinical practice. Clinical nurses rely on this knowledge to support and validate the care for patients, families and communities (Broome & Fairman, 2018; Cheraghi et al., 2014). Also, PhD-prepared nurses also have the responsibility to prepare the next generation of nurse scientist (Broome & Fairman, 2018). The shortage of PhD-prepared nurses is a barrier for advancing the profession, nursing education and nursing care since more PhD-prepared nurses are needed to build the scientific foundation for the discipline and to expand nursing programmes for a growing number of nursing students (Bednash et al., 2014; McNelis et al., 2019).

Given the current turbulent and rapidly changing health care environment and the increased emphasise on evidence-based nursing practice, there is a clear need for PhD nurses who can lead cutting-edge research, quality improvement and teaching (Broome, 2015; Broome & Fairman, 2018). Most conceptualizations of leadership include a person who is effective in influencing and engaging others in achieving a common goal that reflects a common vision (Cummings et al., 2018; Northouse, 2016). PhD-prepared nurses have the potential to become academic leaders as they have advocacy skills and the courage to continue to seek new innovative approaches (Broome, 2015). Various systematic reviews have shown leadership to be positively associated with improved patient, professional and organisational outcomes (Cummings et al., 2018; Wong et al., 2013). It is assumed that most PhD-prepared nurses learn basic leadership skills during doctoral education when working in research teams. However, it is unknown how many doctoral nursing students and PhD-prepared nurses have access to opportunities to develop leadership competences (McKenna, 2021). Also, for those who have access, the exposure to leadership theory and practice is inconsistent as they often work alone and have no access to situations or programmes to further develop their leadership skills (Broome, 2015; Hafsteinsdóttir et al., 2017).

Over the last decade, it has been well reported that PhD-prepared nurses often experience barriers related to career development including a lack of nursing research cultures and career frameworks (McKenna, 2021). As a result, PhD-prepared nurses experience limited opportunities for career progression and work in challenging working environments with poor salaries, short-term contracts, high workloads, insufficient time for research, high competition for research funding, limited administrative support and limited recognition for their contributions (Al-Nawafleh et al., 2013; Bullin, 2018; Hafsteinsdóttir et al., 2017; de Lange et al., 2019; McKenna, 2021). Mentoring by experienced doctorally prepared nurses as well as support by colleagues and peers was found to support leadership and career development of doctorally prepared nurses. Mentoring supported them in their academic work, strengthened academic skills and supported them in developing an academic identity (Al-Nawafleh et al., 2013; Cullen et al., 2017; Hafsteinsdóttir et al., 2017; Nowell et al., 2017). However, to this day, only a limited number of doctorally prepared nurses has access to these resources (McKenna, 2021).

Only small numbers of PhD-prepared nurses find their career in the clinical setting (Andreassen & Christensen, 2018). A recent scoping review reported limited career opportunities for doctorally prepared nurses in clinical settings due to the lack of clinical academic career frameworks and positions (Dobrowolska et al., 2021). Also, doctorally prepared nurses in clinical settings experience difficulties with obtaining research funds, dividing time among research and other (clinical) commitments, and they experience limited opportunities for collaboration as well as limited support from managers and nurses at the bedside (Andreassen & Christensen, 2018; van Oostveen et al., 2017; Trusson et al., 2019).

Although clinical academic positions promote transfer of evidence into nursing practice, which supports quality and cost-effectiveness of nursing care (van Oostveen et al., 2017), still there is limited insight into the work experiences of PhD-prepared nurses in hospitals. Currently, there is a dearth of studies exploring leadership experiences of PhD-prepared nurses (Al-Nawafleh et al., 2013; Hafsteinsdóttir et al., 2017; de Lange et al., 2019), and there are no studies focussing on the influence of leadership on career development or the hospital setting. Therefore, the aim of this study was to explore the leadership experiences and the influence of leadership on the career development of PhD-prepared nurses working in hospitals.

2 METHODS 2.1 Design

A qualitative descriptive study with semi-structured interviews and thematic analysis was conducted between February and June 2018 in the Netherlands. A descriptive qualitative approach was employed as this type of design enables a comprehensive description of the PhD-prepared nurses' leadership experiences and its influence on career development without being aligned to specific methodologic roots (Polit & Beck, 2017). Thematic analysis was performed using the steps of Braun and Clarke (2006), which enabled the development of a comprehensive understanding of the phenomena being explored. The consolidated criteria for reporting qualitative research (COREQ) checklist was used for reporting of the research findings (Appendix S1; Tong et al., 2007).

2.2 Setting and sample

Although doctoral education has been offered to nurses in the Netherlands for the last 30 years (Florence Nightingale Instituut, n.d), the exact size of the PhD-prepared nursing workforce is unknown due to a lack of central registration (Regelink, 2017). At the time of the study, a national database included 140 doctoral dissertations of nurses (Proefschriften Verpleegkunde, n.d.). Earlier research estimated that approximately 41 PhD-prepared nurses worked at clinical departments of hospitals (Regelink, 2017). At the time of the study, no Doctor of Nursing Practice (DNP) programmes are offered in the Netherlands.

Participants were eligible for this study if they had a PhD degree in nursing (not referring to a postdoctoral position) and were employed at a clinical hospital department. Maximum variation sampling was used to recruit participants with different ages, years of experience as PhD-prepared nurse, positions and hospitals across the country (Polit & Beck, 2017).

2.3 Data collection

Eligible participants were recruited through a database based on earlier research (Regelink, 2017). Potential participants were approached using e-mails (LD). Those who agreed to participate were asked to send their Curriculum Vitae to the researcher used to gain insight in the participants' careers and to extract demographic information. Interviews were planned at a date, time and location preferred by participants. Interviews were conducted by a female junior researcher who had no prior relationship with the participants (LD). The same interviewer carried out all interviews to ensure consistency. The interviews were conducted based on a pre-defined interview guide based on earlier studies (Al-Nawafleh et al., 2013; Hafsteinsdóttir et al., 2017; van Oostveen et al., 2017). In the interviews, leadership was defined as: “being able to see the present for what it really is, see the future for what it could be and take action to close the gap between today's reality and the preferred future” (Cummings, 2012). This definition was presented to participants and followed by the question: “How would you define leadership in your position as postdoctoral nurse?” to understand the participants' views on leadership. Then, open-ended questions were used to explore their leadership experiences (Table 1). The researcher used probes to gain in-depth insight in participants' leadership experiences by asking participants to elaborate on the topics and describe exemplary situations. The interview guide was piloted in two interviews. Since no changes were needed, these interviews were included in the analysis. The interviews, conducted in Dutch, were audio-taped, and afterwards, memos were written to capture non-verbal and contextual information. Member checks were performed by means of sending summaries of the transcripts to participants to check interpretations made by the researchers (Noble & Smith, 2015).

TABLE 1. Interview guide Interview questions What is your definition of leadership in the role of doctorally prepared nurse? Can you tell me more about your leadership experiences as doctorally prepared nurse? What are your experiences with initiating change in practice as doctorally prepared nurse? Do you experience barriers to leadership? How would you describe your career development and what was the role of leadership in it? 2.4 Data analysis

Data collection and analysis were performed iterative. Data saturation determined the sample size and was defined as the point when no additional codes was identified (Hennink et al., 2017). The researchers agreed that data saturation emerged after ten interviews. Two additional interviews were conducted to confirm saturation which found new experiences, but no new codes.

Steps of thematic analysis according to Braun and Clarke (2006) were followed in the analysis (Table 2). Interviews were transcribed verbatim (LD), read and reviewed by both researchers. Open coding was applied to identify meaningful paragraphs using Nvivo 11 (QRS international, n.d.) (LD). After coding the first two interviews, agreement on the coding was checked by both researchers. After coding five interviews, the development of themes started by classifying codes into (sub)themes based on their similarities (LD). Constant comparison was used to refine (sub)themes throughout the analysis. After analysing 10 interviews, the researcher (LD) drew a thematic map to construct the overall story. The researchers carefully selected quotes and established names for the themes. To avoid unintended interpretation, translation to English took place after the final themes emerged (Patton, 2015). Translations were conducted by the first researcher (LD) and checked by the second researcher (THB). Two experts provided feedback on the manuscript.

TABLE 2. Steps of thematic analysis according to Braun and Clarke () Phase Description 1. Familiarizing yourself with your data Transcribing data, reading and re-reading the data and noting down initial ideas 2. Generating initial codes Coding interesting features in the data across the entire data set and collating data relevant to each code 3. Searching for themes Collating codes into potential themes and gathering all data relevant to each potential theme 4. Reviewing themes Checking the themes in relation to the coded extracts (level 1) and the entire data set (level 2) and generating a thematic “map” of the analysis 5. Defining and naming themes Ongoing analysis to refine the specifics of each theme and the overall story the analysis tells; generating clear definitions and names for each theme 6. Producing the report Selection of vivid and compelling extracts, relating back of the analysis to the research question and literature and producing a scholarly report of the analysis

The researchers had regular meetings to discuss methodological considerations and the development of codes and (sub)themes. The background of the researchers enabled credibility of the analysis since the researcher, who collected the data, had limited experience within the research area and thereby no pre-existing assumptions towards the research topic (LD) and second researcher had thorough experience with research on leadership, doctorally prepared nurses and in qualitative research (TBH). A reflective approach was used to ensure that the findings were an accurate reflection of the participants' experiences. This meant that researchers remained aware of own experiences and positions and the potential influence on interpretation of the data (Carpenter & Suto, 2008).

2.5 Ethical issues

The study received ethical approval from a Medical Research Ethical Board. The principles of the Declaration of Helsinki were followed (World Medical Association, 2013). Prior to the interviews, participants received written and oral information emphasising voluntary participation and the option to withdraw at any time. Written informed consent was obtained before the interviews. Extra attention was paid to the confidentiality of participants because of the small population of eligible participants. Individual characteristics were not disclosed preventing linking quotes with specific persons.

3 FINDINGS

Thirty-three PhD-prepared nurses were approached, and 12 agreed to participate. The eight women and four men had a median age of 54 years (range 39–61 years). At median, participants finished their PhD three years prior to the study (range 1–12 years). Participants worked in four academic and three general hospitals and were primarily employed as researcher (n = 7), clinical nurse specialist (n = 4) or manager (n = 1) and combined part-time positions in research, clinical practice, teaching and/or management. Six participants were working in clinical practice at the time of the study (Table 3). Most interviews took place at the participants' workplace with only the participant and researcher present in the room. The mean interview length was 58 min (range 47–75 min).

TABLE 3. Demographic characteristics (n = 12) Item Category Frequency Age 30–40 years 2 41–50 years 2 51–60 years 6 61–70 years 2 Gender Male 4 Female 8 Nationality Dutch 11 Other 1 Primary functiona Researcher 6 Nurse specialist and researcher 5 Manager 1 Combination of functions Research and clinical practice 3 Research and education 4 Research, clinical practice and 3 education Research and management 1 Research, education and management 1 Type of hospital Academic 9 General 3 Years of experience postdoctoral nursing 0–5 years 7 5–10 years 2 10–15 years 3 Hours a week spend on researchb 0–8 h 5 9–16 h 0 17–24 h 3 25–32 h 2 33–40 h 2 Hours a week spend on clinical practiceb 0–8 h 0 9–16 h 1 17–24 h 3 25–32 h 2 Hours a week spend on managementb 0–8 h 1 9–16 h 0 17–24 h 0 25–32 h 1 Hours a week spend on educationb 0–8 h 5 a Function in which most time is spend. bThe frequencies do not add up to the sample size because not all participants practiced within these roles.

Three main themes and eight subthemes derived from the data elaborating on leadership experiences. All themes start with an introduction followed by substantive subthemes. The first theme “Leadership needed for career development” focussed on experiences with career development and the role of leadership in it. This theme includes the subthemes “taking the lead” and “support of mentors, supporters and motivators.” The second theme “Practicing leadership behaviours” focussed on leadership experiences in daily working practices and includes the subthemes “effective leadership characteristics” and “feelings associated with leadership.” The third theme “Leadership influenced by the hospital setting” describes the hospital as work environment and includes the subthemes “struggling nursing research culture and infrastructure,” “the importance of suitable positions,” “the importance of managerial support” and “the importance of collaborations” (Figure 1 and Table 4).

Coding tree. This figure includes a simplified version of the coding three including the most frequently described codes in the interviews

TABLE 4. Themes, subthemes and quotes Theme Subtheme Quote Participant Leadership is needed for career development Taking the lead “I am convinced that you have to seize opportunities to realize your ambitions. You have to jump in there. You have to show courage and accept challenges.” 8 “When you are pioneering you are spending a much time on arranging things, not only for yourself but also for others.” 4 Support of mentors, supporters and motivators “I received much support from my former manager, a physician. He was very supportive of nursing. He strengthened my development and positioning. I noticed: when you put people in their strength, they reach their full potential and this is what happened in my case.” 7 “I missed a mentor, someone with the same background, someone you can discuss with. I still miss that and I’m looking for that. Currently I’m pioneering alone.” 7 Practicing leadership behaviours Effective leadership characteristics “For me leadership is about taking the lead. It is important to have a vision and being able to realize changes in collaboration with others” 12 As nurse or even as doctorally prepared nurse you have to fight, if you want to achieve anything you have to fight, work hard and keep going. This is also the case when you to do research 2 Feelings of “being a leader” “When you are asked to submit a research proposal an expert for a closed call and mine gets granted, then you probably can say that you are an important leader within your specialism.” 3 “I do not have a leadership role, because I am not the manager who is responsible for making decisions, however I do give my opinion, but I am not the one making decisions” 9 “In my current function I work quite solo. I am collaborating mostly with physicians, so I do not feel like a leader in nursing.” 1 Leadership influenced by the hospital Struggling nursing research culture and infrastructure “They[the managers] said: you cannot spend your time on research, you are hired to conduct patient care. You are not a researcher. They don't want me to do research.” 1 The need for suitable positions “If you do not watch out, you will be swallowed by patient care, you have to come up for yourself and detach yourself from patient care otherwise you will be interrupted constantly. Sometimes I hide myself outside the department.” 10 “We [the manager and participant] shared our ideas on a suitable position and the manager explained his vision. He valued the contribution of doctorally prepared nurses and me as a person. Therefore he really supported the development of my position” (participant 4). 4 The need for managerial support “The manager decides how I spend my time. A colleague on a different department gets a much more time for research. There is no organization-wide policy.” 6 “Improving nursing care is difficult to express in money, but this [finances] is what makes the managers enthusiastic.” 3 “Many managers do not understand the importance of nursing research as they have no academic background. So, for them it is difficult to stimulate nursing research, because they lack knowledge and are not familiar with it.” 2 The need for collaborations “Within our department the physicians conduct large clinical studies. I think there are easy ways to include nursing components where we could collaborate. What would be more beautiful? However, at the moment it is strictly separated.” 8 “You are not one of them anymore. I did not become nurse scientist because I did not want to be a nurse anymore. I have different interests. You grow apart, you do not have same frame of reference anymore.” 5 3.1 Leadership is needed for career development

Some participants followed linear career paths, starting with a Bachelor in Nursing followed by a Master and doctoral degree, while others made career decisions along the way. Although the variance in career paths, leadership was demonstrated by participants having a vision for their career and taking initiative to accomplish career goals. Participants did not do this alone; they searched and received support from others throughout their career.

3.1.1 Taking the lead Career development of the participants was characterised by taking initiative and planning of their career. Participants shared the importance of showing leadership by means of developing a career vision and a plan of action. They saw their careers as an intentional process, and all felt responsible for planning and taking next steps in their career, even if these were challenging. One participant said:

I am convinced that you have to seize opportunities to realize your ambitions. You have to jump in there. You have to show courage and accept challenges. (Participant 9)

Some participants described facing challenges related to being the first PhD-prepared nurse at the department or even the hospital. This made them feel like they were pioneering and had to find out everything by themselves. This was experienced as waste of time by some as this did not contribute to their ambitions. One participant explained the higher meaning:

When you are pioneering, you are spending much time on arranging things, not only for yourself but also for others. (Participant 4)

For some, pioneering only occurred at the beginning of their career, whereas others have this feeling to this day. For those who needed to pioneer, it did not stop them from chasing their ambitions.

3.1.2 Support of mentors, supporters and motivators The participants acknowledged the importance of mentoring and having support from others while building their careers. This gave them confidence to progress in their careers, for example, by applying for higher positions. Support often came from professors or managers with a medical background working at the department. Professors were seen as motivators and valuable discussion partners because of their expert knowledge and scientific background. Managers were described as motivators and facilitators. One participant said:

I received much support from my former manager, a physician. He was very supportive of nursing. He strengthened my career development and positioning. I noticed: when you put people in their strength, they reach their full potential and this is what happened in my case. (Participant 7)

Despite many participants having someone to provide career guidance, some participants felt less supported regarding their leadership development described as becoming a more experienced and senior professional. Some missed having a more senior colleague as role model. Although some were mentored by a more senior researcher and experienced this as beneficial, others described being in need of mentoring. One participant said:

I missed a mentor, someone with the same background, someone you can discuss with. I still miss that and I’m looking for that. Currently I'm pioneering alone. (Participant 7)

3.2 Practicing leadership behaviours

Participants shared how they used leadership competences in their daily work. Some described this in a detailed way, while others had more abstract ideas. In general, participants described leadership frequently as leading research activities and quality improvement initiatives to strengthen nursing care in collaboration with the nursing discipline and within multidisciplinary settings.

3.2.1 Effective leadership characteristics The participants described various characteristics important to leadership in their daily work like having expert knowledge, passion for nursing and courage to stand out. Important personal characteristics were being enthusiastic, communicative, persevering, motivating, decisive and visionary. One participant said:

For me leadership is about taking the lead. It is important to have a vision and being able to realize changes in collaboration with others. (Participant 12)

Being sensitive for the organisation was found to be important, which was defined as having insight in organisational processes, influence within the organisation and insight in health care systems. The participants also agreed that self-determination was important as it was not evident to have the opportunity to conduct research. One participants stated:

As nurse or even as doctorally prepared nurse you have to fight, if you want to achieve anything you have to fight, work hard and keep going. This is also the case when you to do research. (Participant 2)

3.2.2 Feelings of “being a leader” The participants recognised own leadership behaviours, which they described in a modest way. Participants described feeling like a leader based on their experiences with being experts in specific areas of nursing or having national or international collaborations. One participant described this like:

When you are asked as an expert to submit a research proposal for a closed call and mine gets granted, then you probably can say that you are an important leader within your specialism. (Participant 3)

Others, however, did not feel like leaders in nursing or nursing science, but they described feeling more like leaders within their specialism or at their department. Some participants associated leadership with hierarchal management positions. One participant explained:

I do not have a leadership role, because I am not the manager who is responsible for making decisions, however I do give my opinion, but I am not the one making decisions. (Participant 9)

Others stated that they did not feel like leaders because for them leadership is associated with having followers. One participant explained this:

In my current function I work quite solo. I am collaborating mostly with physicians, so I do not feel like a leader in nursing. (Participant 1)

3.3 Leadership influenced by the hospital setting

The hospital environment influenced the participants' leadership and career development. Some felt it was hard to use their competences and advance their careers, while others experienced the hospital as supporting and facilitating.

3.3.1 Struggling nursing research culture and infrastructure The participants described hospitals generally lacking strong nursing research culture and infrastructure for nursing research. They described the hospitals as being medically orientated. One clinical nurse specialist described:

They [the managers] said: you cannot spend your time on research, you are hired to conduct patient care. You are not a researcher. They don't want me to do research. (Participant 1)

The lack of a strong nursing research culture in the organisational culture of hospitals was reflected by limited research infrastructures and career opportunities for nurses. Others described that nursing research cultures were improving as the importance of nursing science was increasingly being recognised. They described that considerable progress was being made with more nurses being appointed as professors, increased attention towards career pathways for nurse researchers, implementation of joint clinical academic positions and more grant opportunities for nursing research.

3.3.2 The need for suitable positions The participants stated that there were limited suitable positions. Many participants developed positions in collaboration with their manager. One participant explained this:

We [the manager and participant] shared our ideas on a suitable position and the manager explained his vision. He valued the contribution of doctorally prepared nurses and me as a person. Therefore he really supported the development of my position. (Participant 4)

Integrated joint clinical academic positions were valuable to participants as they enabled combining research activities and quality improvement projects with roles in clinical practice or teaching. Combing these roles was highly valued but experienced as challenging due to the priority on patient care. One clinical nurse specialist explained this:

If you do not watch out, you will be swallowed by patient care, you have to come up for yourself and detach yourself from patient care sometimes otherwise you will be interrupted constantly. Sometimes I hide myself outside the department. (Participant 10)

3.3.3 The need for managerial support Some participants described having positive experiences with their managers as they co-created positions and secured access to resources. Participants described that their ability to conduct research was highly dependent of their manager. One participant said:

The manager decides how I spend my time. A colleague on a different department gets much more time for research. There is no organization-wide policy. (Participant 6)

Some other experienced insufficient managerial support and described managers’ having different priorities. One participant explained:

Improving nursing care is difficult to express in money, but this [finances] is what makes managers enthusiastic. (Participant 3)

These participants felt more tolerated than appreciated. Some participants explained that managers had limited knowledge about research or the importance of evidence-based practice. One participant said:

Many managers do not understand the importance of nursing research as they have no academic background. So, for them it is difficult to stimulate nursing research, because they lack knowledge and are not familiar with it. (Participant 2)

3.3.4 The need for collaborations

Some participants described missing collaborations with other researchers and felt isolated. This was especially the case with participants working in general hospitals, where only a small number of (or even no) PhD-prepared nurses worked. They emphasised the importance of collaborations with other nurse researchers at University Medical Centers or universities.

Although some participants had research collaborations with physicians, many felt like they had to compete with them for resources.