J Adv Nurs. 2019;00:1–15. | 1wileyonlinelibrary.com/journal/jan
Received:29August2018 | Revised:10March2019 | Accepted:8April2019DOI: 10.1111/jan.14092
R E V I E W P A P E R
An integrative review of leadership competencies and attributes in advanced nursing practice
Maud Heinen PhD, RN, Senior researcher1 | Catharina van Oostveen PhD, RN, Senior researcher2,3 | Jeroen Peters PhD, RN, Coördinator Master Advanced Nursing Practice4 | Hester Vermeulen PhD, RN, Professor of Nursing Science1,5 | Anita Huis PhD, RN, Senior researcher1
ThisisanopenaccessarticleunderthetermsoftheCreativeCommonsAttributionLicense,whichpermitsuse,distributionandreproductioninanymedium,providedtheoriginalworkisproperlycited.©2019TheAuthors.Journal of Advanced Nursing PublishedbyJohnWiley&SonsLtd
1RadboudUniversityMedicalCenter,RadboudInstituteforHealthSciences,ScientificInstituteforQualityofHealthcare,Nijmegen,TheNetherlands2SpaarneGasthuisHospital,SpaarneGasthuisAcademy,Haarlem,TheNetherlands3ErasmusSchoolofHealthPolicy&Management,ErasmusUniversityRotterdam,Rotterdam,TheNetherlands4HogeschoolvanArnhemenNijmegen,HANUniversityofAppliedSciences,Nijmegen,TheNetherlands5HANUniversityofAppliedSciences,Nijmegen,TheNetherlands
CorrespondenceMaudHeinen,Radbouduniversitymedicalcenter,RadboudInstituteforHealthSciences,ScientificInstituteforQualityofHealthcare,Nijmegen,TheNetherlands.Email:[email protected]
AbstractAim: Toestablishwhatleadershipcompetenciesareexpectedofmasterlevel‐edu‐catednurses liketheAdvancedPracticeNursesandtheClinicalNurseLeadersasdescribedintheinternationalliterature.Background: Developments in health care ask for well‐trained nurse leaders.AdvancedPracticeNursesandClinicalNurseLeadersareideallypositionedtoleadhealthcare reform in nursing.Nurses should be adequately equipped for this rolebased on internationally defined leadership competencies. Therefore, identifyingleadershipcompetenciesandrelatedattributesinternationallyisneeded.Design: Integrative review.Methods: Embase,MedlineandCINAHLdatabasesweresearched(January2005–December2018).Also,websitesofinternationalprofessionalnursingorganizationsweresearchedfor frameworkson leadershipcompetencies.Studyandframeworkselection, identificationofcompetencies,qualityappraisalof includedstudiesandanalysisofdatawereindependentlyconductedbytworesearchers.Results: Fifteenstudiesandsevencompetencyframeworkswereincluded.Synthesisof150identifiedcompetenciesledtoasetof30corecompetenciesintheclinical,pro‐fessional,healthsystems.andhealthpolicy leadershipdomains.Mostcompetenciesfittedinonesingledomainthehealthpolicydomaincontainedtheleastcompetencies.Conclusions: Thissynthesisof30corecompetencieswithinfourleadershipdomainscanbeusedforfurtherdevelopmentofevidence‐basedcurriculaonleadership.Nextsteps includefurtherrefiningofcompetencies,addressinggaps,andthe linkingofknowledge,skills,andattributes.Impact: ThesefindingscontributetoleadershipdevelopmentforAdvancedPracticeNursesandClinicalNurseLeaderswhileaimingatimprovedhealthservicedeliveryandguidingofhealthpoliciesandreforms.
K E Y W O R D S
advancednursingpractice,clinicalnurseleaders,competency,education,leadership,literaturereview
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2 | HEINEN Et al.
1 | INTRODUC TION
Developments inhealthcare, likeagrowingnumberofpatientswithchronicdiseases,anincreasedcomplexityofpatients,astrongerfocusonperson‐centredcareandademandforlessinstitutionalizedcareaskforwell‐trainedmasterlevel‐educatednursesoperatingaspartnersinintegratedcareteams,withleadershipqualitiesatalllevelsofthehealth‐caresystem.ChangesinhealthcarearealsounderlinedbyadefinitionofhealthasproposedbyHuberetal.(Huberetal.,2011)wherehealthisdefinedas‘theabilitytoadaptandselfmanageinthefaceofsocial,physicalandemotionalchallenges’asarefinementoftheWorldHealthOrganization (WHO) definition where health is ‘a state of completephysical,mentalandsocialwellbeing’(WHO,1948).Thisstipulatesthede‐medicalizationofhealthcareandsocietyandemphasizestheneedfor change in theway health care is organized. Also the Institute ofMedicinewiththeirreporton‘TheFutureofNursing’supportstheurgefornursestotaketheirrolestoaddresschanges inhealthcare(IOM,2011).However leadingchange isacomplexandnotyetwellunder‐stood process (Nelson‐Brantley & Ford, 2017). Therefore, especiallymaster level‐educated nurses have to be trained in leadership basedoninternationallyestablishedleadershipcompetencies.Thisreviewin‐vestigateswhatleadershipcompetenciesareexpectedfromandcanbeidentifiedformastereducatednursesfromaninternationalperspective.
1.1 | Background
Clinicalnurseswhoaretrainedatmaster'slevel,forexample,AdvancedPractice Nurses (APNs) and Clinical Nurse Leaders (CNLs), are in auniquepositionto takea leadership role, incollaborationwithotherhealthcare professionals, to shape healthcare reform, as they useextendedandexpanded skills and are trained to focuson improvedpatientoutcomes,theapplicationofevidence‐basedpracticeandas‐sessingcost‐effectivenessofcare(Stanleyetal.,2008).ThefocusofthisreviewisonAPNsandCNLs,whereAPNisregardedasageneraldesignationforallnurseswithanadvanceddegreeinanursingprogram,that is,CertifiedNursePractitioner (NP),CertifiedRegisteredNurseAnaesthetist, Certified Nurse Midwife and Clinical Nurse Specialist(CNS) (APRN JointDialogueGroup, 2008). APNs are preparedwithspecializededucationinadefinedclinicalareaofpractice.WithAPNinthisreview,werefertotheNPandtheCNS.TheCNLiseducatedtoimprovethequalityofcareandcoordinatecareingeneralthroughcollaborationatthemicrosystemslevel intheentirehealthcareteam(APRNJointDialogueGroup,2007).Bothgroupsofprofessionalsaretrainedtointegratescienceinpracticeandeducation,haveincreaseddegreesofautonomyin judgmentsandclinical interventionsandareexpectedtobeengagedincollaborativeandinterprofessionalpracticestoachievethebestoutcomesforpatients,personnelandorganization(AmericanAssociationofCollegesofNursing,2011).Theyarealsoex‐pectedtosubstantiallycontributetoclinicaloutcomesthrough,thatis,continuousqualityimprovementinpatientcareandcreatingasupport‐iveenvironmentfortheircolleagues,andtocontributetothedevel‐opmentoftheirprofession,healthcaresystemsandhealthcarepolicy.(AmericanAssociationofCollegesofNursing,2004;Bender,Williams,
&Su,2016;Hamric,Hanson,Tracy,&O'Grady,2014).Thereforede‐velopingleadershipcompetenciesisanessentialprerequisiteforthesemastereducatednurses,APNshoweverappeartoexperiencealotofdifficultiesinenactingtheirleadershiprole(Begley,Murphy,Higgins,&Cooney,2014;Elliott,Begley,Sheaf,&Higgins,2016a).
Leadershipissubjectofmanydiscussionscanberegardedfromdiffer‐entperspectivesandismostlyrelatedtospecificcontexts.Hence,thereisnosingledefinitionapplicabletoallsettingsandprofessions.Leadershipismostlyregardedinrelationtomanagingateamororganization(Gosling&Mintzberg,2003)butcanalsobedefinedasasetofpersonalskillsortraits,orfocussingontherelationbetweenleadersandfollowers(Alimo‐Metcalfe&Alban‐Metcalfe,2004;Bolden,2004).Transformationalandsituationalleadershiparealsocommonlyusedconceptswheretransfor‐mationalleadershipisregardedastheprocessofleadingandinspiringagrouptoachieveacommongoal(Northouse,2014)andsituationallead‐ershipisfocusingontheinteractionbetweenindividualleadershipstylesandthefeaturesoftheenvironmentorsituationwheretheleaderisoper‐ating.(Fiedler,1967;Hamricetal.,2014;Lynch,McCormack,&McCance,2011). Inthisreview, leadershipisregardedasaprocesswherenursescandevelopobservableleadershipcompetenciesandattributesneededtoimprovepatientoutcomes,andpersonnelandorganizationaloutcomes(Kouzes&Posner,2012).Thisimpliesthatleadershipcompetenciescanbeviewedasintendedanddefinedoutcomesoflearningandthatleader‐shipandleadershipcompetenciesarenotrestrictedtoonesingletheory.Acompetencycanbedefinedas‘anexpectedlevelofperformancethatresults froman integrationofknowledge,skills,abilitiesand judgment’(AmericanNursesAssociation,2013).
The lack of an unambiguous definition of leadership in clini‐calpractice, includingclearlydefined leadershipcompetencies innursing,isreflectedineducation.Formosttrainingprogramsandcurricula, it isunclearwhether theprofilesused ineducationareup‐to‐dateandaiming`atinternationallyacceptedleadershipcom‐petencieswithevidence‐basedmethodstoachievethesecompe‐tencies.Toenhanceleadershipqualitiesinmastereducatednurses,it is necessary to explicitly definewhat leadership competenciesareexpectedfromAPNsandCNLs(Delamaire&Lafortune,2010).Identifying and establishing internationally agreed on leadershipcompetencies inmaster educated nurses is a first step to devel‐oping evidence‐based curricula on leadership (Falk‐Rafael, 2005;Vance&Larson,2002).SuchacurriculumfacilitatesAPNandCNLstudents tonotonlybecomecompetentclinical andprofessionalleadersbutalsowell‐preparedfororganizationalsystemsandpo‐liticalleadership(Hamricetal.,2014).Assuch,itenablesthemtohave a positive and significant impact on patient, personnel andorganizational level outcomes. Accordingly, this review aims toidentifyandintegrateleadershipcompetenciesofthemasterlevel‐educatednurse(APNandCNL)fromaninternationalperspective.
2 | THE RE VIE W
BasedonthedecisionflowchartdevelopedbyFlemmingetal.(Flemming,Booth, Hannes, Cargo, & Noyes, 2018), this review was reported
| 3HEINEN Et al.
accordingtothePreferredReportingItemsforSystematicReviewsandMeta‐Analyses statement (Moher, Liberati, Tetzlaff, & Altman, 2009)andtheEnhancingtransparencyinreportingthesynthesisofqualitativeresearchstatement(Tong,Flemming,McInnes,Oliver,&Craig,2012).
2.1 | Aim
Toidentifyandintegrateleadershipcompetenciesofthemasterlevel‐educatednurse(APNandCNL)fromaninternationalperspective.
2.2 | Design
Anintegrativereviewdesignwasused,whichallowsforthecombina‐tionofvariousstudydesignsanddatasourcestobeincluded.Inusingthis methodology, a rigorous and systematic approach is ensured(Whittemore&Knafl,2005).Wefollowedthefivestagemethodol‐ogybyWhittemoreandKnafl(Whittemore&Knafl,2005),howeverforthedatasynthesisphase,weusedthefourleadershipdomainsofHamricetal(Hamricetal.,2014;Hamric,Spross,&Hanson,2009)asanaprioriframeworktointegratetheextracteddata.
TheAPNLeadership competency is conceptualized byHamricetal. (Hamricetal.,2014)asoccurringinfourprimarydomains; inclinical practice with patients and staff, in professional organiza‐tions,inhealthcaresystemsandinhealthpolicy‐makingarenas.Asstatedabove,thisreviewfocusesontheleadershipcompetenciesofAPNsandCNLs.Additionally,knowledge,skillsandattributes(KSA)neededtodevelopleadershipcompetenciesweretopicofinterest,whereknowledge is regardedasbeingacquired throughcognitivelearning,skillsthroughpracticeandattributesasbehavioursthatarelearnedovertime(Koolen,2016)Wewouldliketoaddareferencetosupportthisone,thefullreferenceisaddedtotheremarkcon‐cerningKooleninthereferencelist.Thereferencethatneedstobeaddedhereis;GuillénandSaris(2013)
2.3 | Search methods
First, MEDLINE, EMBASE and CINAHL databases were searchedfromJanuary2005‐December2018toidentifyarticlesconcerningleadershipinAPNsandCNLs.Tofindallliteraturefittingourscope,weusedthewordsattitude*role*attribute*nexttoleadershipandcompetenc*.Thesearchstrategywasdesignedandconductedwiththehelpofaclinicallibrarian(DataS1).
Articleswereeligibleiftheyexplicitlydescribedleadershipcom‐petencies or related knowledge, skills or attributes in: (a) studiesreporting on theory or theoretical leadershipmodels; (b) develop‐mentalstudiesonleadershipprogrammes(c)studiesreportingontheeffectsofleadershipprogrammes.Norestrictionsonstudydesignswereapplied.Studieswereexcludedwhentheyconcernedmanage‐rial leadership, iftheydidnotconcernAPNsorCNLs(i.e.,bachelornursesand/orundergraduatenurses);ordescribedleadershipstylesingeneral.Boxgivesanoverviewofinandexclusioncriteria.
Secondly,thewebsitesofinternationalprofessionalnursingor‐ganizationsweresearchedfordocumentsonleadershipcompeten‐ciesinNPs,CNSs,andCNLs.Worldwide,therearemorethan100nursing organizations, usually part of one umbrella association orcouncil.Therefore,thisreviewfocusedonframeworksofumbrellaorganizationsinAustralia,Europe,andNorthAmericaandinterna‐tionalnursingcouncils.Frameworkshadtodescribenursingleader‐shipandrelatedcompetenciesinNPs,CNSs,orCNLs.
Eligible articles and frameworks were independently selected bythreereviewers(MH,AH,CvO)basedontherelevanceoftheirtitlesandabstracts,asretrievedbythesearch.Ifarticlesmettheinclusioncriteria,full‐textversionsofthearticleswereobtainedandfurtherscrutinizedforeligibilityby(MH,AH,CvO).HVwasinvolvedinanycasesofdisagree‐ment,whereconsensuswasreachedthroughdiscussion.Thereferencelistsofincludedarticleswerecheckedtodetectanypotentialadditionalstudies.
Box 1 Inclusion and exclusion criteria.
Inclusion Exclusion
• January 2005–December 2018• Research• Studiesonthedevelopmentoftheory/theoreticalmodelsconcerningleadership(APNandCNL)describingleadershipcompetencies
• Studiesonthedevelopmentofleadershipprogrammes(APNandCNL)describingleadershipcompetencies
• Studiesoneffectivenessofleadershipprogrammes(APNandCNL)describingleadershipcompetencies
• Studiesconcerningo ‘Clinicalleadership’o ‘Professionalleadership’o ‘Systemsleadership’o ‘HealthPolicyleadership’o Settings:Acutecare,Longtermcare,Homecare,Mentalcareo EducationAPNandCNL
• Location:Europe,NorthAmerica,Australia
• Editorials,opinionpapers,interviews• Studiesconcerningeffectivenessofleadershiponnursesturnoverandpatientoutcomes(transformationalleadership)
• Studiesconcerningtheeffectsofleadershiponthequalityofcareorqualityimprovement
• Specificleadershipstyles,e.g.hierarchicalleadership,trans‐formationalleadershipetc.
• Managementleadership• Managersofnursingwards• Governance• SouthAmerican,AsianandAfricancountries,duetoex‐pectedlargeculturaldifferenceswithregardtoleadershipinnursing.
4 | HEINEN Et al.
2.4 | Search outcome
ThesearchstrategyinPUBMED,CINAHL,andEMBASEresultedini‐tiallyin4,220records.Afterremovingduplicates,theremaining2,839articleswerescreenedontitleandabstract.Asaresult,168articlesandnineadditionalarticles,addedthroughreferencechecking,wereincludedforfull‐textassessment.Twenty‐fourarticleswerenotavail‐ableinfulltext.Fifteenarticleswereeventuallyincludedinthisreview.Theflowdiagram(Figure1)givesanoverviewoftheinclusionprocess.
2.5 | Quality appraisal
Aqualityappraisal(DataS2)wasconductedbytworesearchers(MH,AH)onall 15 studies.Quality appraisalof the included studieswasconducted using theMixed methods Appraisal Tool MMAT (Hong,Gonzalez‐Reyes, & Pluye, 2018). The MMAT is a critical appraisaltoolthatisdesignedfortheappraisalstageofsystematicmixedstud‐iesreviews.Itpermitstoappraisethemethodologicalqualityoffivecategoriesstudies.TheMMATstartswithtwoscreeningquestionstodeterminewhetherthestudyisanempiricalstudyandthetoolcanbeused.Foreachcategory,fivecriteriaaredefinedtoratethequalityofthestudies.Itisadvisednottocalculateanoverallscorefromtherat‐ingsofeachcriterionandexcludingstudieswithlowmethodologicalqualityisdiscouraged.Qualitywasthereforenotusedtoincludeorex‐cludestudiesfromthereview,alsobecauseofthedifficultiesincom‐paringqualityofstudiesusingdifferentdesigns(Whittemore&Knafl,2005).Thegoalofthequalityappraisalwastoevaluatethequalityof
studies and the degree of evidence in an unbiased and transparentway.Aqualityappraisalofincludedframeworkswasnotconducted.
2.6 | Data extraction
Data extraction was performed using a pre‐defined, structureddataextractionsheetandwasdouble‐checkedbythreeresearchers(MH,AH,CvO).Thefollowingdatawereextracted:author,yearofpublication,title,methodology,countryandsetting,master'sAPNsor CNLs. Competencies and KSA were derived from the frame‐worksandstudies,bythesamethreeresearchers (MH,AH,CvO).Involvementofthreeindependentresearcherswasusedtoensurerigourofdataextraction(Whittemore&Knafl,2005).
2.7 | Synthesis
Competenciesdescribed in theoriginalstudiessubsequentlyweredesignated to the leadership domains described by Hamric et al.(Hamricetal.,2014)bythreeresearchers(MH,AH,CvO).Incasesofdiscrepancy, theselecteddomainswerediscusseduntil consensuswas reached.Thenext stepconsistedofclusteringofoverlappingcompetencies by two researchers (MH,AH),whichwere checkedbyathirdresearcher(CvO).Thecompetencyfromtheoverlappingitemsthatbestdescribedthecontentwaschosenforthefinalover‐viewofcompetencies,sometimeswithaminoradaptationtofullygrasp theessenceof this competency.The sameprocesswas fol‐lowedfortheKSA‐items.
F I G U R E 1 Flowdiagram(PRISMA2009)
Iden
tific
atio
n E
ligib
ility
Incl
uded
S
cree
ning Records screened after
duplicates removed(n = 2,839)
Full-text articles excluded(n = 162)
24 not available
138 due to exclusion criteria; bachelor nurses, no competencies or attributes described, leadershipstyles, management, opinion papers
Full-text(n = 168 + 9 snowball = 177)
Records excluded tiab(n = 2,671 )
Studies included(n = 15)
Records identified throughsearching Embase, Medline
and CINAHL (n = 4,220)
| 5HEINEN Et al.
TAB
LE 1
Overviewofincludedstudies(15)andframeworks(7)
Firs
t Aut
hor/
O
rgan
izat
ion
Year
Title
Met
hodo
logy
and
aim
stu
dy/
Shor
t des
crip
tion
fram
ewor
kPa
rtic
ipan
tsCo
untr
yN
P/CN
S/ C
NL
Studies
1. A
iley
2015
Educ
atin
g nu
rsin
g st
uden
ts in
clin
ical
leadership
Casestudy/TodescribetheuseofSituated
LearninginNursingLeadershipinCNLeducation
22Generalistmaster
stud
ents
USA
CNL
2.Bahouth
2011
Centralizedresourcesfornursepractitioners:
commonearlyexperiencesamongleaders
ofsixlargehealthsystems
Surveyandfocusgroupdiscussions/Todescribe
experiencesofimplementingaleadershiprolefor
hospital‐basedNPs
6Leadersofacademic
inst
itutio
nsUSA
NP
3.Bearnholdt
2011
TheClinicalNurseLeader–newnursingrole
withglobalimplications
Shortreportoftheliterature–CNLroleandeduca‐
tiondevelopment
NA
USA
CNL
4.Bender
2016
Refiningandvalidatingaconceptualmodel
ofClinicalNurseLeaderintegratedcare
deliv
ery
Sequentialmixedmethodscombininginitialqualita‐
tive(modelrefinementandsurveydevelopment)
andsubsequentquantitative(survey)adminis‐
trationandanalysis)approaches/Toempirical
validateaconceptualmodelofCNLintegrated
care
del
iver
y
CNLs,clinicians,admin‐
istr
ator
s in
volv
ed in
CNLinitiatives
USA
CNS
5.Carryer
2007
Thecoreroleofthenursepractitioner:
Practice,professionalismandclinical
leadership
Interviews/Todrawonempiricalevidencetoillus‐
tratethecoreroleofnursepractitioners
15Nursepractitioners
NewZealand
&Australia
NP
6.Gardner
2006
Nursepractitionercompetencystandards:
findingsfromcollaborativeAustralianand
NewZealandresearch
Interpretivesynthesiswithmultipledatasources
publisheddataofpoliciesandcurricula/To
developcorestandardsthatcouldinformnurse
practitionercompetencies
NA
Australia&
NewZealand
NP
7.Gerard
2012
Coursestrategiesforclinicalnurseleader
development
Descriptionandqualitativeevaluationofcourse
strategiesforclinicalnurseleaderdevelopment
9Nursingmaster
stud
ents
USA
CNL
8.Goldberg
2016
Developmentofacurriculumforadvanced
nursepractitionersworkingwitholderpeo‐
plewithfrailtyintheacutehospitalthrough
amodifiedDelphiprocess
Literaturereview,workshopsandathreeround
modifiedDelphi‐study/Toestablishanexpert
consensusontheroledescriptionandessential
competenciesforANPs
31experts
UK
NP
9.Leggat
2015
Developingclinicalleaders:theimpactofan
actionlearningmentoringprogrammefor
advancedpracticenurses
Pre‐postlongitudinalinterventionstudy/To
determinewhetheraformalmentoringpro‐
grammeassistsnursepractitionercandidatesto
developcompetenceintheclinicalleadership
competencies
18NPcandidates,17
seni
or n
urse
sA
ustr
alia
NP
10.Maag
2006
AConceptualFrameworkforaClinicalNurse
LeaderProgram
Descriptionofandexplainingthecomponents
oftheconceptualmodelforaCNLeducational
program
NA
USA
CNL
11.Nieminen
2011
Advancedpracticenurses'scopeofpractice:
aqualitativestudyofadvancedclinical
competencies
Qualitative/TodescribeandexploreAdvanced
PracticeNurses’clinicalcompetenciesandhow
theseareexpressedinclinicalpractice
26APNand6APN
stud
ents
Finl
and
NP
(Continues)
6 | HEINEN Et al.
Firs
t Aut
hor/
O
rgan
izat
ion
Year
Title
Met
hodo
logy
and
aim
stu
dy/
Shor
t des
crip
tion
fram
ewor
kPa
rtic
ipan
tsCo
untr
yN
P/CN
S/ C
NL
12.Kalb
2006
Acompetency‐basedapproachtopublic
healthnursingperformanceappraisal
Pilottestingofassessmenttool,developedbased
onareviewofpublichealthnursecompetency
literature/Tointegratepublichealthnursingcom‐
petenciesintoacomprehensivereviewinstrument
50NursesfromPHN
workforce
USA
NP/CNS
13.O'Rourke
2016
ActivitiesandAttributesofNurse
PractitionerLeaders:Lessonsfroma
PrimaryCareSystemChange
Interviewsanddocumentanalysis/Toexaminethe
activitiesandattributesoftwoNPleaders
6Healthcareprovid‐
ers,3managersand7
healthpolicyadvisors
Canada
NP
14.Thompson
2011
ClinicalNurseSpecialistEducation;
ActualizingtheSystemsLeadership
competency
Overviewofeducationalstrategiesaidinginthe
acquisitionofsystemsleadershipandchangeagent
skillsofCNS/Toshowhowsequencededucational
strategiesaidintheacquisitionofsystemsleader‐
shipandchangeagentskills
NA
USA
CNS
15.Sievers
2006
AchievingClinicalNursespecialist
CompetenciesandOutcomesThrough
InterdisciplinaryEducation
Plandostudyactcycles/Tocreateaninterdisci‐
plinaryeducationalexperienceforclinicalnurse
specialist(CNS)students
7Learners
USA
CNS
Frameworks
1. A
mer
ican
A
ssoc
iatio
n ofCollegesof
Nursing
2013
Master'sEssentialsandClinicalNurse
Leader®Competencies
TheMaster'sEssentials&ClinicalNurseLeader
Competenciesareimbeddedin9domains.Core
leadershipcompetenciesaremainlydescribed
intheessential‘OrganizationalandSystems
Leadership’
NA
USA
CNL
2. A
mer
ican
A
ssoc
iatio
n ofCollegesof
Nursing
2006
TheEssentialsofDoctoralEducationfor
AdvancedNursingPractice,
Leadershipcompetenciesandrolesareimbeddedin
eightdomains
NA
USA
NP
3.ANMC
2014
Nursepractitionerstandardsforpractice
Theleadershipdomainiscouchedwithintheclini‐
callyfocusedstandards.
NA
Aus
tral
iaNP
4.TheCanadian
Nurses
Ass
ocia
tion
2010
Canadiannursepractitionercorecompe‐
tencyframework
Leadershipcompetencieswithinthecat‐
egory‘ProfessionalRole,Responsibilityand
Accountability’
NA
Canada
NP
5.ICN
2015
InternationalCouncilofNursesLeadership
ForChange™(LFC)program
Leadershipcompetencies&rolesarefocusedon3
strategicaimsandinclude11definedoutcomes
NA
Europe
CNL
6.TheNational
Organizationof
ClinicalNurse
Specialists
2008
ClinicalNurseSpecialistCoreCompetencies
SystemLeadershipcompetencyisoneofthe7
ClinicalNurseSpecialistcorecompetencies,
describedbybehaviour,sphereofinfluenceand
nursecharacteristicsneeded.
NA
USA
CNS
TAB
LE 1
(Continued)
(Continues)
| 7HEINEN Et al.
3 | RESULTS
3.1 | Individual studies
Oneoutof15articlesconcernedboththeNPandtheCNS,sevenwereabouttheNP,threewereabouttheCNSandfourarticlesfo‐cusedontheCNL.Mostarticles(9/15)originatedfromtheUnitedStatesofAmerica(USA),threefromAustraliaandthreearticlesorig‐inatedfromCanada,theUK,andFinlandrespectively.Twoarticlespublisheddifferentaspectsofthesameresearch(Carryer,Gardner,Dunn,&Gardner,2007;Gardner,Carryer,Gardner,&Dunn,2006)(Table1).
Sample sizes were relatively small, ranging from 6‐50 re‐spondents and consistedofnurse leaders (Bahouthet al., 2013;Goldberg et al., 2016; O'Rourke & Higuchi, 2016), experiencednurses(Bender,Williams,Su,&Hites,2017;Carryeretal.,2007;Gardneretal.,2006;Kalbetal.,2006;Leggat,Balding,&Schiftan,2015;Nieminen,Mannevaara, & Fagerström, 2011) and APN orCNL students (Ailey, Lamb,Friese,&Christopher,2015;Gerard,Grossman,&Godfrey,2012;Leggatetal.,2015;Nieminenetal.,2011;Sievers&Wolf,2006).
Multiple research designswere used. These included surveys,interviews, and focus groups to describe experiences on integrat‐ingNPsandCNSsintohospitals(Bahouthetal.,2013;O'Rourke&Higuchi,2016;Sievers&Wolf,2006)andexpressedclinicalcompe‐tences(Nieminenetal.,2011),acasestudyonaneducationprogramforCNLs(Aileyetal.,2015),exploringtheeffectofamentorpro‐gramofNPstudentsondevelopingleadershipcompetencies(Leggatetal.,2015),pilotinganassessmentforperformancereviewofNPsandCNSs(Kalbetal.,2006)andmulti‐methodresearchtodevelopsharedcompetenciesandeducationalstandardsforAPNs (Benderetal.,2017;Carryeretal.,2007;Gardneretal.,2006;Goldbergetal.,2016).Eightweredescriptivestudieson(experienceswith)edu‐cationalprogramsforCNLsorCNSs(Aileyetal.,2015;Baernholdt&Cottingham,2011;Gerardetal.,2012;Goldbergetal.,2016;Leggatetal.,2015;Maag,Buccheri,Capella,&Jennings,2006;Sievers&Wolf, 2006; Thompson & Nelson‐Marten, 2011) Baernholdt andCottingham(Baernholdt&Cottingham,2011)alsoreportedonthedevelopmentof theCNLrole inpractice.Sixstudiesexplicitlyde‐scribedleadershipcompetencies(Benderetal.,2017;Gardneretal.,2006;Gerardetal.,2012;Goldbergetal.,2016;Kalbetal.,2006;Nieminenetal.,2011).Furthermore,studiesfocusedonknowledge(Aileyetal.,2015;Carryeretal.,2007),leadershipskills(Baernholdt&Cottingham,2011;Maagetal.,2006;Thompson&Nelson‐Marten,2011) and leadership attributes (Bahouth et al., 2013; Sievers &Wolf,2006).
Foreightoutof15studies,qualitycouldnotbedeterminedonthebasisofqualityappraisaltoolsforresearch(DataS2),fivestud‐iesscoredpositiveonallfiveMMETdomains(Benderetal.,2017;Carryer et al., 2007;Goldberget al., 2016;Nieminenet al., 2011;O'Rourke&Higuchi,2016),onestudyscoredpositiveonfouroutoffivedomains(Leggatetal.,2015)andonestudyscoredpositiveononedomain(Bahouthetal.,2013).Fi
rst A
utho
r/
Org
aniz
atio
nYe
arTi
tleM
etho
dolo
gy a
nd a
im s
tudy
/ Sh
ort d
escr
iptio
n fr
amew
ork
Part
icip
ants
Coun
try
NP/
CNS/
CN
L
7.TheNational
Organization
ofNurse
Practotioner
Facu
lties
2014
Adelineationofsuggestedcontentspecific
totheNPcorecompetencies,
Leadershipis1of9domains,theleadershipdomain
itselfincludes7competencies
NA
USA
NP
Abbreviation:NA,NotApplicable.
TAB
LE 1
(Continued)
8 | HEINEN Et al.
3.2 | Frameworks
Sevencompetencyframeworks,includingleadershipcompeten‐cies,wereidentified.Theframeworksweredevelopedbetween2006 and 2014 and originated internationally in Europe (1/7)
(ICN, 2015), theUSA (4/7) (AmericanAssociation of Collegesof Nursing, 2006, 2013; The National Organization of NursePractotioner Faculties, 2014), Canada (1/7) (The CanadianNurses Association, 2010) and Australia (1/7) (Nursing andMidwifery Board of Australia, 2014). All frameworks describe
TA B L E 2 Final30leadershipCorecompetencieswithin(four)leadershipdomains
ClinicalLeadershipdomain–Corecompetencies(N = 8)1.Providesleadershiptothehealthcareteamtopromotehealth,facilitateself‐caremanagement,optimizepatientengagement,andpreventfu‐turedeclineincludingprogressiontohigherlevelsofcareandreadmissions.Actsasaresourceperson,preceptor,mentor/coach,androlemodeldemonstratingcriticalandreflectivethinking
2.Assumesasaclinicalexpert,aleadershiproleinestablishingandmonitoringstandardsofpracticetoimproveclientcare,includingintra‐andinterdisciplinarypeersupervisionandreview
3.Analysesorganizationalsystemsforbarriersandpromotesenhancementsthataffectclienthealthcarestatus.4.Engagesinadvancednursingpracticeandprovideleadershipforevidence‐basedpractice.Thisrequirescompetenceinknowledgeapplicationactivities:identifiescurrentrelevantscientifichealthinformation,thetranslationofresearchinpractice,theevaluationofpractice,improve‐mentofthereliabilityofhealthcarepracticeandoutcomes,andparticipationincollaborativeresearch
5.Providesleadershipandactsasaliaisonwithotherhealthagenciesandprofessionals,andparticipatesinassessingandevaluatinghealthcareservicestooptimizeoutcomesforpatients/clients/communities
6.Collaborateswithhealthcareprofessionals,includingphysicians,advancedpracticenurses,nursemanagers,andothers,toplan,implement,andevaluateanimprovementopportunity.
7. Alignspracticewithoverallorganizational/contextualgoals8.Guides,initiates,andprovidesleadershipin1)thedevelopmentandimplementationofstandards,practiceguidelines,qualityassurance,and2)education,and3)researchinitiatives.
ProfessionalLeadershipdomain–Corecompetencies(N=6)1.Participatesinprofessionalorganizationsandactivitiesthatinfluenceadvancedpracticenursing2.Providesleadershipinthedevelopmentandintegrationofthenursepractitionerrolewithinthehealthcaresystem.3.Assumesresponsibilityforownprofessionaldevelopmentbypursuingeducation,participatinginprofessionalcommitteesandworkgroups,andcontributingtoaworkenvironmentwherecontinualimprovementsinpracticearepursued
4.Employsconsultativeandleadershipskillswithintraprofessionalandinterprofessionalteamstocreatechangeinhealthcareandcomplexhealthcaredeliverysystems.
5.Participatesinpeer‐reviewactivitiese.g.publications,research,andpractice6.Participatesinrelevantnetworks;regional,national,andinternational
HealthSystemsLeadershipdomain–Corecompetencies(N = 8)1.Contributestodevelopment,implementation,andmonitoringoforganizationalperformancestandards2.Assumesaleadershiproleofaninterprofessionalhealthcareteamwithafocusonthedeliveryofpatient‐centredcareandtheevaluationofqualityandcost‐effectivenessacrossthehealthcarecontinuum
3.Demonstratesaleadershiproleinenhancinggroupdynamicsandmanaginggroupconflictswithintheorganization4.Plansandimplementstrainingandprovidestechnicalassistanceandnursingconsultationtohealthdepartmentstaff,healthproviders,policymakers,andpersonnelinothercommunityandgovernmentalagenciesandorganizations
5.Delegatesandsupervisestasksassignedtoparaprofessionalstaff6.Createsacultureofethicalstandardswithinorganizationsandcommunities7. Identifiesinternalandexternalissuesthatmayimpactdeliveryofessentialmedicalandpublichealthservices8.Demonstratesworkingknowledgeofthehealthcaresystemanditscomponentparts,includingsitesofcare,deliverymodels,paymentmodels,andtherolesofhealthcareprofessionals,patients,caregivers,andunlicensedprofessionals
HealthPolicyLeadershipdomain–Corecompetencies(N = 2)1.Guides,initiates,andprovidesleadershipinpolicy‐relatedactivitiestoinfluencepractice,healthservicesandpublicpolicy2.Articulatesthevalueofnursingtokeystakeholdersandpolicy‐makers
ClinicalandHealthSystemsLeadershipdomain–Corecompetencies(N = 4)1.Usesadvancedcommunicationskills/processestoleadqualityimprovementandpatientsafetyinitiativesinhealthcaresystems.2.Employsprinciplesofbusiness,finance,economics,andhealthpolicytodevelopandimplementeffectiveplansforpractice‐leveland/orsys‐tem‐widepracticeinitiativesthatwillimprovethequalityofcaredelivery.
3.Advocatesforandparticipatesincreatinganorganizationalenvironmentthatsupportssafeclientcare,collaborativepracticeandprofessionalgrowth.
4.Createpositivehealthy(work)environmentsandmaintainaclimateinwhichteammembersfeelheardandsafe
ProfessionalandHealthSystemsLeadershipdomain–Corecompetencies(N = 1)1.Preparesthroughmentoringandcoachingfuturegenerationsofnurseleaders
Clinical,HealthSystemsandHealthPolicyLeadershipdomain–Corecompetencies(N = 1)1.Providesleadershipintheevaluationandresolutionofethicalandlegalissueswithinhealthcaresystemsrelatingtotheuseofinformation,informationtechnology,communicationnetworks,andpatientcaretechnology.
| 9HEINEN Et al.
leadership competencies for theNP,CNS, orCNLbut the ex‐tent to which the four leadership domains (i.e., clinical‐, pro‐fessional‐, system‐, and health policy leadership) are covereddiffered (Table1). InAustralia, leadership is linkedtofourde‐fined practice standards in the nursing process. Additionally,leadership is defined as the ability to lead care teams wheretheNP supports other professionals through clinical supervi‐sionandmentoring(NursingandMidwiferyBoardofAustralia,2014). The Canadian Nurse Practitioner Core CompetenciesFramework identifies leadershipasacorecompetence for theNPthatshouldbereflectedinexcellentclinicalpracticeandbymentoringcolleaguesandstudents.LeadershipactivitiesshouldnotbelimitedtotheNPs'ownpracticeorinstitutionbutshouldfocusontheentirecarecontinuum,alsoincludingthepoliticalfield of health care (TheCanadianNursesAssociation, 2010).The NONPF‐USA defines nursing leadership as the ability tochange care systems, create partnerships, establish adequatecommunicationandtoparticipateinprofessionalorganizations(The National Organization of Nurse Practotioner Faculties,2014). The Clinical Nurse Specialist Core CompetenciesFrameworkhasassignedleadershipcompetenciesmainlytotheheading ‘System leadership’ and describes specific leadershipbehaviour and associated sphere of influence and nurse char‐acteristicsneeded(TheNationalOrganizationofClinicalNurseSpecialists, 2010). The Essentials of Doctoral Education forAdvancedNursingPractice (AmericanAssociationofCollegesofNursing,2006)isdesignedtopreparenursesforthehighestlevelofleadershipinpracticeandscientificinquiry.
Leadership competencies mainly refer to the category‘Organizationalandsystemleadershipforqualityimprovementandsystemsthinking’.Leadershipcompetenciesareapplied inclinicalpractice, aswell in theentire fieldofhealth care.The
‘Master's Essentials and Clinical Nurse Leader Competencies’outlined in the ‘Competencies and Curricular Expectationsfor Clinical Nurse Leader Education and Practice’ (AmericanAssociationofCollegesofNursing,2013)describestheCNLas‘aleaderinthehealthcaredeliverysysteminallsettingswherehealthcare is delivered’ (American Association of Colleges ofNursing, 2013, p. 4). The leader competencies are embeddedin nine categories, with the core leadership competenciesmainly described in ‘Essential 2: Organisational and SystemsLeadership’. Finally, the International Council of NursesLeadershipforChange™(LFC)programisdevelopedtopreparenurses to take a leadership role during health sector changeand reform and enhance their contribution to health services(ICN,2015).Leadershipcompetenciesaremainlyfocusedonasystem‐andhealthpolicyleadership.Fourframeworksprovidesuggestions for curriculum development concerning requiredKSAorperformanceindicators(ICN,2015).
3.3 | Data synthesis
The150competenciesderivedfromtheliteraturearedisplayedinData S3. Table 2 shows the final synthesis of the extracted com‐petencieswhichresultedintheidentificationof30coreleadershipcompetencies,assignedtothefourleadershipdomainsofHamricetal.(Hamricetal.,2014).Thehighestnumberofcompetencies(n = 8) was designated to the clinical and to the systems leadership do‐mains,sixtotheprofessionalandtwotothehealthpolicyleadershipdomains.Sixcompetenciesfittedmorethanonedomain,ofwhichone competency related to three domains, the clinical, the healthsystems,andthehealthpolicydomainsandfourcompetencieswerelinkedtotheclinical,andtothehealthsystemsleadershipdomains.Onecompetencywasdesignatedtotheprofessionalandthehealth
F I G U R E 2 Modelcompetencies
Clinical leadershipn = 8
ProfessionalLeadership
n = 6
n = 1
Radboud
n = 1Health policyleadership
n = 2
Health systemsleadership
n = 8
n = 4
umc
10 | HEINEN Et al.
TA B L E 3 Overviewofidentifiedneedsforknowledge,skills,andattributes
Leadership domain
Knowledge–theAPNhasknowledgeof
1.Legalandethicaldimensionsofpractice,policydirectivesandbestpracticeguidelinesthatinfluencetheirownpracticeandthepracticeofthepeopletheylead(Aileyetal.,2015;Bahouthetal.,2013;Carryeretal.,2007)
CL
2.Sciences/socialsciences,disparities,socialdeterminants(Aileyetal.,2015) CL
3.Informatics(Aileyetal.,2015) HS
4.Economics,policy,finance(Aileyetal.,2015) HS,HP
5.Outcomesmanagementandqualityimprovement(Aileyetal.,2015) CL,HS
6.Collaborationwithconsumersandstakeholders(Aileyetal.,2015) CL,HS
7.Interprofessionalleadership(TheNationalOrganizationofNursePractotionerFaculties,2014) CL
8.Leadershippositionsinprofessional,political,orregulatoryorganizations(TheNationalOrganizationofNursePractotionerFaculties,2014)
HS,HP
9.Structureandfunctionsofeditorial/boardroles(TheNationalOrganizationofNursePractotionerFaculties,2014)
All
10.Leadership,change,andmanagementtheorieswithapplicationtopractice(Aileyetal.,2015;TheNationalOrganizationofNursePractotionerFaculties,2014)
All
11.Politicalprocesses,politicaldecision‐makingprocesses,andhealthcareadvocacy(TheNationalOrganizationofNursePractotionerFaculties,2014)
HP
Skills–theAPNshowsskillsto…
1.Integratecare(Maagetal.,2006) CL
2.Advocateforaclient'sinterests(Maagetal.,2006) CL
3.Applyevidence‐basedpractice,research/standardsofpractice(Aileyetal.,2015) CL
4.Criticalthinking(Baernholdt&Cottingham,2011) All
5.Challengingcurrentpolicies,proceduresandpracticeenvironmentsusingchangetheoryandthetheoryof6.Diffusionofdissemination.(Baernholdt&Cottingham,2011)
HS,HP
6.Accessing,evaluating,anddisseminatingknowledgeatthesystemlevel(Baernholdt&Cottingham,2011) HS
7.Reasoningtomovefromindividualpatientcareconcernstogroup/populationconcernsandsystemsolutions(Aileyetal.,2015)
HS
8.Systemsthinking(TheNationalOrganizationofClinicalNurseSpecialists,2010) All
9.Collaboration(TheNationalOrganizationofClinicalNurseSpecialists,2010) All
10.Responsetodiversity(TheNationalOrganizationofClinicalNurseSpecialists,2010) All
11.Clinicaljudgment(TheNationalOrganizationofClinicalNurseSpecialists,2010) CL
12.Clinicalenquiry(TheNationalOrganizationofClinicalNurseSpecialists,2010) CL
13.Identifytheneedforchange(Thompson&Nelson‐Marten,2011) CL
14.Designprogramstofacilitatebehaviourchange(Thompson&Nelson‐Marten,2011) CL
15.Persuadeandencourageadoptionofthechange(Thompson&Nelson‐Marten,2011) All
16.Evaluateoutcomes(Thompson&Nelson‐Marten,2011) CL
17.Synthesizetheliterature(Thompson&Nelson‐Marten,2011) PR
18.Problemsolving
a.Influencingandnegotiation(Maagetal.,2006;TheNationalOrganizationofNursePractotionerFaculties,2014)
All
b.Conflictmanagement(TheNationalOrganizationofNursePractotionerFaculties,2014) All
c.Strategicthinking(TheNationalOrganizationofNursePractotionerFaculties,2014) HS,HP
d.Managingchange(TheNationalOrganizationofNursePractotionerFaculties,2014) All
19.Communication
a.Scholarlywriting,manuscript,andabstractpreparation(Baernholdt&Cottingham,2011;Bahouthetal.,2013;TheNationalOrganizationofNursePractotionerFaculties,2014)
PR
(Continues)
| 11HEINEN Et al.
systems leadership domains. Themodel in Figure 2 presents thissynthesisofcompetencies.
Seven studies and two frameworks reported on knowledge(Aileyetal.,2015;Bahouthetal.,2013;Carryeretal.,2007;TheNationalOrganizationofNursePractotionerFaculties,2014),skills(Ailey et al., 2015; Baernholdt & Cottingham, 2011;Maag et al.,2006; The National Organization of Clinical Nurse Specialists,2010;TheNationalOrganizationofNursePractotionerFaculties,2014;Thompson&Nelson‐Marten,2011)andattributes(Aileyetal.,2015;Bahouthetal.,2013).BothAileyetal.(Aileyetal.,2015;Sievers&Wolf,2006)andtheNONPF(TheNationalOrganization
ofNursePractotionerFaculties,2014)describedskillsandknowl‐edge in termsofexplicit curriculacontent forAPNs.Other stud‐iesreportedbroadlyformulatedKSA.Elevenknowledgeitems,21skillsand21attributeswereidentified(Table3)andassignedtoaleadershipdomain.
4 | DISCUSSION
Theresultsofthisintegrativereviewleadtothesynthesisof30lead‐ershipcompetenciesforAPNsandCNLsderivedfrominternational
Leadership domain
b.Structuringandpresentingpersuasivearguments(Baernholdt&Cottingham,2011;Bahouthetal.,2013;TheNationalOrganizationofNursePractotionerFaculties,2014)
All
20.Peerreview
a.Publications
b.Presentations
c.Research
d.Practice(TheNationalOrganizationofNursePractotionerFaculties,2014) PR
21.Leadershipdevelopment
Influencedecision‐makingbodiesatthesystem,state,ornationallevel(TheNationalOrganizationofNursePractotionerFaculties,2014)
HS,HP
Attributes–theAPN..
1.ischampionofAPNpractice(Bahouthetal.,2013) CL
2.iscollaborativeinissuesthatbridgenursingandmedicine(Bahouthetal.,2013) PR
3.isresponsivetotheneedsofdiversestakeholdersincludingtheCEO,CFO,CMO,CNO,supervisingphysicians,andAPNs.(Bahouthetal.,2013)
HS
4.isshowinginteractionmodalities(Baernholdt&Cottingham,2011) All
5.hastheabilitytomentorAPNsinprofessionaldevelopment(Bahouthetal.,2013) PR
6.isflexibleinatransitionfromclinicalroletoexecutivepolicydecision‐making(Bahouthetal.,2013) HP
7.isapproachablebyalllevelsofmedicalandnursingstaff(Bahouthetal.,2013) CL
8.isabletoaccesskeyresourcesandrelationshipsforthebenefitoftheAPNs(Bahouthetal.,2013) PR
9.isabletofoster/translateresearchintopracticeandfosterongoingresearch(Bahouthetal.,2013) CL
10.isarticulateregardingadvantagescost‐effective,qualitycareprovidedbyAPNs(Bahouthetal.,2013) HS
11.ispoliticallyastuteregardingorganizationalnuances,politicalandphilosophicalissuesrelativetheAPNroleinrelationtophysicianpracticeintheacuteandcriticalcareenvironment.(Bahouthetal.,2013)
HP
12.isknownforpreviousexperienceinstrategicplanning,participationinexecutivepolicy,anddecision‐mak‐ing(Bahouthetal.,2013)
HS,HP
13.isknownforqualityleadershipwithintheinstitution(Bahouthetal.,2013) CL,HS
14.isawareofclinicalleadershiptoleadershipatmicroandmezzolevel(Aileyetal.,2015) CL
15.isconfidentwhileadvocatingfortheroleofnursing(Sievers&Wolf,2006) PL,HS
16.ishonestwhileadvocatingfortheroleofnursing(Sievers&Wolf,2006) PL,HS
17.iswillingtotakeriskwhileadvocatingfortheroleofnursing(Sievers&Wolf,2006) PL,HS
18.solicitedpeerfeedback(Sievers&Wolf,2006) CL
19.isopentolearningnewconcepts(Sievers&Wolf,2006) CL
20.supportsgroupsdiversityandculture(Sievers&Wolf,2006) CL,HS
21.isabletoarticulatetheCNSroleandscopeofpracticetoothers(Sievers&Wolf,2006) HS
Note:Abbreviations:CL,clinical;PR,professional;HS,healthsystems;HP,healthpolicy.
TA B L E 3 (Continued)
12 | HEINEN Et al.
literatureandofficialdocumentsof internationalnursingorganiza‐tions. Competencies were furthermore designated to the clinical,professional,healthsystemsorthehealthpolicyleadershipdomains,according toHamric et al. (Hamric et al., 2014). Six competencieswerelinkedtomorethanonedomain.Theclinical,professionalandthe health systems domains dominated regarding the number ofcompetencies.
Intheclinicalleadershipdomain,corecompetenciesarefocusedondeliveringexcellentpatientcareandconcernitemslikecollabo‐rationwithprofessionalsandotherhealthagencies,implementationof innovations, andenhancingEBP.AlthoughEBP isoftenviewedasa stand‐alonecompetency (Hamricetal.,2014), leadershipandEBParestronglyconnected(Sastre‐Fullanaetal.,2017).Stetleretal.(Stetler,Ritchie,Rycroft‐Malone,&Charns,2014)assumesupportiveleadershipasakeydriver for the successful institutionalizationofEBPinanorganization(Stetleretal.,2014).
Competenciesontheprofessionalleadershipdomainappeartobeclearlyformulatedandprovideforsufficientdirectiontofurtherdevelopthenursingprofession.This is importantbecausehospitaldecisionmakersneedtolearnfromprofessionalsabouttheirrolesand a collaborative evidence‐based vision on APN (Carter et al.,2013)(Kilpatricketal.,2014;Kleinpell,2013).
TheleadershipcompetenciesintheHealthSystemsdomainareshiftingfromdirectpatientcaretothestrategic level. Influencingatthestrategiclevelrequiresanin‐depthunderstandingofhealth‐caresystemstocreateandshareanorganizationalvisiononqual‐ityimprovement,leadingtotheimplementationofchangesandtoevaluatetheirresults.(Thompson&Nelson‐Marten,2011;Walker,Cooke,Henderson,&Creedy,2011).Healthsystemleadershipalsomeans thatAPNsandCNLsarticulate thenursingperspectivebyjoiningorchairinginterdisciplinarycommitteesandraisetheirvoiceintheboardroom.However,formalpositionsforAPNsandCNLsatstrategiclevelarenotself‐evident.Systemleadershipcanthereforeonlybereinforcedwhensupportedbymanagersandadministratorsoftheorganization(Hanson,2015;Higginsetal.,2014).
Competencies related to the health policy domain weremini‐mallypresent.Identifiedcorecompetenciesinthehealthpolicydo‐mainweretheguidingandinitiatingof leadershipinpolicy‐relatedactivities, to practice influence in health care and the articulationof the value of nursing to key stakeholders and policymakers onthe(inter)nationallevel.Theseratherabstractcompetenciesdonotallowforaclearunderstandingofthecontentandnatureofhealthpolicy leadership. Further specification and operationalization areneededtoguidenurses tothepoliticalarena.Forexample,healthpolicy competences should be focussing on in‐depth understand‐ing of global trends in relevant health issues and the profession'sinvolvement inhealthcarepolicydecisions (Rains&Barton‐Kriese,2001).Additionally, information technology including e‐health ap‐plicationsand‘BigData’analyticsareimportantissuesonthehealthpolicyagendaandthenursingperspectiveshouldbepartofdeci‐sion‐makingprocessesinthisarea.
HalfofthestudiesandtwoframeworksreportedonKSA(table3) needed for the development of leadership competencies. The
distinction between KSA however, appeared somewhat unclear.Beingknowledgeableaboutlegalruleswasdescribedasanattributeinonestudy(Bahouthetal.,2013)andasknowledgeinothers(Aileyetal.,2015;Carryeretal.,2007).AlthoughKSAarecloselyrelatedtoeachother,adistinction ishelpful tospecifywhat isneededtoachievedefinedleadershipcompetencies.
Acquiring leadership competencies and related KSA occursovertimeand iscomparablewithBenner'scontinuum ‘fromnov‐ice toexpert’ (Benner,1982).BothAPNsandCNLscurriculaandclinicallearningprogramsshouldtrainandempowertheirstudentstobecomeleaders.Evidenced‐basedtrainingprogramsforclinical,professional,andsystemsleadershiparescarce(Elliott,Farnum,&Beauchesne,2016b).Trainingprogramsforpoliticalleadershipareevenscarcer,which is in linewith the identifiedcompetencygapinthehealthpolicydomain.Themodellaidoutinthispapercouldprovideausefulbaseforevidence‐basedcurriculumdevelopment,although identified competenciesneed tobe further refinedanddiscussed and completedwith KSA related to each competency.Educational programs which integrate course work and clinicallearning seem promising in developing and improving leadershipcompetenciesinespeciallytheclinicalandsystemsdomains(Aileyet al., 2015; Sievers&Wolf, 2006; Thompson&Nelson‐Marten,2011).Ainslie (Ainslie,2017)advocates thatorganizationsshouldmap leadership competences to observable milestones so thatprogresscanbeclearlydetermined.Thiscompetence‐basedlearn‐ing has similarities with the concept of Entrustable ProfessionalActivity(EPA).EPAsareelementsofprofessionalpractice,thatis,tasksorresponsibilitiesthatareobservableandmeasurableintheirprocessandoutcome (TenCate,2013)andmayalsobeuseful indeveloping leadership in APNs and CNLs. An assessment deter‐mines the entry competency levels and point out a personalizedleadership development path. An APN, for example,may test atthe expert level for ‘promoting and performing EBP’ but test atthe novice level for ‘leading inter professional healthcare teams’.Additionally,situatedcoachingandmentoringisconsideredanes‐sentialelementineducationalandclinicallearningprograms(Aileyetal.,2015;Elliott,2017).
Positive results are found for the effects of hierarchical lead‐ershipinnursingonqualityofcareand,morespecifically,onnurs‐ing‐sensitive patient outcomes (Vaismoradi, Griffiths, Turunen, &Jordan,2016;Wong,Cummings,&Ducharme,2013).However,fur‐therresearchisneededtoestablishtherelationshipbetweenlead‐ership practices of APNs and CNLs and nursing‐sensitive patientoutcomes(Duboisetal.,2017;Kapu&Kleinpell,2013).
Alimitationofthisreviewisthefactthat24ofthe177literaturear‐ticlesincludedbasedontitleandabstractwerenotavailableinfulltextandthefinalselectionofonly15studiesconsistedofvaryingstudydesigns and quality. Furthermore,most studies originated from theUnitedStatesandAustraliawhichmightbechallengingtherepresenta‐tivenessofthisreviewfromaninternationalperspective.Nonetheless,thisreviewrepresentsanintegrativeoverviewincludingagapanalysisofleadershipcompetenciesforAPNsandCNLsinthecurrentlitera‐tureandasestablishedbyinternationalnursingorganizations.
| 13HEINEN Et al.
5 | CONCLUSION
This review identified 30 core leadership competencies for APNsandCNLsintheclinical,professional,healthsystems,andhealthpol‐icyleadershipdomains.Thenextstepsinclude:(a)discussinggapsinthis overviewof competencieswithmaster level‐educated nursesandeducationalinstitutesandlinkingKSAtoeachoftheestablishedleadership core competencies; (b) translating these competenciesandalignedKSAtocurriculaandclinicallearningprograms;and(c)evaluating the effect of leadership competencies on nurse sensi‐tiveoutcomes.Thesestepsshouldbepartofacontinuousprocessneededforcontinuousqualityimprovement,healthcarereform,andhigh‐reliabilityhealthcare.
AUTHOR CONTRIBUTIONS
MH, CvO, JP, HV, AH: made substantial contributions to con‐ception anddesign, or acquisition of data, or analysis and inter‐pretationofdata;MH,CvO,JP,HV,AH: Involved indraftingthemanuscriptor revising itcritically for important intellectualcon‐tent;MH,CvO,JP,HV,AH:Givenfinalapprovaloftheversiontobepublished.Eachauthorshouldhaveparticipatedsufficientlyintheworktotakepublicresponsibilityforappropriateportionsofthecontent;MH,CvO,JP,HV,AH:Agreedtobeaccountableforall aspectsof thework inensuring thatquestions related to theaccuracyorintegrityofanypartoftheworkareappropriatelyin‐vestigated and resolved.
ORCID
Maud Heinen https://orcid.org/0000‐0001‐7536‐1327
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