Maud Heinen, PhD, RN, Senior researcher , 1 Catharina van Oostveen, PhD, RN, Senior researcher , 2 , 3 Jeroen Peters, PhD, RN, Coördinator Master Advanced Nursing Practice , 4 Hester Vermeulen, PhD, RN, Professor of Nursing Science , 1 , 5 and Anita Huis, PhD, RN, Senior researcher 1
1 Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Institute for Quality of Healthcare, Nijmegen The Netherlands
Find articles by Maud Heinen2 Spaarne Gasthuis Hospital, Spaarne Gasthuis Academy, Haarlem The Netherlands
3 Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam The Netherlands
Find articles by Catharina van Oostveen4 Hogeschool van Arnhem en Nijmegen, HAN University of Applied Sciences, Nijmegen The Netherlands
Find articles by Jeroen Peters1 Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Institute for Quality of Healthcare, Nijmegen The Netherlands
5 HAN University of Applied Sciences, Nijmegen The Netherlands
Find articles by Hester Vermeulen1 Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Institute for Quality of Healthcare, Nijmegen The Netherlands
Find articles by Anita Huis1 Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Institute for Quality of Healthcare, Nijmegen The Netherlands
2 Spaarne Gasthuis Hospital, Spaarne Gasthuis Academy, Haarlem The Netherlands3 Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam The Netherlands
4 Hogeschool van Arnhem en Nijmegen, HAN University of Applied Sciences, Nijmegen The Netherlands 5 HAN University of Applied Sciences, Nijmegen The Netherlands Maud Heinen, Email: ln.cmuduobdar@nenieH.duaM , https://twitter.com/MaudHeinen . Corresponding author.* Correspondence
Maud Heinen, Radboud university medical center, Radboud Institute for Health Sciences, Scientific Institute for Quality of Healthcare, Nijmegen, The Netherlands.
Email: ln.cmuduobdar@nenieH.duaM ,
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To establish what leadership competencies are expected of master level‐educated nurses like the Advanced Practice Nurses and the Clinical Nurse Leaders as described in the international literature.
Developments in health care ask for well‐trained nurse leaders. Advanced Practice Nurses and Clinical Nurse Leaders are ideally positioned to lead healthcare reform in nursing. Nurses should be adequately equipped for this role based on internationally defined leadership competencies. Therefore, identifying leadership competencies and related attributes internationally is needed.
Embase, Medline and CINAHL databases were searched (January 2005–December 2018). Also, websites of international professional nursing organizations were searched for frameworks on leadership competencies. Study and framework selection, identification of competencies, quality appraisal of included studies and analysis of data were independently conducted by two researchers.
Fifteen studies and seven competency frameworks were included. Synthesis of 150 identified competencies led to a set of 30 core competencies in the clinical, professional, health systems. and health policy leadership domains. Most competencies fitted in one single domain the health policy domain contained the least competencies.
This synthesis of 30 core competencies within four leadership domains can be used for further development of evidence‐based curricula on leadership. Next steps include further refining of competencies, addressing gaps, and the linking of knowledge, skills, and attributes.
These findings contribute to leadership development for Advanced Practice Nurses and Clinical Nurse Leaders while aiming at improved health service delivery and guiding of health policies and reforms.
Keywords: advanced nursing practice, clinical nurse leaders, competency, education, leadership, literature review
Developments in health care, like a growing number of patients with chronic diseases, an increased complexity of patients, a stronger focus on person‐centred care and a demand for less institutionalized care ask for well‐trained master level‐educated nurses operating as partners in integrated care teams, with leadership qualities at all levels of the healthcare system. Changes in health care are also underlined by a definition of health as proposed by Huber et al. (Huber et al., 2011) where health is defined as ‘the ability to adapt and self manage in the face of social, physical and emotional challenges’ as a refinement of the World Health Organization (WHO) definition where health is ‘a state of complete physical, mental and social well being’ (WHO, 1948). This stipulates the de‐medicalization of health care and society and emphasizes the need for change in the way health care is organized. Also the Institute of Medicine with their report on ‘The Future of Nursing’ supports the urge for nurses to take their roles to address changes in health care (IOM, 2011). However leading change is a complex and not yet well understood process (Nelson‐Brantley & Ford, 2017). Therefore, especially master level‐educated nurses have to be trained in leadership based on internationally established leadership competencies. This review investigates what leadership competencies are expected from and can be identified for master educated nurses from an international perspective.
Clinical nurses who are trained at master's level, for example, Advanced Practice Nurses (APNs) and Clinical Nurse Leaders (CNLs), are in a unique position to take a leadership role, in collaboration with other healthcare professionals, to shape healthcare reform, as they use extended and expanded skills and are trained to focus on improved patient outcomes, the application of evidence‐based practice and assessing cost‐effectiveness of care (Stanley et al., 2008). The focus of this review is on APNs and CNLs, where APN is regarded as a general designation for all nurses with an advanced degree in a nursing program, that is, Certified Nurse Practitioner (NP), Certified Registered Nurse Anaesthetist, Certified Nurse Midwife and Clinical Nurse Specialist (CNS) (APRN Joint Dialogue Group, 2008). APNs are prepared with specialized education in a defined clinical area of practice. With APN in this review, we refer to the NP and the CNS. The CNL is educated to improve the quality of care and coordinate care in general through collaboration at the microsystems level in the entire healthcare team (APRN Joint Dialogue Group, 2007). Both groups of professionals are trained to integrate science in practice and education, have increased degrees of autonomy in judgments and clinical interventions and are expected to be engaged in collaborative and inter professional practices to achieve the best outcomes for patients, personnel and organization (American Association of Colleges of Nursing, 2011). They are also expected to substantially contribute to clinical outcomes through, that is, continuous quality improvement in patient care and creating a supportive environment for their colleagues, and to contribute to the development of their profession, healthcare systems and healthcare policy. (American Association of Colleges of Nursing, 2004; Bender, Williams, & Su, 2016; Hamric, Hanson, Tracy, & O'Grady, 2014). Therefore developing leadership competencies is an essential prerequisite for these master educated nurses, APNs however appear to experience a lot of difficulties in enacting their leadership role (Begley, Murphy, Higgins, & Cooney, 2014; Elliott, Begley, Sheaf, & Higgins, 2016a).
Leadership is subject of many discussions can be regarded from different perspectives and is mostly related to specific contexts. Hence, there is no single definition applicable to all settings and professions. Leadership is mostly regarded in relation to managing a team or organization (Gosling & Mintzberg, 2003) but can also be defined as a set of personal skills or traits, or focussing on the relation between leaders and followers (Alimo‐Metcalfe & Alban‐Metcalfe, 2004; Bolden, 2004). Transformational and situational leadership are also commonly used concepts where transformational leadership is regarded as the process of leading and inspiring a group to achieve a common goal (Northouse, 2014) and situational leadership is focusing on the interaction between individual leadership styles and the features of the environment or situation where the leader is operating. (Fiedler, 1967; Hamric et al., 2014; Lynch, McCormack, & McCance, 2011). In this review, leadership is regarded as a process where nurses can develop observable leadership competencies and attributes needed to improve patient outcomes, and personnel and organizational outcomes (Kouzes & Posner, 2012). This implies that leadership competencies can be viewed as intended and defined outcomes of learning and that leadership and leadership competencies are not restricted to one single theory. A competency can be defined as ‘an expected level of performance that results from an integration of knowledge, skills, abilities and judgment’ (American Nurses Association, 2013).
The lack of an unambiguous definition of leadership in clinical practice, including clearly defined leadership competencies in nursing, is reflected in education. For most training programs and curricula, it is unclear whether the profiles used in education are up‐to‐date and aiming` at internationally accepted leadership competencies with evidence‐based methods to achieve these competencies. To enhance leadership qualities in master educated nurses, it is necessary to explicitly define what leadership competencies are expected from APNs and CNLs (Delamaire & Lafortune, 2010). Identifying and establishing internationally agreed on leadership competencies in master educated nurses is a first step to developing evidence‐based curricula on leadership (Falk‐Rafael, 2005; Vance & Larson, 2002). Such a curriculum facilitates APN and CNL students to not only become competent clinical and professional leaders but also well‐prepared for organizational systems and political leadership (Hamric et al., 2014). As such, it enables them to have a positive and significant impact on patient, personnel and organizational level outcomes. Accordingly, this review aims to identify and integrate leadership competencies of the master level‐educated nurse (APN and CNL) from an international perspective.
Based on the decision flowchart developed by Flemming et al. (Flemming, Booth, Hannes, Cargo, & Noyes, 2018), this review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses statement (Moher, Liberati, Tetzlaff, & Altman, 2009) and the Enhancing transparency in reporting the synthesis of qualitative research statement (Tong, Flemming, McInnes, Oliver, & Craig, 2012).
To identify and integrate leadership competencies of the master level‐educated nurse (APN and CNL) from an international perspective.
An integrative review design was used, which allows for the combination of various study designs and data sources to be included. In using this methodology, a rigorous and systematic approach is ensured (Whittemore & Knafl, 2005). We followed the five stage methodology by Whittemore and Knafl (Whittemore & Knafl, 2005), however for the data synthesis phase, we used the four leadership domains of Hamric et al (Hamric et al., 2014; Hamric, Spross, & Hanson, 2009) as an a priori framework to integrate the extracted data.
The APN Leadership competency is conceptualized by Hamric et al. (Hamric et al., 2014) as occurring in four primary domains; in clinical practice with patients and staff, in professional organizations, in healthcare systems and in health policy‐making arenas. As stated above, this review focuses on the leadership competencies of APNs and CNLs. Additionally, knowledge, skills and attributes (KSA) needed to develop leadership competencies were topic of interest, where knowledge is regarded as being acquired through cognitive learning, skills through practice and attributes as behaviours that are learned over time (Koolen, 2016). We would like to add a reference to support this one, the full reference is added to the remark concerning Koolen in the reference list. The reference that needs to be added here is; Guillén and Saris (2013)
First, MEDLINE, EMBASE and CINAHL databases were searched from January 2005 ‐ December 2018 to identify articles concerning leadership in APNs and CNLs. To find all literature fitting our scope, we used the words attitude* role* attribute* next to leadership and competenc*. The search strategy was designed and conducted with the help of a clinical librarian (Data S1).
Articles were eligible if they explicitly described leadership competencies or related knowledge, skills or attributes in: (a) studies reporting on theory or theoretical leadership models; (b) developmental studies on leadership programmes (c) studies reporting on the effects of leadership programmes. No restrictions on study designs were applied. Studies were excluded when they concerned managerial leadership, if they did not concern APNs or CNLs (i.e., bachelor nurses and/or undergraduate nurses); or described leadership styles in general. Box gives an overview of in and exclusion criteria.