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:Maud.Heinen@radboudumc.nl

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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