An integrative review of leadership competencies and attributes in advanced nursing practice

J Adv Nurs. 2019 Nov; 75(11): 2378–2392.

Maud Heinen, PhD, RN, Senior researcher,

Abstract

Aim

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.

Background

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.

Design

Integrative review.

Methods

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.

Results

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.

Conclusions

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.

Impact

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

1. INTRODUCTION

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.

1.1. Background

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.

2. THE REVIEW

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).

2.1. Aim

To identify and integrate leadership competencies of the master level‐educated nurse (APN and CNL) from an international perspective.

2.2. Design

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)

2.3. Search methods

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.

BOX 1

Inclusion and exclusion criteria.

1.

Secondly, the websites of international professional nursing organizations were searched for documents on leadership competencies in NPs, CNSs, and CNLs. Worldwide, there are more than 100 nursing organizations, usually part of one umbrella association or council. Therefore, this review focused on frameworks of umbrella organizations in Australia, Europe, and North America and international nursing councils. Frameworks had to describe nursing leadership and related competencies in NPs, CNSs, or CNLs.

Eligible articles and frameworks were independently selected by three reviewers (MH, AH, CvO) based on the relevance of their titles and abstracts, as retrieved by the search. If articles met the inclusion criteria, full‐text versions of the articles were obtained and further scrutinized for eligibility by (MH, AH, CvO). HV was involved in any cases of disagreement, where consensus was reached through discussion. The reference lists of included articles were checked to detect any potential additional studies.

2.4. Search outcome

The search strategy in PUBMED, CINAHL, and EMBASE resulted initially in 4,220 records. After removing duplicates, the remaining 2,839 articles were screened on title and abstract. As a result, 168 articles and nine additional articles, added through reference checking, were included for full‐text assessment. Twenty‐four articles were not available in full text. Fifteen articles were eventually included in this review. The flow diagram (Figure ​1) gives an overview of the inclusion process.

2.5. Quality appraisal

A quality appraisal (Data S2) was conducted by two researchers (MH, AH) on all 15 studies. Quality appraisal of the included studies was conducted using the Mixed methods Appraisal Tool MMAT (Hong, Gonzalez‐Reyes, & Pluye, 2018). The MMAT is a critical appraisal tool that is designed for the appraisal stage of systematic mixed studies reviews. It permits to appraise the methodological quality of five categories studies. The MMAT starts with two screening questions to determine whether the study is an empirical study and the tool can be used. For each category, five criteria are defined to rate the quality of the studies. It is advised not to calculate an overall score from the ratings of each criterion and excluding studies with low methodological quality is discouraged. Quality was therefore not used to include or exclude studies from the review, also because of the difficulties in comparing quality of studies using different designs (Whittemore & Knafl, 2005). The goal of the quality appraisal was to evaluate the quality of studies and the degree of evidence in an unbiased and transparent way. A quality appraisal of included frameworks was not conducted.

2.6. Data extraction

Data extraction was performed using a pre‐defined, structured data extraction sheet and was double‐checked by three researchers (MH, AH, CvO). The following data were extracted: author, year of publication, title, methodology, country and setting, master's APNs or CNLs. Competencies and KSA were derived from the frameworks and studies, by the same three researchers (MH, AH, CvO). Involvement of three independent researchers was used to ensure rigour of data extraction (Whittemore & Knafl, 2005).

2.7. Synthesis

Competencies described in the original studies subsequently were designated to the leadership domains described by Hamric et al. (Hamric et al., 2014) by three researchers (MH, AH, CvO). In cases of discrepancy, the selected domains were discussed until consensus was reached. The next step consisted of clustering of overlapping competencies by two researchers (MH, AH), which were checked by a third researcher (CvO). The competency from the overlapping items that best described the content was chosen for the final overview of competencies, sometimes with a minor adaptation to fully grasp the essence of this competency. The same process was followed for the KSA‐items.

3. RESULTS

3.1. Individual studies

One out of 15 articles concerned both the NP and the CNS, seven were about the NP, three were about the CNS and four articles focused on the CNL. Most articles (9/15) originated from the United States of America (USA), three from Australia and three articles originated from Canada, the UK, and Finland respectively. Two articles published different aspects of the same research (Carryer, Gardner, Dunn, & Gardner, 2007; Gardner, Carryer, Gardner, & Dunn, 2006) (Table ​1).

Table 1

Overview of included studies (15) and frameworks (7)

Sample sizes were relatively small, ranging from 6‐50 respondents and consisted of nurse leaders (Bahouth et al., 2013; Goldberg et al., 2016; O'Rourke & Higuchi, 2016), experienced nurses (Bender, Williams, Su, & Hites, 2017; Carryer et al., 2007; Gardner et al., 2006; Kalb et al., 2006; Leggat, Balding, & Schiftan, 2015; Nieminen, Mannevaara, & Fagerström, 2011) and APN or CNL students (Ailey, Lamb, Friese, & Christopher, 2015; Gerard, Grossman, & Godfrey, 2012; Leggat et al., 2015; Nieminen et al., 2011; Sievers & Wolf, 2006).

Multiple research designs were used. These included surveys, interviews, and focus groups to describe experiences on integrating NPs and CNSs into hospitals (Bahouth et al., 2013; O'Rourke & Higuchi, 2016; Sievers & Wolf, 2006) and expressed clinical competences (Nieminen et al., 2011), a case study on an education program for CNLs (Ailey et al., 2015), exploring the effect of a mentor program of NP students on developing leadership competencies (Leggat et al., 2015), piloting an assessment for performance review of NPs and CNSs (Kalb et al., 2006) and multi‐method research to develop shared competencies and educational standards for APNs (Bender et al., 2017; Carryer et al., 2007; Gardner et al., 2006; Goldberg et al., 2016). Eight were descriptive studies on (experiences with) educational programs for CNLs or CNSs (Ailey et al., 2015; Baernholdt & Cottingham, 2011; Gerard et al., 2012; Goldberg et al., 2016; Leggat et al., 2015; Maag, Buccheri, Capella, & Jennings, 2006; Sievers & Wolf, 2006; Thompson & Nelson‐Marten, 2011) Baernholdt and Cottingham (Baernholdt & Cottingham, 2011) also reported on the development of the CNL role in practice. Six studies explicitly described leadership competencies (Bender et al., 2017; Gardner et al., 2006; Gerard et al., 2012; Goldberg et al., 2016; Kalb et al., 2006; Nieminen et al., 2011). Furthermore, studies focused on knowledge (Ailey et al., 2015; Carryer et al., 2007), leadership skills (Baernholdt & Cottingham, 2011; Maag et al., 2006; Thompson & Nelson‐Marten, 2011) and leadership attributes (Bahouth et al., 2013; Sievers & Wolf, 2006).

For eight out of 15 studies, quality could not be determined on the basis of quality appraisal tools for research (Data S2), five studies scored positive on all five MMET domains (Bender et al., 2017; Carryer et al., 2007; Goldberg et al., 2016; Nieminen et al., 2011; O'Rourke & Higuchi, 2016), one study scored positive on four out of five domains (Leggat et al., 2015) and one study scored positive on one domain (Bahouth et al., 2013).

3.2. Frameworks

Seven competency frameworks, including leadership competencies, were identified. The frameworks were developed between 2006 and 2014 and originated internationally in Europe (1/7) (ICN, 2015), the USA (4/7) (American Association of Colleges of Nursing, 2006, 2013; The National Organization of Nurse Practotioner Faculties, 2014), Canada (1/7) (The Canadian Nurses Association, 2010) and Australia (1/7) (Nursing and Midwifery Board of Australia, 2014). All frameworks describe leadership competencies for the NP, CNS, or CNL but the extent to which the four leadership domains (i.e., clinical‐, professional‐, system‐, and health policy leadership) are covered differed (Table ​1). In Australia, leadership is linked to four defined practice standards in the nursing process. Additionally, leadership is defined as the ability to lead care teams where the NP supports other professionals through clinical supervision and mentoring (Nursing and Midwifery Board of Australia, 2014). The Canadian Nurse Practitioner Core Competencies Framework identifies leadership as a core competence for the NP that should be reflected in excellent clinical practice and by mentoring colleagues and students. Leadership activities should not be limited to the NPs' own practice or institution but should focus on the entire care continuum, also including the political field of health care (The Canadian Nurses Association, 2010). The NONPF‐USA defines nursing leadership as the ability to change care systems, create partnerships, establish adequate communication and to participate in professional organizations (The National Organization of Nurse Practotioner Faculties, 2014). The Clinical Nurse Specialist Core Competencies Framework has assigned leadership competencies mainly to the heading ‘System leadership’ and describes specific leadership behaviour and associated sphere of influence and nurse characteristics needed (The National Organization of Clinical Nurse Specialists, 2010). The Essentials of Doctoral Education for Advanced Nursing Practice (American Association of Colleges of Nursing, 2006) is designed to prepare nurses for the highest level of leadership in practice and scientific inquiry.

Leadership competencies mainly refer to the category ‘Organizational and system leadership for quality improvement and systems thinking’. Leadership competencies are applied in clinical practice, as well in the entire field of health care. The ‘Master's Essentials and Clinical Nurse Leader Competencies’ outlined in the ‘Competencies and Curricular Expectations for Clinical Nurse Leader Education and Practice’ (American Association of Colleges of Nursing, 2013) describes the CNL as ‘a leader in the healthcare delivery system in all settings where healthcare is delivered’ (American Association of Colleges of Nursing, 2013, p. 4). The leader competencies are embedded in nine categories, with the core leadership competencies mainly described in ‘Essential 2: Organisational and Systems Leadership’. Finally, the International Council of Nurses Leadership for Change™ (LFC) program is developed to prepare nurses to take a leadership role during health sector change and reform and enhance their contribution to health services (ICN, 2015). Leadership competencies are mainly focused on a system‐ and health policy leadership. Four frameworks provide suggestions for curriculum development concerning required KSA or performance indicators (ICN, 2015).

3.3. Data synthesis

The 150 competencies derived from the literature are displayed in Data S3. Table ​2 shows the final synthesis of the extracted competencies which resulted in the identification of 30 core leadership competencies, assigned to the four leadership domains of Hamric et al. (Hamric et al., 2014). The highest number of competencies (n = 8) was designated to the clinical and to the systems leadership domains, six to the professional and two to the health policy leadership domains. Six competencies fitted more than one domain, of which one competency related to three domains, the clinical, the health systems, and the health policy domains and four competencies were linked to the clinical, and to the health systems leadership domains. One competency was designated to the professional and the health systems leadership domains. The model in Figure ​2 presents this synthesis of competencies.

Table 2

Final 30 leadership Core competencies within (four) leadership domains

Seven studies and two frameworks reported on knowledge (Ailey et al., 2015; Bahouth et al., 2013; Carryer et al., 2007; The National Organization of Nurse Practotioner Faculties, 2014), skills (Ailey et al., 2015; Baernholdt & Cottingham, 2011; Maag et al., 2006; The National Organization of Clinical Nurse Specialists, 2010; The National Organization of Nurse Practotioner Faculties, 2014; Thompson & Nelson‐Marten, 2011) and attributes (Ailey et al., 2015; Bahouth et al., 2013). Both Ailey et al. (Ailey et al., 2015; Sievers & Wolf, 2006) and the NONPF (The National Organization of Nurse Practotioner Faculties, 2014) described skills and knowledge in terms of explicit curricula content for APNs. Other studies reported broadly formulated KSA. Eleven knowledge items, 21 skills and 21 attributes were identified (Table ​3) and assigned to a leadership domain.

Table 3

Overview of identified needs for knowledge, skills, and attributes

4. DISCUSSION

The results of this integrative review lead to the synthesis of 30 leadership competencies for APNs and CNLs derived from international literature and official documents of international nursing organizations. Competencies were furthermore designated to the clinical, professional, health systems or the health policy leadership domains, according to Hamric et al. (Hamric et al., 2014). Six competencies were linked to more than one domain. The clinical, professional and the health systems domains dominated regarding the number of competencies.

In the clinical leadership domain, core competencies are focused on delivering excellent patient care and concern items like collaboration with professionals and other health agencies, implementation of innovations, and enhancing EBP. Although EBP is often viewed as a stand‐alone competency (Hamric et al., 2014), leadership and EBP are strongly connected (Sastre‐Fullana et al., 2017). Stetler et al. (Stetler, Ritchie, Rycroft‐Malone, & Charns, 2014) assume supportive leadership as a key driver for the successful institutionalization of EBP in an organization (Stetler et al., 2014).

Competencies on the professional leadership domain appear to be clearly formulated and provide for sufficient direction to further develop the nursing profession. This is important because hospital decision makers need to learn from professionals about their roles and a collaborative evidence‐based vision on APN (Carter et al., 2013) (Kilpatrick et al., 2014; Kleinpell, 2013).

The leadership competencies in the Health Systems domain are shifting from direct patient care to the strategic level. Influencing at the strategic level requires an in‐depth understanding of healthcare systems to create and share an organizational vision on quality improvement, leading to the implementation of changes and to evaluate their results. (Thompson & Nelson‐Marten, 2011; Walker, Cooke, Henderson, & Creedy, 2011). Health system leadership also means that APNs and CNLs articulate the nursing perspective by joining or chairing interdisciplinary committees and raise their voice in the boardroom. However, formal positions for APNs and CNLs at strategic level are not self‐evident. System leadership can therefore only be reinforced when supported by managers and administrators of the organization (Hanson, 2015; Higgins et al., 2014).

Competencies related to the health policy domain were minimally present. Identified core competencies in the health policy domain were the guiding and initiating of leadership in policy‐related activities, to practice influence in health care and the articulation of the value of nursing to key stakeholders and policymakers on the (inter)national level. These rather abstract competencies do not allow for a clear understanding of the content and nature of health policy leadership. Further specification and operationalization are needed to guide nurses to the political arena. For example, health policy competences should be focussing on in‐depth understanding of global trends in relevant health issues and the profession's involvement in healthcare policy decisions (Rains & Barton‐Kriese, 2001). Additionally, information technology including e‐health applications and ‘Big Data’ analytics are important issues on the health policy agenda and the nursing perspective should be part of decision‐making processes in this area.

Half of the studies and two frameworks reported on KSA (table ​3) needed for the development of leadership competencies. The distinction between KSA however, appeared somewhat unclear. Being knowledgeable about legal rules was described as an attribute in one study (Bahouth et al., 2013) and as knowledge in others (Ailey et al., 2015; Carryer et al., 2007). Although KSA are closely related to each other, a distinction is helpful to specify what is needed to achieve defined leadership competencies.

Acquiring leadership competencies and related KSA occurs over time and is comparable with Benner's continuum ‘from novice to expert’ (Benner, 1982). Both APNs and CNLs curricula and clinical learning programs should train and empower their students to become leaders. Evidenced‐based training programs for clinical, professional, and systems leadership are scarce (Elliott, Farnum, & Beauchesne, 2016b). Training programs for political leadership are even scarcer, which is in line with the identified competency gap in the health policy domain. The model laid out in this paper could provide a useful base for evidence‐based curriculum development, although identified competencies need to be further refined and discussed and completed with KSA related to each competency. Educational programs which integrate course work and clinical learning seem promising in developing and improving leadership competencies in especially the clinical and systems domains (Ailey et al., 2015; Sievers & Wolf, 2006; Thompson & Nelson‐Marten, 2011). Ainslie (Ainslie, 2017) advocates that organizations should map leadership competences to observable milestones so that progress can be clearly determined. This competence‐based learning has similarities with the concept of Entrustable Professional Activity (EPA). EPAs are elements of professional practice, that is, tasks or responsibilities that are observable and measurable in their process and outcome (Ten Cate, 2013) and may also be useful in developing leadership in APNs and CNLs. An assessment determines the entry competency levels and point out a personalized leadership development path. An APN, for example, may test at the expert level for ‘promoting and performing EBP’ but test at the novice level for ‘leading inter professional healthcare teams’. Additionally, situated coaching and mentoring is considered an essential element in educational and clinical learning programs (Ailey et al., 2015; Elliott, 2017).

Positive results are found for the effects of hierarchical leadership in nursing on quality of care and, more specifically, on nursing‐sensitive patient outcomes (Vaismoradi, Griffiths, Turunen, & Jordan, 2016; Wong, Cummings, & Ducharme, 2013). However, further research is needed to establish the relationship between leadership practices of APNs and CNLs and nursing‐sensitive patient outcomes (Dubois et al., 2017; Kapu & Kleinpell, 2013).

A limitation of this review is the fact that 24 of the 177 literature articles included based on title and abstract were not available in full text and the final selection of only 15 studies consisted of varying study designs and quality. Furthermore, most studies originated from the United States and Australia which might be challenging the representativeness of this review from an international perspective. Nonetheless, this review represents an integrative overview including a gap analysis of leadership competencies for APNs and CNLs in the current literature and as established by international nursing organizations.

5. CONCLUSION

This review identified 30 core leadership competencies for APNs and CNLs in the clinical, professional, health systems, and health policy leadership domains. The next steps include: (a) discussing gaps in this overview of competencies with master level‐educated nurses and educational institutes and linking KSA to each of the established leadership core competencies; (b) translating these competencies and aligned KSA to curricula and clinical learning programs; and (c) evaluating the effect of leadership competencies on nurse sensitive outcomes. These steps should be part of a continuous process needed for continuous quality improvement, healthcare reform, and high‐reliability health care.

AUTHOR CONTRIBUTIONS

MH, CvO, JP, HV, AH: made substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; MH, CvO, JP, HV, AH: Involved in drafting the manuscript or revising it critically for important intellectual content; MH, CvO, JP, HV, AH: Given final approval of the version to be published. Each author should have participated sufficiently in the work to take public responsibility for appropriate portions of the content; MH, CvO, JP, HV, AH: Agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Supporting information

Notes

Heinen M, van Oostveen C, Peters J, Vermeulen H, Huis A. An integrative review of leadership competencies and attributes in advanced nursing practice. J Adv Nurs. 2019;75:2378–2392. 10.1111/jan.14092 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

REFERENCES

• American Association of Colleges of Nursing . (2004). Working Statement Comparing the Clinical Nurse Leadersm and Clinical Nurse Specialist Roles: Similarities, Differences and Complementarities. Washington, DC.
• American Association of Colleges of Nursing . (2006). The Essentials of doctoral Education for Advanced Nursing Practice. Washington, DC.
• American Association of Colleges of Nursing . (2007). White paper on the education and role of the clinical nurse leader. Retrieved from http://www.aacn.nche.edu/publications/white-papers/ClinicalNurseLeader.pdf
• APRN Joint Dialogue Group . (2008). Consensus model for APRN regulation: licensure, accreditation, certification & education. APRN Joint Dialogue Group Report, July 7, 2008.
• American Association of Colleges of Nursing . (2011). The Essentials of Master’s Education in Nursing. Washington, DC.
• American Association of Colleges of Nursing . (2013). Master's essentials and clinical nurse leader competencies. Washington, DC.
• AHPRA . (2014). Nursing and Midwifery Board of Australia. Nurse practitioner standards for practice, Nursing and Midwifery board of Australia. Melbourne VIC 3001. Retrieved from www.nursingmidwiferyboard.gov.au
• Ailey, S. , Lamb, K. , Friese, T. , & Christopher, B. A. . (2015). Educating nursing students in clinical leadership. Nursing Management, 21(9), 23–28. [PubMed] [Google Scholar]
• Ainslie, M. (2017). Dissertation. Competency based clinical education for advanced practice registered nurses: Raising the bar. Plymouth State University. New Hampshire.
• Alimo‐Metcalfe, B. , & Alban‐Metcalfe, J. (2004). Leadership in public organisations. London, UK: Routledge Taylor & Francis group. [Google Scholar]
• American Nurses Association (2013). Competency Model, Embark on the Journey. ANA Leadership Intitute.
• Baernholdt, M. , & Cottingham, S. (2011). The Clinical Nurse Leader – new nursing role with global implications. International Nursing Review, 58(1), 74–78. 10.1111/j.1466-7657.2010.00835.x [PubMed] [CrossRef] [Google Scholar]
• Bahouth, M. N. , Ackerman, M. , Ellis, E. F. , Fuchs, J. , McComiskey, C. , Stewart, E. S. , & Thomson‐Smith, C. (2013). Centralized resources for nurse practitioners: Common early experiences among leaders of six large health systems. Journal of the American Association of Nurse Practitioners, 25(4), 203–212. 10.1111/j.1745-7599.2012.00793.x [PubMed] [CrossRef] [Google Scholar]
• Begley, C. , Murphy, K. , Higgins, A. , & Cooney, A. (2014). Policy‐makers' views on impact of specialist and advanced practitioner roles in Ireland: The SCAPE study. Journal of Nursing Management, 22(4), 410–422. 10.1111/jonm.12018 [PubMed] [CrossRef] [Google Scholar]
• Bender, M. , Williams, M. , & Su, W. (2016). Diffusion of a nurse‐led healthcare innovation: Describing certified clinical nurse leader integration into care delivery. Journal of Nursing Administration, 46(7–8), 400–407. [PubMed] [Google Scholar]
• Bender, M. , Williams, M. , Su, W. , & Hites, L. (2017). Refining and validating a conceptual model of Clinical Nurse Leader integrated care delivery. Journal of Advanced Nursing, 73(2), 448–464. 10.1111/jan.13113 [PubMed] [CrossRef] [Google Scholar]
• Benner, P. (1982). From novice to expert. American Journal of Nursing, 82(3), 402–407. [PubMed] [Google Scholar]
• Bolden, R. (2004). What is Leadership? University of Exeter, Centre for Leadership studies. Exeter. [Google Scholar]
• Canadian Nurses Association . (2010). Canadian nurse practitioner core competency framework, Ottawa.
• Carryer, J. , Gardner, G. , Dunn, S. , & Gardner, A. (2007). The core role of the nurse practitioner: Practice, professionalism and clinical leadership. Journal of Clinical Nursing, 16(10), 1818–1825. 10.1111/j.1365-2702.2007.01823.x [PubMed] [CrossRef] [Google Scholar]
• Carter, N. , Dobbins, M. , Ireland, S. , Hoxby, H. , Peachey, G. , & DiCenso, A. (2013). Knowledge gaps regarding APN roles: What hospital decision‐makers tell us. Nurs Leadersh (Tor Ont), 26(4), 60–75. 10.12927/cjnl.2013.23629 [PubMed] [CrossRef] [Google Scholar]
• Delamaire, M. , & Lafortune, G. (2010). Nurses in advanced roles: A description and evaluation of experiences in 12 developed countries In OECD Health Working Papers (Vol. 54), Paris: OECD Publishing. [Google Scholar]
• Dubois, C. A. , D'Amour, D. , Brault, I. , Dallaire, C. , Dery, J. , Duhoux, A. , … Zufferey, A. (2017). Which priority indicators to use to evaluate nursing care performance? A discussion paper. Journal of Advanced Nursing, 73(12), 3154–3167. 10.1111/jan.13373 [PubMed] [CrossRef] [Google Scholar]
• Elliott, N. (2017). Building leadership capacity in advanced nurse practitioners ‐ the role of organisational management. Journal of Nursing Management, 25(1), 77–81. 10.1111/jonm.12444 [PubMed] [CrossRef] [Google Scholar]
• Elliott, N. , Begley, C. , Sheaf, G. , & Higgins, A. (2016a). Barriers and enablers to advanced practitioners' ability to enact their leadership role: A scoping review. International Journal of Nursing Studies, 60, 24–45. 10.1016/j.ijnurstu.2016.03.001 [PubMed] [CrossRef] [Google Scholar]
• Elliott, N. , Farnum, K. , & Beauchesne, M. (2016b). Utilizing team debate to increase student abilities for mentoring and critical appraisal of global health care in doctor of nursing practice programs. Journal of Professional Nursing, 32(3), 224–234. 10.1016/j.profnurs.2015.10.009 [PubMed] [CrossRef] [Google Scholar]
• Falk‐Rafael, A. (2005). Speaking truth to power: Nursing's legacy and moral imperative. Advances in Nursing Science, 28(3), 212–223. 10.1097/00012272-200507000-00004 [PubMed] [CrossRef] [Google Scholar]
• Fiedler, F. E. (1967). Leader style and accomplishment of groups acting together. Zeitschrift Fur Experimentelle Und Angewandte Psychologie, 14(2), 200–217. [PubMed] [Google Scholar]
• Flemming, K. , Booth, A. , Hannes, K. , Cargo, M. , & Noyes, J. (2018). Cochrane Qualitative and Implementation Methods Group guidance series‐paper 6: Reporting guidelines for qualitative, implementation and process evaluation evidence syntheses. Journal of Clinical Epidemiology, 97, 79–85. 10.1016/j.jclinepi.2017.10.022 [PubMed] [CrossRef] [Google Scholar]
• Gardner, G. , Carryer, J. , Gardner, A. , & Dunn, S. (2006). Nurse practitioner competency standards: Findings from collaborative Australian and New Zealand research. International Journal of Nursing Studies, 43(5), 601–610. 10.1016/j.ijnurstu.2005.09.002 [PubMed] [CrossRef] [Google Scholar]
• Gerard, S. , Grossman, S. , & Godfrey, M. (2012). Course strategies for clinical nurse leader development. Journal of Professional Nursing, 28(3), 147–155. 10.1016/j.profnurs.2011.11.012 [PubMed] [CrossRef] [Google Scholar]
• Goldberg, S. E. , Cooper, J. O. , Blundell, A. , Gordon, A. L. , Masud, T. , & Moorchilot, R. (2016). Development of a curriculum for advanced nurse practitioners working with older people with frailty in the acute hospital through a modified Delphi process. Age & Ageing, 45(1), 48–53. 10.1093/ageing/afv178 [PubMed] [CrossRef] [Google Scholar]
• Gosling, J. , & Mintzberg, H. (2003). The five minds of a manager. Harvard Business Review, 81, 54–63. [PubMed] [Google Scholar]
• Guillén, L. , & Saris, W. E. (2013). Competencies, personality traits, and organizational rewards of middle managers: A motive-based approach. Human Performance, 26(1), 66–92. [Google Scholar]
• Hamric, A. , Hanson, C. , Tracy, M. , & O'Grady, E. (2014). Advanced Practice Nursing, An Integrative Approach. Philadelphia, PA: Elsevier Saunders. [Google Scholar]
• Hamric, A. , Spross, J. , & Hanson, C. (2009). Advanced practice nursing : An integrative approach. Philadelphia, PA: Saundesr Elsevier. [Google Scholar]
• Hanson, M. D. (2015). Role of the clinical nurse specialist in the journey to magnet recognition. AACN Advanced Critical Care, 26(1), 50–57 10.1097/NCI.0000000000000068 [PubMed] [CrossRef] [Google Scholar]
• Higgins, A. , Begley, C. , Lalor, J. , Coyne, I. , Murphy, K. , & Elliott, N. (2014). Factors influencing advanced practitioners' ability to enact leadership: A case study within Irish healthcare. Journal of Nursing Management, 22(7), 894–905 12p 10.1111/jonm.12057 [PubMed] [CrossRef] [Google Scholar]
• Hong, Q. N. , Gonzalez‐Reyes, A. , & Pluye, P. (2018). Improving the usefulness of a tool for appraising the quality of qualitative, quantitative and mixed methods studies, the Mixed Methods Appraisal Tool (MMAT). J Eval Clin Pract, 24(3), 459–467. 10.1111/jep.12884 [PubMed] [CrossRef] [Google Scholar]
• Huber, M. , Knottnerus, A. , Green, L. , van der Hors, H. , Jadad, A. , Kromhout, D. , … Smid, H. (2011). How should we define health? BMJ, 343, d4163 10.1136/bmj.d4163 [PubMed] [CrossRef] [Google Scholar]
• ICN . (2015). International Council of Nurses Leadership. For Change™ (LFC) program.
• IOM (2011). The future of nursing: Leading change, Advancing Health. Washington, DC: Institute of Medicine. [Google Scholar]
• Kalb, K. B. , Cherry, N. M. , Kauzloric, J. , Brender, A. , Green, K. , Miyagawa, L. , & Shinoda‐Mettler, A. (2006). A competency‐based approach to public health nursing performance appraisal. Public Health Nursing, 23(2), 115–138 24p 10.1111/j.1525-1446.2006.230204.x [PubMed] [CrossRef] [Google Scholar]
• Kapu, A. N. , & Kleinpell, R. (2013). Developing nurse practitioner associated metrics for outcomes assessment. Journal of the American Association of Nurse Practitioners, 25(6), 289–296. 10.1111/1745-7599.12001 [PubMed] [CrossRef] [Google Scholar]
• Kilpatrick, K. , Kaasalainen, S. , Donald, F. , Reid, K. , Carter, N. , Bryant‐Lukosius, D. , … DiCenso, A. (2014). The effectiveness and cost‐effectiveness of clinical nurse specialists in outpatient roles: A systematic review. Journal of Evaluation in Clinical Practice, 20(6), 1106–1123. 10.1111/jep.12219 [PubMed] [CrossRef] [Google Scholar]
• Kleinpell, R. (2013). Measuring outcomes in advanced practice nursing. Outcome assessment in advanced practice nursing. New York, NY: Springer Publishing Company. [Google Scholar]
• Koolen, E. (2016). Competencies, attributes and traits: What’s the difference?. Retrieved from https://emilykoolen.com/2016/10/07/competencies-attributes-and-traits-whats-the-difference/
• Kouzes, J. M. , & Posner, B. Z. (2012). The leadership challenge: How to Make Extraordinary Things Happen in Organizations. San: Francisco: Jossey‐Bass. [Google Scholar]
• Leggat, S. G. , Balding, C. , & Schiftan, D. (2015). Developing clinical leaders: The impact of an action learning mentoring programme for advanced practice nurses. Journal of Clinical Nursing, 24(11‐12), 1576–1584. 10.1111/jocn.12757 [PubMed] [CrossRef] [Google Scholar]
• Lynch, B. M. , McCormack, B. , & McCance, T. (2011). Development of a model of situational leadership in residential care for older people. Journal of Nursing Management, 19(8), 1058–1069. 10.1111/j.1365-2834.2011.01275.x [PubMed] [CrossRef] [Google Scholar]
• Maag, M. M. , Buccheri, R. , Capella, E. , & Jennings, D. L. (2006). A conceptual framework for a clinical nurse leader program. Journal of Professional Nursing, 22(6), 367–372. 10.1016/j.profnurs.2005.11.002 [PubMed] [CrossRef] [Google Scholar]
• Moher, D. , Liberati, A. , Tetzlaff, J. , & Altman, D. G. & Group, P (2009). Preferred reporting items for systematic reviews and meta‐analyses: The PRISMA statement. PLoS Medicine, 6(7), e1000097. [PMC free article] [PubMed] [Google Scholar]
• National Organization of Clinical Nurse Specialists. NACNS . (2010). Clinical Nurse Specialist Core Competencies. The National CNS competency taskforce.
• Nelson‐Brantley, H. V. , & Ford, D. J. (2017). Leading change: A concept analysis. Journal of Advanced Nursing, 73(4), 834–846. 10.1111/jan.13223 [PubMed] [CrossRef] [Google Scholar]
• Nieminen, A.‐L. , Mannevaara, B. , & Fagerström, L. (2011). Advanced practice nurses' scope of practice: A qualitative study of advanced clinical competencies. Scandinavian Journal of Caring Sciences, 25(4), 661–670 10p 10.1111/j.1471-6712.2011.00876.x [PubMed] [CrossRef] [Google Scholar]
• Northouse, P. G. (2014). Leadership: Theory and Practice (3rd, ed). Thousand Oaks, CA: Sage Publications. [Google Scholar]
• O'Rourke, T. , & Higuchi, K. S. (2016). Activities and attributes of nurse practitioner leaders: Lessons from a primary care system change. Canadian Journal of Nursing Leadership, 29(3), 46–60. 10.12927/cjnl.2016.24892 [PubMed] [CrossRef] [Google Scholar]
• Rains, J. W. , & Barton‐Kriese, P. (2001). Developing political competence: A comparative study across disciplines. Public Health Nursing, 18(4), 219–224. 10.1046/j.1525-1446.2001.00219.x [PubMed] [CrossRef] [Google Scholar]
• Sastre‐Fullana, P. , Morales‐Asencio, J. M. , Sesé‐Abad, A. , Bennasar‐Veny, M. , Fernandez‐Dominguez, J. , & DePedro‐Gomez, J. E. (2017). Advanced Practice Nursing Competency Assessment Instrument (APNCAI): Clinimetrci validation. British Medical Journal Open, 7, e013659. [PMC free article] [PubMed] [Google Scholar]
• Sievers, B. , & Wolf, S. (2006). Achieving clinical nurse specialist competencies and outcomes through interdisciplinary education. Clinical Nurse Specialist, 20(2), 75–80. 10.1097/00002800-200603000-00008 [PubMed] [CrossRef] [Google Scholar]
• Stanley, J. M. , Gannon, J. , Gabuat, J. , Hartranft, S. , Adams, N. , Mayes, C. , … Burch, D. (2008). The clinical nurse leader: A catalyst for improving quality and patient safety. Journal of Nursing Management, 16(5), 614–622. 10.1111/j.1365-2834.2008.00899.x [PubMed] [CrossRef] [Google Scholar]
• Stetler, C. B. , Ritchie, J. A. , Rycroft‐Malone, J. , & Charns, M. P. (2014). Leadership for evidence‐based practice: Strategic and functional behaviors for institutionalizing EBP. Worldviews on Evidence‐Based Nursing, 11(4), 219–226. 10.1111/wvn.12044 [PMC free article] [PubMed] [CrossRef] [Google Scholar]
• Ten Cate, O. (2013). Nuts and bolts of entrustable professional activities. Journal of Graduate Medical Education, 5(1), 157–158. 10.4300/JGME-D-12-00380.1 [PMC free article] [PubMed] [CrossRef] [Google Scholar]
• The National Organization of Nurse Practotioner Faculties . (2014). Nurse Practitioner Core competencies. NONPF Report
• Thompson, C. J. , & Nelson‐Marten, P. (2011). Clinical nurse specialist education: Actualizing the systems leadership competency. Clinical Nurse Specialist CNS, 25(3), 133–139. 10.1097/NUR.0b013e318217b5c5 [PubMed] [CrossRef] [Google Scholar]
• Tong, A. , Flemming, K. , McInnes, E. , Oliver, S. , & Craig, J. (2012). Enhancing transparency in reporting the synthesis of qualitative research: ENTREQ. BMC Medical Research Methodology, 12, 181 10.1186/1471-2288-12-181 [PMC free article] [PubMed] [CrossRef] [Google Scholar]
• Vaismoradi, M. , Griffiths, P. , Turunen, H. , & Jordan, S. (2016). Transformational leadership in nursing and medication safety education: A discussion paper. Journal of Nursing Management, 24(7), 970–980. 10.1111/jonm.12387 [PubMed] [CrossRef] [Google Scholar]
• Vance, C. , & Larson, E. (2002). Leadership research in business and health care. Journal of Nursing Scholarship, 34(2), 165–171. 10.1111/j.1547-5069.2002.00165.x [PubMed] [CrossRef] [Google Scholar]
• Walker, R. , Cooke, M. , Henderson, A. , & Creedy, D. K. (2011). Characteristics of leadership that influence clinical learning: A narrative review. Nurse Education Today, 31(8), 743–756. 10.1016/j.nedt.2010.12.018 [PubMed] [CrossRef] [Google Scholar]
• Whittemore, R. , & Knafl, K. (2005). The integrative review: Updated methodology. Journal of Advanced Nursing, 52(5), 546–553. 10.1111/j.1365-2648.2005.03621.x [PubMed] [CrossRef] [Google Scholar]
• WHO . (1948). Preamble to the constitution of the world health organization as adopted by the international health conference. New York, 19-22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948.
• Wong, C. A. , Cummings, G. G. , & Ducharme, L. (2013). The relationship between nursing leadership and patient outcomes: A systematic review update. Journal of Nursing Management, 21(5), 709–724. 10.1111/jonm.12116 [PubMed] [CrossRef] [Google Scholar]