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

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.


| INTRODUC TI ON
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.

| 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.
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 leveleducated nurse (APN and CNL) from an international perspective.

| THE RE VIE W
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).

| Aim
To identify and integrate leadership competencies of the master leveleducated nurse (APN and CNL) from an international perspective.

| 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 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) 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.

| Search methods
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.

| 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.

| 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.

| 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).

| 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.

| 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) (  (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 ( 1. Provides leadership to the healthcare team to promote health, facilitate self-care management, optimize patient engagement, and prevent future decline including progression to higher levels of care and readmissions. Acts as a resource person, preceptor, mentor/coach, and role model demonstrating critical and reflective thinking 2. Assumes as a clinical expert, a leadership role in establishing and monitoring standards of practice to improve client care, including intra-and interdisciplinary peer supervision and review 3. Analyses organizational systems for barriers and promotes enhancements that affect client healthcare status. 4. Engages in advanced nursing practice and provide leadership for evidence-based practice. This requires competence in knowledge application activities: identifies current relevant scientific health information, the translation of research in practice, the evaluation of practice, improvement of the reliability of healthcare practice and outcomes, and participation in collaborative research 5. Provides leadership and acts as a liaison with other health agencies and professionals, and participates in assessing and evaluating healthcare services to optimize outcomes for patients/clients/communities 6. Collaborates with healthcare professionals, including physicians, advanced practice nurses, nurse managers, and others, to plan, implement, and evaluate an improvement opportunity. 7. Aligns practice with overall organizational/ contextual goals 8. Guides, initiates, and provides leadership in 1) the development and implementation of standards, practice guidelines, quality assurance, and 2) education, and 3) research initiatives.
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 (

| Data synthesis
The 150 competencies derived from the literature are displayed in Data S3. Table 2 (Table 3) and assigned to a leadership domain.

| D ISCUSS I ON
The results of this integrative review lead to the synthesis of 30 leadership competencies for APNs and CNLs derived from international 15. is confident while advocating for the role of nursing (Sievers & Wolf, 2006) PL, HS 16. is honest while advocating for the role of nursing (Sievers & Wolf, 2006) PL, HS 17. is willing to take risk while advocating for the role of nursing (Sievers & Wolf, 2006) PL, HS 18. solicited peer feedback (Sievers & Wolf, 2006) CL 19. is open to learning new concepts (Sievers & Wolf, 2006) CL 20. supports groups diversity and culture (Sievers & Wolf, 2006) CL, HS 21. is able to articulate the CNS role and scope of practice to others (Sievers & Wolf, 2006 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 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).