Competencies of military nurse managers: A scoping review and unifying framework

Abstract Aim(s) To identify competencies of military nurse managers and develop a unifying framework of military nurse managers’ competencies. Background Military nurse managers shoulder multiple responsibilities because of duality roles, and they should possess competencies that enable them to manage human and material resources during peacetime and wartime. Therefore, nursing management within military context is demanding, such that a comprehensive understanding of their competencies is needed for effective military nursing management. Although relevant studies have focused on different military branches and different levels of managers, there is no standard evaluation framework. Evaluation A scoping review of studies focusing on competencies of military nurse managers from seven databases was carried out. Key issues Nine studies were included in this review, and a framework consisting of six domains of military nurse managers’ competencies was identified: clinical expertise, role model, leadership competencies, human competencies, financial competencies and deployment competencies. Conclusion Existing knowledge of competencies of military nurse managers is limited, and a comprehensive understanding of this topic can provide direction for future work. Implications for Nursing Management Military nurse managers play substantial roles within the military nursing context. A unifying framework can facilitate personnel recruitment and competency measurement, as well as training protocol development.


| INTRODUC TI ON
An increase in health care demands and the ever-changing health care environment has resulted in nurse managers shouldering most of the responsibility of increasing patient and staff satisfaction (Emmons, 2018). Nurse managers at the executive level are in charge of clinical nursing services, strategic planning, administration as well as clinical leadership, while the head nurses or first-line nurse managers are responsible for patient care activities that occur 24 hr a day in their units (Chase, 2010;Duffield, Gardner, Doubrovsky, & Wise, 2019;Gunawan & Aungsuroch, 2017). Notably, nursing managers are responsible for maintaining the link between an institution's administrative mission and the nurses who provide nursing care in the clinical unit, as well as being in charge of efficient patient care activities by ensuring that subordinate nurses are qualified for the tasks allocated to them. This is one of the reasons why their roles are considered most complex in health care institutions (Chase, 2010). Additionally, the leadership style of nurse managers has huge influences on staff members' turnover and the quality of patient care they deliver; so, they should have the necessary competencies to ensure the smooth running of their units (Pishgooie, Atashzadeh-Shoorideh, Falcó-Pegueroles, & Lotfi, 2019;Saleh et al., 2018).
Historically, military nurses were indispensable during wars, disasters and United Nations (UN) peacekeeping missions as evidenced by Florence Nightingale when she cared for wounded soldiers during the Crimean War. It is still common practice for military nurses to be deployed in response to natural disasters or epidemics to save human life. The scope of practice for a military nurse is twofold as a soldier and a professional nurse practising in the fluctuating military health care environment and meeting demanding military operational requirements which differs from the nursing environment of civilian nurses (Griffiths & Jasper, 2008;Lundberg, Kjellström, & Sandman, 2019). When deployed in a disaster area or a combat zone, military nurses deliver medical tasks in an austere environment. One common challenge military nurses face during deployment is to adapt to the dangerous environment which results in fear of the unknown (Rivers, 2016;Rivers & Gordon, 2017). Military nurses also face ethical dilemmas when facing multiple patients and shortage of supplies (Almonte, 2009). This is further confounded by the fact that, at times, military nurse officers lacking experience during deployment are elevated to head nurses of medical missions because of their military rank (Beaumont & Allan, 2012). Thus, the management competencies of military nurses differ slightly from those of civilian nurses because of the versatile environment causing physical and psychological strains. Other expectations of a military nurse manager include ensuring the quality and safety of patients and personnel in a complex working environment and acting as a role model who has a positive impact on junior nurses and encourages the team to overcome challenges (Barr, Ferro, & Prion, 2019).
To ensure high-quality patient care, many scholars and institutions have studied and explored leadership and management competencies over the past decades. Among the published assessment tools of competencies of nurse managers, the Chase Nurse Manager Competency Instrument (NMCI) is a valid and reliable measurement scale of nurse managers' competencies, which was developed by Dr.
Chase in 1994 and further validated in 2010, based on the American Organization of Nurse Executive (AONE) Leadership Collaborative Framework and Katz's conceptual framework (Chase, 1994(Chase, , 2010(Chase, , 2012Katz, 1955  This methodology provides an overview of empirical and non-empirical studies focusing on a particular topic and supports summarization of emerging evidence (Arksey & O'Malley, 2005;Levac et al., 2010). Additionally, a five-step procedure, including formulating the research question; identifying relevant studies; selecting relevant studies; data charting; and collating, summarizing and reporting results, was taken (Levac et al., 2010).

| Formulating the research question
The research question 'what competencies of military nurse managers have been described?' was formulated and used to guide this review.

| Identifying relevant studies
'Nurse manager' in this review refers to managers at all levels including tactical/direct, operational/organisational and strategic level (VanFosson, 2012

| Selecting relevant studies
Studies were included in the review if they (a) focused on competencies of military managers at different levels, including executive level, military nurse officer and head nurse; (b) were qualitative studies, quantitative studies, literature review or mixed-method studies; (c) written in English or Chinese. Studies were excluded if they (a) were case studies, abstracts or citations; (b) were not specifically related to competencies of military managers; (c) publish with language other than English or Chinese. The selection of relevant studies was undertaken independently by two researchers.
A total of ninety studies (Figure 1) was yielded and then imported into EndNote X9 (Clarivate Analytics). After duplicates were removed, sixty-two studies remained. These sixty-two studies were assessed to determine whether they met the inclusion and exclusion criteria based on the title and abstract. Fifty studies failed to meet the inclusion criteria were excluded. The remaining twelve full-text studies were retrieved and independently evaluated by two researchers. After careful examination based on inclusion and exclusion criteria, nine studies were remained and included in this review.

| Data charting
Data from all the included studies were extracted and categorized into subgroups by the following headings: author, publish year, country, aim, design, type of nurse manager and all factors that could be identified as being related to competencies of military nurse managers (Table 1).

| Description of studies
A total of nine studies, published between 2007 and 2017, were included (Table 1).
These researches were undertaken in two countries: the United States (n = 7) and China (n = 2). The samples consisted of nurse managers from different organisational levels, including executive level (n = 1), military nurse officers (n = 4) and head nurses (n = 4). All the identified competencies were compared with the five domains of NMCI (Table 1). Nine studies mentioned competencies identified

| Comparison among military nursing managers of different levels
Anderson (2016) Table 2).

Domain Items
Clinical

| Role model
A nurse leader is expected to be a role model for their staff in the way treating patients, family members and other health care team members in a kind and considerate manner (Harris, 2007). The term 'role model' refers to leading by example and displaying good character. Leading by example requires military nurse managers to exhibit good nursing practice at all times especially when treating multiple and seriouswounded patients in austere environments (Dai, 2010;Harris, 2007).

Their actions should be grounded in military values and professional
ethics by displaying good characters such as dedication, confidence, integrity, loyalty, passion for work and social responsibility (Li, 2007).

| Leadership competencies
Leadership involves influencing all levels of personnel to accomplish a shared goal, and effective leadership can have a positive effect on patient outcome (Wong, Cummings, & Ducharme, 2013).
Military nurse managers should have foundational thinking skills, personal journey disciplines, the ability to use systems thinking, succession planning, change management and stress management (Anderson, 2016;VanFosson, 2012). In detail, they should have the ability to lead a team, collaborate with individuals and organisations in developing a vision, motivating others, making decision, resolving conflicts, solving problems, managing change and stress, as well as being adaptable (Anderson, 2016;Dai, 2010;Funari et al., 2011;Harris, 2007;Li, 2007;Palarca, 2007;Porter, 2017; VanFosson, 2012).

| Human competencies
Human competencies refer to the ability to work effectively in a medical group and to exert a cooperative effort in the team (Katz, 1955). Human competencies include two key components:  (Anderson, 2016;Dai, 2010;Harris, 2007;Li, 2007;Palarca, 2007;Porter, 2017). Organising is the ability to plan activities and allocate resources including personnel management, staff development and professional development (Anderson, 2016;Dai, 2010;Harris, 2007;Li, 2007;Palarca, 2007).

| Financial competencies
In deployment to a conflict environment, military nurse managers might be provided with limited resources; thus, financial management is a required competency. Financial competencies include knowledge of basic business management practices (financial, supply and budget), formalizing a strategic business plan, financial management skills, budget analysis and management skills, analytical ability, and military medicine business practices (Funari et al., 2011;Palarca, 2007;Porter, 2017).  (Li, 2007;Palarca, 2007;Porter, 2017;Ross, 2010).

| Deployment competencies
Combat casualty care management is necessary in caring for highly complex trauma patients such as victims of chemical, biological or radiological terrorism and seriously injured combatants (Ross, 2010).
Military skills encompass knowledge of the military mission and battlefield, the ability to interact according to military protocols, knowledge of military regulations and survival skills (Palarca, 2007;Ross, 2010). Military cultural competencies include skills related to interfacing with patients of different cultural background and facilitating cooperation among three military services and civilian services (Ross, 2010). Leadership is the ability to guide and manage, to make decisions under pressure or in dealing with unpredictable circumstances and to inspire other team members to follow (Brewer & Ryan-Wenger, 2009). The Army Nursing Leader Capabilities Map clearly defined five key competencies of leadership, including foundational thinking, personal journey disciplines, systems thinking, succession planning and change management (VanFosson, 2012). Besides the above five competencies, stress management is also essential to leadership, especially when performing contingency operations (Anderson, 2016). Based on the fact that leadership development is a lifetime career goal, from unit level to strategic level (Raimondo, Pierce, & Bruzek-Kohler, 2008;Wilmoth & Shapiro, 2014), the personal journey disciplines enable nurse managers to seek self-development, which includes seeking direct feedback and adjusting, applying new knowledge, setting initial personal, professional and career goals, as well as identifying positive role models (VanFosson, 2012). Besides focusing on personal development, military nurse managers should also put their effort into succession planning (Phillips, Evans, Tooley, & Shirey, 2018); in detail, they should motivate junior nurses, discover potentials of their staff and prepare themselves for the next leadership level (VanFosson, 2012). Personal journey disciplines and succession planning are the guarantees for the stable management of a nursing team from the unit level to the strategic level.

| D ISCUSS I ON
A role model competency is when a military nurse manager becomes a role model by committing themself to their duty, thereby encouraging their core team members to see how their roles contribute to the overall effectiveness of the team (Hughes, 2018). This is similar to the actions of Florence Nightingale who successfully led her team during the Crimean war (Stanley & Sherratt, 2010 Military nurse managers should also possess human competencies, as they depend on their subordinates to achieve goals and to complete missions. It is essential for them to have good communication and interpersonal skills as well as organising abilities to motivate their subordinates and to assign tasks, especially when they are facing life-threatening challenges when deployed in combat zones. For example, health care workers working in armed conflicts should know the importance of internal communication among their team and also consider the local context to prevent putting the team at risk (Baucom, 2017). Moreover, qualitative studies of deployment experiences constantly highlight the fact that military nurses felt unprepared to deliver nursing care in an austere environment (Conlon, Wiechula, & Garlick, 2019;Finnegan et al., 2016 (Dai, 2010;Harris, 2007;Li, 2007)

| IMPLI C ATI ON S FOR N UR S ING MANAG EMENT
Military nurse managers play a substantial role in ensuring nurs- Additionally, this framework can also provide a basis for training civilian nurse managers to be better prepared for emergency public health event.