leadership and management in healthcare essay

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Developing a model for effective leadership in healthcare: a concept mapping approach

Charles william hargett.

1 Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine

Joseph P Doty

2 Feagin Leadership Program

Jennifer N Hauck

3 Department of Anesthesiology

Allison MB Webb

4 School of Medicine

Steven H Cook

5 Department of Neurosurgery

Nicholas E Tsipis

Julie a neumann.

6 Department of Orthopaedic Surgery

Kathryn M Andolsek

7 Department of Community and Family Medicine, Duke University School of Medicine, Durham, NC, USA

Dean C Taylor

Despite increasing awareness of the importance of leadership in healthcare, our understanding of the competencies of effective leadership remains limited. We used a concept mapping approach (a blend of qualitative and quantitative analysis of group processes to produce a visual composite of the group’s ideas) to identify stakeholders’ mental model of effective healthcare leadership, clarifying the underlying structure and importance of leadership competencies.

Literature review, focus groups, and consensus meetings were used to derive a representative set of healthcare leadership competency statements. Study participants subsequently sorted and rank-ordered these statements based on their perceived importance in contributing to effective healthcare leadership in real-world settings. Hierarchical cluster analysis of individual sortings was used to develop a coherent model of effective leadership in healthcare.

A diverse group of 92 faculty and trainees individually rank-sorted 33 leadership competency statements. The highest rated statements were “Acting with Personal Integrity”, “Communicating Effectively”, “Acting with Professional Ethical Values”, “Pursuing Excellence”, “Building and Maintaining Relationships”, and “Thinking Critically”. Combining the results from hierarchical cluster analysis with our qualitative data led to a healthcare leadership model based on the core principle of Patient Centeredness and the core competencies of Integrity, Teamwork, Critical Thinking, Emotional Intelligence, and Selfless Service.

Using a mixed qualitative-quantitative approach, we developed a graphical representation of a shared leadership model derived in the healthcare setting. This model may enhance learning, teaching, and patient care in this important area, as well as guide future research.

Introduction

Physicians must become effective healthcare leaders in order to influence the care of individual patients, the performance of diverse clinical teams, and the direction of major healthcare organizations and beyond. The importance of effective healthcare leadership is difficult to overestimate as leadership not only improves major clinical outcomes in patients, but also improves provider well-being by promoting workplace engagement and reducing burnout. 1 – 5 We define the ability to influence as the foundation of our definition of healthcare leadership: Healthcare leadership is the ability to effectively and ethically influence others for the benefit of individual patients and populations.

Over the last ten years, we have created, implemented, and refined several undergraduate medical education (UME) and graduate medical education (GME) leadership development educational programs. We have found that medical students, residents (synonymous with junior registrar), and fellows (postgraduate trainees; synonymous with advanced specialist registrar) are exposed to little intentional education to prepare them for their current and future personal and professional leadership challenges. Importantly, from a developmental and educational perspective, omitting topics such as leadership in medical education “is a powerful, if unintended signal, that these issues are unimportant”. 6 Our programs are not designed to prepare individuals for specific leadership roles. Rather, they facilitate individuals’ learning and development of leadership skills that will prepare them to influence many facets of life, including healthcare.

We have found that leadership models are extremely helpful for learners to grasp new concepts, make sense of lessons learned through their experiences, afford structure that facilitates lasting comprehension through reflection, and provide a basis for learner assessment and program evaluation. 7 In the formative years of our programs, we used business leadership models as the foundation to teach leadership skills. Our review of other leadership development schools and professions (for example, the Wharton School of Business - University of Pennsylvania, the Fuqua Business School at Duke University, the United States Service Academies, and the Department of the Army) were helpful, yet they lacked emphasis on subtle aspects unique to healthcare leadership. We then looked for explicit healthcare leadership models and found that few existed. Further, none seemed to facilitate effective leadership learning in UME and GME.

Our inability to find an appropriate healthcare leadership model led us to create a leadership model specific to healthcare. This model needed to be based on competencies that were recognized as the most important attributes for effective healthcare leadership. The purpose of the paper is to present the research process that resulted in the Duke Healthcare Leadership Model, as shown in Figure 1 .

The Duke Healthcare Leadership Model.

Note: ©2017 Dean C. Taylor, MD. All rights reserved.

The study was a mixed method study using a modified concept mapping approach to derive, prioritize, and thematically structure the fundamental competencies of healthcare leadership. Concept mapping is a mixed methods approach that combines qualitative group processes such as brainstorming and interpretive sorting with rigorous quantitative data analysis to produce a visual depiction of the composite thinking of the group. This process of structured conceptualization has been used to address complex issues in healthcare, and provides a framework that can guide action planning, program development or evaluation and measurement. 8 , 9 We used a comprehensive literature review and focus groups to develop a set of statements that described healthcare leadership competencies. Next, we implemented a card sorting task, followed by analysis and interpretation. Finally, we created and refined a graphical representation of healthcare leadership. These successive steps are illustrated in Figure 2 and will be explained in more detail in following sections. The study was approved by the Duke Health Institutional Review Board after it was determined to be exempt from full review. Participation was voluntary, and informed consent was not required.

Sequence of steps in the concept mapping approach to derive, prioritize, and thematically structure the fundamental competencies of leadership in medicine.

Literature review

Building upon our prior meta-analysis exploring leadership curricula used to teach medical students, we performed an updated literature search and review of existing leadership models. 10 Information gleaned was used to develop semi-structured focus group interview questions, a list of common healthcare leadership attributes, and a script to be used in focus group discussions.

Focus groups

Participants were recruited to collect expert opinion on the leadership competencies required of a healthcare leader in any environment . Each focus group lasted approximately two hours, and was led by the same team of moderators. Moderators used the script developed from the semi-structured focus group interview questions to lead the discussions. One of the moderators took notes of the comments from the group members and from subsequent debriefing sessions. The focus groups were also asked to critique the leadership attributes identified from the literature. Participants were asked to rank the top 10 attributes required of a healthcare medical leader. The focus group data were analyzed through constant comparison analysis by identifying common themes through saturation within each group and across groups. An initial set of competency statements was derived and further refined by eliminating duplication and targeting specifically for healthcare settings. The resulting competency statements formed the basis for the quantitative card sorting and cluster analysis.

Card sorting task

The sorting procedure was administered online with the open source program FlashQ. 11 Following an introduction with instructions, participants were presented with the focus group leadership competency statements in random order and asked to sort them in order of importance based on their individual point of view. More specifically, participants were asked to rate the relative importance of each leadership attribute based on its value or importance in contributing to effective leadership performance in real-world clinical situations. During the sorting process, participants placed one unique statement in each box on a grid with a fixed quasi-normal distribution. Competency statements could be allocated to a ranking position ranging from +5 (most important) to −5 (least important). Respondents could change the placement of cards until the final positioning of all statements reflected their ranking of the statements relative to each other in importance. After completing the card sorting, participants were asked to provide their rationale for placing the competency statements at the extreme ends (+5 or −5 columns) of the sorting grid. All responses were anonymous, though respondents could elect to enter demographic data, including sex, current role, and leadership experience.

Hierarchical cluster analysis

Demographic data and importance scores were calculated using descriptive statistics. All data were analyzed with JMP Pro 13.0 (SAS Institute Inc., Cary, NC, USA). Cluster analysis is a statistical technique to find similar groups of cases in a data set and is particularly useful in the development of a classification or conceptual scheme. Hierarchical cluster analysis (Ward’s method, squared Euclidean distances) was used to classify leadership competency statements based on the similarity of individual sorting responses of each participant. Guided by the dendrogram and agglomeration schedule, investigators (CWH, JPD, DCT) determined the final number of clusters by consensus and based on the criterion that the clusters should reflect meaningful, distinct domains related to effective leadership in a healthcare setting.

Mixed methods analysis

We analyzed the quantitative data in conjunction with the qualitative data obtained from the focus group discussions and the statements provided by card sorting participants. This mixed methods analysis helped us define the primary healthcare leadership competency themes. Earlier versions of the model originated within our Feagin Leadership Program and the Leadership Education And Development (LEAD) Curriculum, which are internal initiatives within our UME and GME programs. The initial models were refined based on input and feedback obtained from multiple faculty, house staff, and residents over a three-year period.

The literature review found that healthcare leadership is a skill that must be 12 – 14 and can be 15 – 17 intentionally taught. Further, the literature review provided information on healthcare leadership attributes and content 18 – 25 that we used to guide the discussion to the semi-structured focus group interview questions. Thirty-nine healthcare leadership attributes were identified and used to determine the competency statements in the focus groups.

Three focus groups were carried out with a total of 19 participants, many being clinical faculty with administrative or leadership roles . From the 39 healthcare leadership attributes identified through the literature review, the focus groups’ work led to a set of 33 competency statements that represent important aspects of healthcare leadership (Supplementary material). These statements formed the basis for the card sorting task. Each one of the statements:

• Described some of the fundamental knowledge, skills, or attitudes related to leadership (influencing others) in a healthcare setting
• Represented the basic competencies that may be demonstrated by successful physician leaders, regardless of their work setting
• Described the knowledge, skills, and attitudes that combine to enable residents and fellows to demonstrate behaviors that help assure effective leadership performance in real-world clinical situations

In addition to identifying the statements for our quantitative card sorting task, the focus groups also provided important qualitative data. All three focus groups emphasized that Patient Centeredness and Selfless Service are two competencies essential to effective healthcare leadership. Further, each focus group emphasized that Patient Centeredness was essential to any healthcare leadership model as this principle differentiated healthcare leadership from leadership in other fields.

Approximately 200 faculty (attending physicians and non-physician professionals) and learners (medical students, residents, and fellows) were recruited via email to participate in the card sorting exercise. Ninety-two participants responded (46 percent) (22 medical students, 29 physicians-in-training, 25 attending physicians, and 16 non-physician professionals). Sixty percent were men, and two-thirds reported prior formal leadership training. Table 1 presents a basic summary of the participants in the card sorting task. Table 2 summarizes the mean values for importance of the top competency statements.

Characteristics of participants in card sorting

Note: Discrepancies in totals are due to incomplete responses as demographic questions were optional.

Top competency statements ranked by mean (SD) importance score

Through hierarchical cluster analysis, the competency statements fell into five domains. We labeled four of the domains based on the predominant themes of the competency statements in those domains: Integrity, Teamwork, Critical Thinking, and Emotional Intelligence. A fifth domain comprised a set of low-rated competency statements for which no unifying theme could be identified ( Figure 3 ). Fundamental leadership domains with mean importance scores for each leadership competency statement are presented in Table 3 .

Organization of competency statements based on hierarchical cluster analysis and mixed quantitative and qualitative assessment.

Five fundamental competency themes in leadership in medicine with mean importance score for each competency statement

Mixed methods analysis of the quantitative and qualitative data resulted in two additional competency themes for the healthcare leadership model. We used the qualitative input from the focus groups and the card sorting comments to separate Patient Centeredness and Selfless Service from the Emotional Intelligence domain ( Figure 3 ). The focus group affirming that Patient Centeredness is a unique, defining component found in effective healthcare leaders was confirmed through feedback and experience we received when testing early versions of the model in leadership education settings. We concluded that Patient Centeredness is more than a competency for healthcare leadership; it is a core principle.

We also identified the highly rated statement of “Communicating Effectively” (originally clustered in the Integrity domain) as essential to each domain, and not a separate competency. Similarly, “Pursuing Excellence”, although highly rated and part of the Critical Thinking domain, is a statement that is an aspirational goal and, as such, a part of each competency.

Finally, we modified the graphic representation of the model based on its use in teaching students, residents, and fellows, along with the feedback we received from these learners and faculty. The resulting model ( Figure 1 ) features that the central core principle of Patient Centeredness is surrounded by the overlapping five core competencies. We recognize Emotional Intelligence 26 , 27 as the core competency that holds the other competencies together, and therefore it is positioned as the “keystone” in the model; if Emotional Intelligence is removed, the model will crumble. Integrity and Selfless Service are intentionally positioned at the base of the model; although they may be difficult to teach, they are extremely important to effective healthcare leadership and must be recognized and emphasized as essential “foundational” core competencies. Critical Thinking and Teamwork are positioned as the “framework core competencies”, holding the model together and overlapping with the other three competencies.

From curricular, pedagogical, and assessment perspectives, a model serves as the foundational starting point for learning and as an organizing framework for the developing leadership curricula. The model presented here addresses this need. We used a concept mapping approach to create a model specific to the needs of learning in healthcare leadership.

Our model was developed based on a comprehensive literature review, focus groups, concept mapping, and hierarchical clustering. Each of the 33 competency statements is an important concept of healthcare leadership. Our methods determined which statements were most important and which coalesced into themes. We began with an initial model that had been drafted within our UME and GME leadership programs (the Feagin Leadership Progam and LEAD Curriculum). Those initial drafts were further refined over a three-year period based on feedback we received from numerous people within our institution with varied levels of healthcare experience and training (faculty, fellows, residents, students, administrators, and non-physician educators). That input led to a model that has face validity, is well accepted, and can be used in pedagogical processes that help all of us learn to be better leaders.

Recent literature emphasizes the importance and need for the intentional, explicit promotion of leadership development curricula and training in medical education. 28 – 31 Clearly, leadership development education should be intentional and not informal or implicit. The model presented here provides a framework for intentionally teaching leadership skills in healthcare education.

There continue to be efforts to appropriately characterize “content” 32 and define competencies. 33 Sonnino argues for two dozen competencies, the most important of which are finances and economics, emerging issues and strategic planning, personal professional development, adaptive leadership, conflict management, time management, ethical considerations, and personal life balance. 34 Seven of those eight align well with our model; we would argue that finances and economics are more managerial skills and context dependent. Further emphasizing the significance of leadership development in postgraduate medical education, in 2015 the Canadian residency CanMeds competency framework replaced their role of “manager” with that of “leader”. 35

There are several limitations to our study. Foremost, model creation is not an exact science. Our mixed methods approach involves subjective interpretation of how to organize overlapping concepts. For example, communication could be considered a separate competency. Instead, we chose to include communication as essential for all core competencies - learning to communicate better enables one to be better at each healthcare leadership competency. Others’ subjective assessments may have led to different interpretations.

This model is also derived from research done at a single institution, and as a result may not be generalizable to other settings. We do not suggest that ours is the only or best healthcare leadership model. It is offered as a model that others can use and refine for their own environments. The methods we describe can serve as a guide if others desire to create their own institutionally specific model. Nonetheless, this model has guided our teaching of skills and concepts that lead to improved competency in areas recognized as essential for effective, ethical healthcare leadership. It has subsequently led to an assessment of learners and an evaluation of our programs.

Models are most useful when validated. Preliminary validation of our model is complete. Our group is committed to re-validate the model in more diverse and larger healthcare settings. Our next steps involve developing, refining, and validating an evaluation instrument that assesses the competencies and core principle in the model. This work is underway through the Health Evaluation Assessment of Leadership. 36

We designed a leadership model specific to healthcare using concept mapping. The research led to a model based on the core principle of Patient Centeredness and core competencies of Emotional Intelligence, Integrity, Selfless Service, Critical Thinking, and Teamwork. We have found this model useful for teaching leadership skills, and are currently designing a relevant evaluation instrument.

Supplementary materials

Competency statement definitions.

• Acting with Personal Integrity – behaving in an open, honest, and trustworthy manner
• Communicating Effectively – ability to communicate with patients and team; successfully navigating difficult conversations and providing feedback
• Acting with Professional Ethical Values – applying medical ethical principles to difficult situations
• Pursuing Excellence – striving for excellence in all areas of personal, team, and organizational life
• Building And Maintaining Relationships – listening to and supporting others; gaining trust; and showing understanding
• Thinking Critically – being able to think analytically and conceptually to evaluate and solve problems
• Motivating – inspiring oneself and others to achieve goals
• Optimizing Team Dynamics – understanding team members’ roles, strengths, and weaknesses; influencing diverse talents to achieve common goals
• Managing People – delegating, providing direction, and promoting equality and diversity
• Maintaining Patient Centeredness – focusing on patients’ best interests; working in partnership with patients; ensuring patient safety
• Adapting To Change – flexibility, adapting to change readily, being the first to change when required
• Managing Personal and Team Performance – the ability to assess successes and failures of oneself and team members and make adjustment as needed
• Being Decisive – using values and evidence to act decisively, especially in difficult situations
• Encouraging Improvement and Innovation – creating a climate of continuous quality improvement and identifying areas for growth
• Encouraging Contribution – creating an environment where others have the opportunity to share their thoughts and ideas without fear of criticism
• Planning – developing short-term and long-term plans to achieve personal, team, and organizational goals
• Developing Self-awareness – being aware of one’s own values, principles, and assumptions
• Fostering Vision – developing an organizational vision, communicating that vision, and embodying its principles
• Developing and Implementing Strategy – integrating and aligning plans, resources, and people to achieve goals
• Managing Self – organizing and self-regulating actions and emotions
• Serving Selflessly – ability to put others’ needs before one’s own; demonstrating great concern for common good/other people
• Continuing Personal Development – learning through continuous professional development and being open to feedback
• Managing Resources – knowing what resources are available and using one’s influence to ensure that resources are used efficiently and safely, reflecting the diversity of needs within given populations
• Cultivating Personal Resilience – ability to cope with demanding situations
• Applying Knowledge and Evidence – the ability to translate research and evidence-based practice in order to optimize outcomes
• Maintaining Personal Balance – prioritizing activities to maintain mental and physical health
• Having A Strong Knowledge Base – being an expert in a given field and demonstrating mastery of core knowledge
• Facilitating Transformation – actively contributing to positive change
• Evaluating Systemic Impact – measuring and evaluating outcomes; taking corrective action where necessary
• Understanding Situational Context – seeking broader perspectives on problems; understanding community and stakeholders perspectives
• Developing Networks – developing professional connections with stakeholders inside and outside the institution
• Understanding Community Impact – having awareness that decisions about patient care impact population health
• Understanding Historical Context – being aware of the history, culture, and traditions of the institution and including these in decision-making

Acknowledgments

The authors thank members of the Feagin Leadership Program for their extensive backing of this project. The authors acknowledge all of the participants of the focus groups and other non-author members of their team including Prinny Anderson, MBA, Med; Jane Boswick-Caffery, MBA, MPH; Matthew Boyle, MD; Thomas Mullin, MD; and John Yerxa, MD. We also thank Saumil Chudgar, MD, MS, for feedback and editing work on this paper.

The authors acknowledge the assistance of Donald T Kirkendall, ELS, a contracted medical editor, for his assistance in preparing the manuscript for submission.

The views, opinions, and/or findings contained in this report are those of the author(s) and should not be construed as an official Department of the Army position, policy, or decision. Citation of trade names in this presentation does not constitute an official DA endorsement or approval of the use of such commercial items.

Allison MB Webb is currently a resident in the National Capital Consortium’s program Combined Internal Medicine – Psychiatry Residency at Walter Reed National Military Medical Center, Bethesda, MD, USA. Nicholas E Tsipis is an Emergency Medicine Resident at Georgetown University Hospital/Washington Hospital Center, Washington DC, USA. Julie A Neumann is a sports medicine fellow at Kerlan-Jobe Orthopaedic Clinic. The authors report no conflicts of interest in this work.

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How does leadership differ from management in medicine?

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• Peer review
• Matthew Limb , freelance journalist
• 1 BMJ Careers
• Limb{at}btinternet.com

Matthew Limb looks at what leadership and management mean for doctors and whether the two concepts can be considered separately from one another

“Leadership” and “management” are so often used interchangeably in discussions about the health service that any distinction between the two roles is often lost.

Michael West, head of thought leadership at the health think tank the King’s Fund, believes that management is about “supporting, resourcing, and facilitating day to day work,” whereas leadership “creates direction, alignment, and commitment.” He says, “The two are interlinked, and it is slightly artificial and misleading to separate them out and treat them as distinct. Leaders must manage to be effective, and management very much involves leadership.”

Lisi Gordon, a research fellow at Dundee University’s Centre for Medical Education, says, “Management is absolutely about process: the day to day to running of known processes. Leadership is more about change: it’s more about continuously reviewing and exploring possibilities for improvement and change.”

Jonathan Fielden, medical director at University College Hospital, London, agrees. “Leaders without management skills rarely become good leaders, and managers without the ability to lead people rarely can achieve what they need to,” he says. In practice, most senior roles demand management and leadership qualities, whether these are informal roles or formal roles such as medical director, chief executive, consultant, clinical leader.

He adds, “It’s really important, particularly for doctors, that they understand that they have both leadership and managerial responsibilities whatever their roles are. Individuals do tend to move more towards one than the other, but you need both skill sets.”

Creative thinking about roles

Doctors who want to be leaders can sometimes feel that they are being sucked into the business of just managing because of political, budgetary, and other pressures. Gordon says, “I can understand how there may be a feeling that people get bogged down with the day to day management, the processes.” But she believes that people need to step back and think more creatively about their roles and regard the wider service they provide.

Peter Wilson, a fellow of the Health Foundation’s Generation Q leadership development programme, says, “I don’t believe that in a good organisation management and leadership are separate.” As clinical director at Southampton Children’s Hospital, he says that he is managerially held accountable for targets and performance but also leads a “change agenda.”

Doctors may tend to see themselves “as leaders but not managers,” but that thought process has to change, Wilson says. “Actually, everybody is a leader and a manager simultaneously, because they are managing situations and leading situations. I think it’s a cop-out to pretend we’re not. It’s a way of dodging the bullets as it were. Leadership has to be about how you look at situations, utilise the data that you’ve got . . . and challenge where it needs to be challenged.”

Stephen Gillam, a GP and lecturer at Cambridge University’s Institute of Public Health, admits that he has “never got too hung up about the demarcation” between leadership and management.

But he believes that the current desire to aim for “distributed leadership,” which he interprets as “telling doctors you’re all leaders now,” risks underplaying or “sanitising” a salient characteristic of leadership. “Proper leadership requires sticking your head up above the parapet in a rather more prominent way and is more than just doing the things we all do like leading teams,” he says.

Detachment and toughness

One of the difficulties for clinical leaders is that they may often have to “be awkward” and challenge their colleagues to bring about changes, he believes. “You have to be a certain sort of individual to take that on,” he says. “You have to have a detachment and toughness very often to be an effective leader.”

Simon Bird, who leads on UK healthcare practice at the consultancy firm Hay Group, says that the term “clinical leader” has itself become “unhelpful” for doctors wishing to develop their careers. He believes that it has been “overused” by employing organisations, which often fail to define it or spell out accountabilities, leaving doctors without the support or resources to perform effectively. “At worse, doctors can then feel hoodwinked or caught out for being asked to do an impossible job,” he says.

Bird, a former NHS manager who works with NHS organisations on leadership and organisational development, says that trusts should be more “thoughtful and serious” about what they mean by clinical leader roles.

He also suggests that senior doctors in leadership roles who seem reluctant to accept management type duties are almost behaving like teenagers. “It’s almost naive to expect to be able to have the benefits of a leadership role without having to take on some of the other stuff that might be less attractive that comes your way with it,” he says. “I think it’s now impossible to separate the two.”

• DOI: 10.30574/ijsra.2024.11.1.0271
• Corpus ID: 267753140

Leadership styles and their impact on healthcare management effectiveness: A review

• Ekene. Ezinwa , Fumilola Olatundun Olatoye , +3 authors James Olakunle Oladapo
• Published in International Journal of… 28 February 2024
• Business, Medicine

2 Citations

Transformational leadership, psychological empowerment, and organizational citizenship behaviors among nursing workforce: a single mediation analysis, online learning and community engagement: strategies for promoting inclusivity and collaboration in education, 45 references, burnout and leadership style in behavioral health care: a literature review, nursing leadership styles and their impact on intensive care unit quality measures - an integrative review., leadership in healthcare: transitioning from clinical professional to healthcare leader, complexity leadership: nursing's role in health care delivery, the association of leadership styles and nurses well-being: a cross-sectional study in healthcare settings, leadership roles, behaviors and styles for self-managed teams in the healthcare sector : a systematic literature review, the need for nursing leadership in uncertain times., leadership styles and nurses’ job satisfaction. results of a systematic review, authentic leadership, organizational culture and the effects of hospital quality management practices on quality of care and patient satisfaction., adaptive leadership of doctors during covid-19., related papers.

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Analysis of The Importance of Management and Leadership in Healthcare

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Published: Dec 18, 2018

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Works Cited

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Leadership and Management in Healthcare -a critical approach

An overview of leadership theory and the issues relating to it: gender, teamworking, interpersonal relationships, quality.

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SOCIETY. INTEGRATION. EDUCATION. Proceedings of the International Scientific Conference

Aelita Skarbaliene

Leadership is overwhelming the thinking of contemporary society. A well-functioning organization is first identified with its leader very often. Therefore, it is very important to question the attitude of leadership constantly, not to devalue it, but to understand it better and realize it. Moreover, the expression of leadership in different organizations is very distinct, and its specificity in areas such as health care is still insufficiently explored. Healthcare organizations hold strict hierarchy, therefore leadership is considered as equal to the administrative position. Modern conceptualizations such as transactional, shared, authentic and other leadership theories point to the educational power of a leadership; however, implementation remains challenging. The article presents the analytical-theoretical point of view and interpretive approach for case study about leadership. Firstly, the article introduces research evidence analysis of leadership educational impact for integrat...

Susan Thomas

In recent years the perspective and training in the management of health care has changed dramatically. In many countries, due to instances of inefficiency in their health care delivery, healthcare providers are adopting transformational change not only in their leadership but also management practices which are crucial in overall organizational performance. The Institute of Medicine in US (IOM) in 2008 has defined quality of care as ‘the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. Providing high quality of health care delivery is important to the stakeholders. The delivery of health care must be managed in order to sustain the quality of care given to patients. Every care giver must be able to portray a “clinician role model”, be compassionate towards patients and take responsibility in the management of treatment. The primary goals of this paper are to present insights from the views of patients and doctors on the leadership and management practices in the health care delivery at the hospital wards. The data was explored from two tertiary hospitals in Malaysia. Qualitative field research that focused on triangulation methods was used in this study. Data collection strategies included in-depth interviews with patients and doctors, observation, field notes and records of episodes at research sites. Purposive sampling method based on patient’s medical condition was carefully considered in this research. The results show that hospitals have excellent training plans and management practices. Patients are generally satisfied with the overall care and services given to them by the hospital team. The findings also reveal that majority of the care givers have shown good leadership skills and management skills. However, some patients have reported dissatisfaction in not being given autonomy in making decisions. On the other hand, some doctors face problems in patient compliance because of cultural and religious beliefs. There are also reports on lack of resources and insufficient equipment. As a result, these situational factors faced by the doctors have influenced their leadership styles and decision making. The in-depth exploration from the findings may form as a conceptual framework to evaluate quality care and productivity in a healthcare setting. Future studies at a broader range may allow the inclusion of new variables and outcomes.

Health Services Management Research

Matilde Rosso

Being largely considered a human right, healthcare needs leaders who are able to make choices and to set directions. Following the recommendations expressed by Gilmartin and D'Aunno's review and roadmap compiled in 2008, today, it is important to acknowledge researchers' contributions to outline this landscape. The realist review of 77 publications answered questions such as “what works, for whom, and in which circumstances” highlighting: the effectiveness and acceptance of transformational and collaborative approaches; professionalism, expertise, and good task delegation within operational teams; distributed leadership, relationships, and social responsibility at a systemic level. The relevancy and need of leadership development programs, framed within a wider strategy, emerged. Nonetheless, gaps still exist and require further investigation: particular needs in public vs. private contexts; professionals' and women's differentiating characters; generational gaps...

Aladeen Alloubani , Mohammad Almatari

Abstract Background :There are progressive changes in the work of hospital leaders, included descriptions of how hospital leader work is perceived in a global context. Hospital leaders have had to respond to new technology, new organizational goals and new challenges. The most effective leaders have responded to the dynamism of the healthcare field by altering their leading skill set. Aim: To understand the nature of leadership work of the hospital managers in order to examine their perceptions of the most essential roles, skills and training courses as hospital managers. Also to identify the challenges, obstacles and problems facing hospital leaders. Methods : Hospital leaders were compared to more traditional leaders, highlighting important, yet subtle differences between them. Studies appropriate for inclusion were randomized controlled trials studying the effectiveness of leadership styles among hospital leaders, head nurse managers and healthcare workers. An integrative review of studies from ProQuest, PubMed and Emerald databases was undertaken to explore and analyses studies about leaders and leadership and its effects on outcome. Keywords and phrases used were: Nursing leaders, head nurse manager, nursing leadership, health leader, health leadership, leader functions, leader roles, hospital, healthcare system, job motivation, health policy, qualification needs, professional development, and challenges facing hospital leaders. Findings: Several research studies in the field of leadership found that transformational leadership attributes and behaviours were positively related to organizational outcomes such as teamwork success, effectiveness, staff satisfaction, commitment and extra effort and more. Moreover, transformational leadership processes have been found to enhance followers’ work-oriented values and shape self-efficiencies of followers. European Scientific Journal June 2014 edition vol.10, No.18 ISSN: 1857 – 7881 (Print) e - ISSN 1857- 7431 119 Conclusion: According to literature incorporated in this review it can be concluded that effective leadership is one of the most crucial factors that lead an organization towards success. Nowadays the key challenge for modern organization is to recognize the effects of strong leadership upon the nursing performance and success of the organization. Implication for Nursing and health policy: A proficient leader leads nurses and provides direction for an organization towards accomplishing desired goals. The advantages of leadership effectiveness should be stated for nursing administrative and healthcare policy makers. Keywords: Leadership, Healthcare, Transformational, Quality of Services

Nursing Standard

adele nightingale

Quality and Safety in Health Care

Jenny Firth-Cozens

Journal of the Liaquat University of Medical and Health Sciences

Waris Qidwai

Healthcare and medical profession stands at crossroads today. Unprecedented technological advances as a result of ongoing scientific research has revolutionized healthcare around the world. Despite these developments, we are still faced with a huge burden of communicable diseases, an ever rising burden of noncommunicable diseases, coupled with an increasing load of mental health diseases and accidents in healthcare.1,2 There are several reasons for our failure to address healthcare issues of our populations, including a desperate need to revamp existing medical and health care related curriculum.3 In addition to considering curriculum change, perhaps single most needed change we need to address is a growing need to develop leadership in medical healthcare related profession.4

Journal of Healthcare Leadership

Elaine Scott

In current clinical settings, effective clinical leadership ensures a high-quality health care system that consistently provides safe and efficient care. It is useful, then, for health care professionals to be able to identify the leadership styles and theories relevant to their nursing practice. Being adept in recognizing these styles not only enables nurses to develop their skills to become better leaders but also improves relationships with colleagues and leaders who have previously been challenging to work with. This article aims to use different leadership theories to interpret a common scenario in clinical settings in order to improve leadership effectiveness. Ultimately, it is found that different leadership styles are needed for different situations, and leaders should know which approach is most effective in a given scenario to achieve the organization's goals.

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Healthcare Management and Leadership

Leadership theories, transformational leadership.

The importance of healthcare management is being understood on the medicine front with various players and places. It works with a variety of health professionals. Medical experts do advanced researches and healthcare management is devoted to making the best use of the services of these people and places (Ronald Jefferson,2008, para 1).

Nancy M. Lorenzi et al. (2004) describe that leadership plays a significant role in all organizations but its importance has been understood more in the area of health informatics since it is complex; it has interdisciplinary nature; it is dependant on constant changing technology and it has the participation of users. This chaotic environment needs a leader who is actually extraordinary: an excellent communicator, knowledgeable in both the fields as technology and clinical domains; innovative and adaptable and be tactful to convince many different smart people from different backgrounds so they can achieve goals. Leaders have to be extra brilliant in informatics otherwise if they are bad leaders and fail in projects, stakeholders and users of informatics become hesitant in giving them the next projects.

Nancy M. Lorenzi et al. (2004) further say that researchers believe that leadership is the combination of traits and skills and has a clear vision. It consists of the ability to encourage people to carry out that vision. These supposed trait theories of leadership have surrendered to contingency and situation theories to take the leaders, the followers and the context into consideration. There is not any skill of that type that can be applied any time on any organization. According to Goleman emotional intelligence is the ability which manage one’s relationship with others and this ability is required by a good leader. He has made four categories of these abilities: self-awareness, self-management, social awareness and social skills.

• Trait Theory : According to McGregor, “Researches say that it is more successful to think leadership as a relationship between leader and the situation than to think it as a universal pattern of characteristics acquired by specific people.” (Linda Roussel et al, 2005). This statement entails that leadership is dependent upon human relations roles and needs different characteristics due to different situations. Some traits are very common in all good leaders like integrity, trustworthiness, honesty, goal-oriented, experienced communicator, hardworking, dedicated and commitment (Linda Roussel et al, 2005). Gardener’s writing has related leadership with two traits: The Tasks of Leadership and Leader Constituent Interaction. According to Gardener, a leader performs nine tasks as affirming values, envisioning goals, motivating, achieving workable unity, managing, serving as a symbol, explaining, renewing, representing the group. In Leader Constituent Interaction Gardener talks about Charisma as a quality that makes one person different from others: superhuman, supernatural, gifted with exceptional qualities or power. This leadership can be good or bad (Linda Roussel et al, 2005).
• Behavioral Theories : Douglas McGregor’s X and Y theory narrates that each person is an individual and interacts with other individuals. Then this individual reflects the behavior of other individuals. This individual is affected by the emotions and attitudes of others. The constituent becomes dependant on the leader and needs fair treatment. Both the constituent and the leader wish for a successful relationship that materializes through the actions of the leader (Linda Roussel et al, 2005). A knowledgeable person proves to be an effective leader. Leaders try to maintain the standards and also make efforts that their constituents meet those standards. A secure and independent atmosphere makes constituents responsible. Leaders also need security before they give any responsibility to the constituents (Linda Roussel et al, 2005).

Fiedler’s Contingency Model of Leadership Effectiveness says that an organization is responsible for a leader’s success and failure so the leaders can be trained to handle the situation and to learn which situation is better for them and which is not. His theory states that a leadership style can be effective or ineffective based on the situation. (Linda Roussel et al, 2005).

Linda Roussel et al (2005) believe that transforming leaders are concerned with the people’s basic needs, hopes, wants and expectations. They are innovative. Leaders should make their constituents independent and should develop their strengths in them.

Linda Roussel et al (2005) state that the healthcare system is going through a major change. These organizations are being redesigned and restructured to face the challenges of these changes and to meet the requirements of patient care. Additionally, People in rural areas and inner cities have a shortage of hospitals and healthcare personnel. Leaders should discover ways to motivate their staff to make balance in this chaotic kind of situation. They should be flexible and should understand the uncertainty. They should understand the needs and values of constituents.

Bennis and Nanus define a transformational leader as the one, ‘who makes people work; who transforms followers into leaders and who may translate these leaders into agents of change.’ They believe that the center of leadership is power and which has the energy to instigate and continue action transforming intention into reality’ These leaders do not make use of power to control constituents, instead, they strengthen constituents to visualize the organization and trust the leaders to achieve goals which are advantageous for them as well as for the organization (Linda Roussel et al, 2005).

Linda Roussel et al (2005) argue that leadership cannot be considered the exercise of power instead it is the empowerment of others. Here the goal of the leader and the constituent become one, having a combined purpose. Transformational leaders will organize their staff by concentrating on the wellbeing of the individual and cultivating the modern work environment. Experts appreciate that leadership signifies cooperation instead of competition. People are encouraged when they participate in decision making and they are praised for quality and excellence rather than punishment. In nursing, empowerment outcomes with improved patient care, fewer staff sick days and less destruction. Nurses who become transformational leaders possess a satisfactory staff that is happy with their job and serves the organization for a longer period.

Bennis has discovered four skills for effective transformational leadership (Linda Roussel et al, 2005):

• Management of attention- it is achieved by keeping vision and sense of goals. This vision defines in which direction the health organization should go and how should it serve society.
• Management of meaning- Nursing leaders make changes in the social architecture and culture of health care organizations and for that, they use group discussion, agreements and consensus-building. They favor skills like creativity and innovation in an individual. Barker believes that nurse transformational leaders will take care of vision, goals, objectives, rewards, support and appraisal. The important thing is all these elements will appeal to these leaders.
• Management of trust- it is related to reliability. Nurses give value to those leaders who believe in fair decisions and whose judgment is sound and consistent.
• Management of self- it tells about knowing one’s skills and using them effectively. If the leaders are not effective they can discourage a nursing unit which can lead to poor patient care. When stress is reduced, nurse leaders need to master the skills of leadership (Linda Roussel et al, 2005).

Chiapello (1998) mentions when there are strong competitive values of different worlds, there is an approach to leadership of co-leaders, like the administrative and clinical leaders of a health care organization, who actually signify individual worlds and can connect personally with the domestic world (Ewan Ferlie et al, 2005).

Linda Roussel et al (2005) discuss that successful leaders trust in the concept of decision making and even if their decisions are not much admired they do not stop taking responsibility for decision making. Constituents also become willing to participate in the decision-making process but they want the direction of their leader. It generally happens in a time of crisis.

All the above-discussed theories look for the effective skills in a healthcare leader which should actually impact his constituents. A leader is supposed to be patient, caring and tactful to handle the situation according to the needs of the healthcare management as well as the patients and this should really be done by taking care of his constituent’s benefits also.

A leader may face difficulties in achieving his target of making everyone satisfied but this proves his impression and his efficiency to handle everyone successfully. His innovative ideas can make powerful not only the whole organization but also the constituents working with him.

Linda Roussel et al (2005) finally review that transformational leaders have flexibility and adaptability according to leadership styles to face the changes happening in this healthcare environment. Gender issues related to leadership in health care organizations have not been studied well. Gender differences in leadership style do not transform one style to other. Nurses may accept leaders who have unique leadership quality and this environment will be favorable for both men and women nurses to grow self-confidence and become strong leaders.

Ferlie , Ewan et al. (2005), The Oxford handbook of public management (p.457), New York, Oxford University Press.

Jefferson, Roland (2008), Health Care Management Employs Effective Leaders , Article base free online directory.

Lorenzi, Nancy M et al. (2004), ‘Leadership’, Transforming health care through information , Edition: 2 (p.188-189).

Roussel, Linda et al. (2005), ‘Leadership and Evidence-based Management’, Management and leadership for nurse administrators , Edition: 4 (p.165-174), Sudbury, Jones and Bartlett Publishers.

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Health Care Management and Leadership Essay

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Introduction

In this short essay it is the intention to reflect upon the motivators that inspire and attract highly skilled leaders within health care services. These leaders come from a wide range of disciplines: caring, economical, operational and strategic concepts in which many of which are professionals within a specific field.

However, in the current climate of care, in particular within the National Health Service (NHS), these roles are fragmented and composite within the political sphere of devolved health care in the United Kingdom.

The specific role that is currently under significant levels of leadership change is that of the nurse practitioner, moreover, the desire for leadership is often tangled in a wider complexity of motivational factors and conditions. In stating this, it is vital to acknowledge that the role has become extremely ambiguous within a much wider scope of ‘doing’ duties, that are, themselves practically complex and diverse.

In reflecting on the practitioner’s role moves through a plethora of: administrative duties, human resourcing, service user care and moreover, strong self management and discipline, which has to tightly fit into a wedge of various levels of being a ‘team player’ with a variety of not so well defined roles.

In order to find personal levels of specific motivation the practitioner must be seen to be a ‘hands on’ team player, across a wide range of disciplines cited above. Albeit, the role even though it has significantly changed over recent decades, still demands people of the highest calibre and without wishing to sound, old fashioned, a person with a real ‘vocation’ to nurse, at whatever the level of expertise, drive or experience.

In particular these frontline health care ‘leaders’ have to be able to be proactive, engaged, committed, a maintainer of effectiveness, cohesion and moreover a focused holistic team manager, and one who can and will ensure that the ‘team’ engages operationally and strategically across the many diverse levels of NHS management and accountability.

To ensure that the nurse practitioner is enabled to be the ‘team leader’, he/she needs to be completely self motivated, accountable for their own and the actions of the team; cohesive, dynamic, a problem solver, passionately focused, upon motivating and supporting others.

Self managed leaders in the area of nursing are often seen as team oriented people, who through a level of professional discipline, can command the respect of colleagues, lower and higher levels of a diverse strategic and operational intra-organisational and inter-organisational command and accountability structure.

Being able to ensure that through their own ‘self managed’ abilities, they are enabled to ‘hone’ their skills, aspirations, needs, care and discipline necessary to ensure that the disciplines of care within the leadership role, noted above, are carefully brought together in both the philosophy of care and its practice; within the scope and sphere of the given leadership tasks.

In this short reflective essay, we have considered aspects of the role of nurse practitioner within health service leadership. In so doing, we have succinctly consider the role, its dynamics, concepts and motivators.

The nursing practitioner at any senior level which engages a multi-faceted level of disciplines across, a wide range of management systems must be a serious ‘self motivated’ professional.

In which through their own role, they are competently able to influence outcomes, manage operational strategies and ensure that they have full command of a wide and varied plethora of tasks and duties, that flow in a seamless style of management, because of their skills; in essence provide the motivational factors for being a health service leader within the NHS.

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A leadership in healthcare

Info: 3500 words (14 pages) Nursing Essay Published: 11th Feb 2020

Reference this

Introduction

• briefly discuss the concept of leadership;
• highlight why leadership is important in healthcare;
• make a distinction between the closely-related concepts of leadership and management;
• briefly highlight how power relates to leadership;
• describe some leadership approaches applicable within the context of healthcare organisations;
• describe leadership styles visible in healthcare;
• present a case study set in a teaching hospital practice setting in Africa ;
• critically assess the leadership approaches operating within the setting and its effect on organisational performance ;and
• make recommendations on improving leadership practice within the specified setting.

What is leadership?

Why leadership in healthcare.

• Effective leadership and management has been found to contribute to efficiency of health care services, performance (McColl-Kennedy and Anderson 2002) and satisfaction of staff employed within them.(Bradley and Alimo-Metcalfe 2008) researched the causal relationship between leadership behaviours and the performance and productivity of staff and found that ‘engaging leadership' improved employee engagement and performance.
• (Morrison, Jones et al. 1997) studied the relationship between leadership style, empowerment, and job satisfaction on nursing staff at a regional medical centre. They used Bass's Multifactor Leadership Questionnaire to measure leadership style, items from Spreitzer's Psychological Empowerment instrument to measure empowerment, and the Warr, Cook, and Wall's job satisfaction questionnaire to measure job satisfaction. The authors found that both transformational and transactional leadership were positively associated with job satisfaction.
• Some other researchers reported that good leadership skills impacted on patient safety and quality of care (Corrigan, Lickey et al. 2000; Firth-Cozens and Mowbray 2001; Mohr, Abelson et al. 2002).Furthermore, leadership skills are essential in the world of public health policy and leadership is one of the core competencies required of public health trainees(Faculty of Public Health 2010).

Leadership versus management

Leadership theories and styles in healthcare, transformational leadership.

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• idealised influence-describes the ability of the leader to act as role model s whose followers emulate. This factor is sometimes mentioned as being the same as charisma;
• inspirational motivation-the ability to inspire the members of the group to become integrated with the vision of the organisation while transcending their own self-interest ;
• intellectual stimulation-the stimulation of creativity and innovation in the followers so that they are able to discover and develop new ways of sorting out issues within the organisation as they arise; and
• individualised consideration-portrays the need for leaders to recognise the strength and weakness of each member of the group foster on the development of followers and help each in the achievement of goals through personal development.

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Leadership and management for nurses working at an advanced level

Senior Lecturer, Leadership and Management: Public Health, Birmingham City University

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Leadership and management form a key part of advanced clinical practice (ACP) and work in synergy with the other pillars of advanced practice. Advanced clinical practitioners focus on improving patient outcomes, and with application of evidence-based practice, using extended and expanded skills, they can provide cost-effective care. They are equipped with skills and knowledge, allowing for the expansion of their scope of practice by performing at an advanced level to assist in meeting the needs of people across all healthcare settings and can shape healthcare reform. Advanced practice can be described as a level of practice, rather than a type of practice. There are four leadership domains of advanced nursing practice: clinical leadership, professional leadership, health system leadership and health policy leadership, each requiring a specific skill set, but with some overlaps. All nurses should demonstrate their leadership competencies—collectively as a profession and individually in all settings where they practice.

Leadership and management form an essential part of advanced clinical practice, as outlined by Health Education England (HEE) in 2017:

‘Advanced clinical practice is delivered by experienced, registered health and care practitioners. It is a level of practice characterised by a high degree of autonomy and complex decision making. This is underpinned by a master's level award or equivalent that encompasses the four pillars of clinical practice, leadership and management, education and research, with demonstration of core capabilities and area specific clinical competence …’

There is an appreciation that leadership and management skills work in synergy with the other pillars of advanced practice. Stanley et al (2008) advised that advanced clinical practitioners (ACPs) can shape healthcare reform, are trained to focus on improved patient outcomes, and with application of evidence-based practice, using extended and expanded skills, they can provide cost-effective care. ACPs are equipped with skills and knowledge, allowing for the expansion of their scope of practice by performing at an advanced level to assist in meeting the needs of people across all healthcare settings.

When considering a nursing context, the Royal College of Nursing (RCN) defined advanced practice as:

‘A level of practice, rather than a type of practice. Advanced nurse practitioners are educated at master's level in clinical practice and have been assessed as competent in practice using their expert clinical knowledge and skills. They have the freedom and authority to act, making autonomous decisions in the assessment, diagnosis and treatment of patients.’

Rose (2015) advocated that ACPs also need to respond to, inform and influence policy, and political and practice changes, while being aware of the complex needs of patients and new healthcare demands. Hamric et al (2014) delineated four leadership domains of advanced nursing practice:

• Clinical leadership
• Professional leadership
• Health system leadership
• Health policy leadership.

Each requires a specific skill set, but with some overlaps. These four leadership domains will guide the discussion that follows, with a focus on advanced nurse leadership.

Background: leadership and autonomy

Revisiting the HEE (2021) use of the word ‘leadership’ and the RCN's (2018) use of the term ‘autonomy’ as part of the definition of advanced nurse practitioners will set the scene and enable these two terms to be briefly examined. Naively, or perhaps traditionally and historically, we tend to put administrator and manager roles into a metaphorical box that considers them as formal leaders, while nurses in clinical roles are either not considered as leaders or they are identified as in formal or clinical leaders. As Scott and Miles (2013) stated, leadership is an expected attribute of all registered nurses, and, yet, leadership in the profession is often considered to be role dependent. All nurses—from student to consultant—are leaders, yet defined clinical leadership competencies are often not reflected in undergraduate nurse education. Research examining the impact of leadership demonstrated by nurses on patients, fellow nurses and other professionals and the broader health and care system is deficient ( Cummings, 2011 ). Nurses need to accept that leadership is a core activity of their role at all levels—once this is acknowledged the transition to advanced roles will be easier. Frequently, nurses approach the topic of leadership when studying for advanced practice as if it is something that they have never done and know little about. Yet they already have an enhanced leadership skill set developed throughout their careers, although they often fail to appreciate this. A solid foundation and affirmation that all nurses are leaders should form the basis of advanced practice.

Despite a blurring of boundaries between management and leadership, the two activities are different ( Bass, 2010 ). Working out who leads and who manages is difficult, with the added anomaly that not all managers are leaders, and some people who lead work in management positions. Kotter's seminal interpretation articulated that leadership processes involve setting a direction, aligning people, motivating and inspiring, and that management relates to organisational aspects such as planning, staffing, budgeting, controlling and solving problems ( Kotter, 1996 ). So leaders cope with new challenges and transform organisations, while managers maintain functional operations using resources effectively.

These explanations direct us to consider what is meant by the allied term of autonomy from the individual and organisational perspective. The Cambridge Dictionary (2020) defines autonomy for an individual as ‘independent and having the power to make your own decisions’ and for a group of people as ‘an autonomous organization, country, or region [that] is independent and has the freedom to govern itself’ (https://tinyurl.com/2h5canfa). In nursing, the concept of autonomy has a range of definitions. Skår defined professional autonomy as:

‘Having the authority to make decisions and the freedom to act in accordance with one's professional knowledge base.’

Skår, 2010:2226

In a clinical practice setting, Kramer et al (2006) outlined three dimensions of autonomy: clinical or practice autonomy, organisational autonomy, and work autonomy. However, they also advised caution with the use of the term autonomy because it has different meanings across the literature. Nevertheless, it has a place within advanced nursing roles, especially in connection with leadership.

Leadership and management for advanced practice

Recent research has examined leadership in advanced nursing practice. Hamric et al (2014) delineated four leadership domains. These link with the findings of Heinen et al (2019) in their review of leadership competencies and attributes in advanced nursing practice. The purpose of their research was to establish which leadership competencies are expected of master's level-educated nurses, such as advanced practice nurses and clinical nurse leaders, as described in the international literature. Note that in North America ‘advanced practice nurse’ is used as an umbrella term to include nurse practitioners and clinical nurse specialists ( Sheer and Wong, 2008 ).

Boxes 1 to 4 are based on the competencies identified by Heinen et al (2019) for the four leadership domains ( Hamric et al, 2014 ), and Box 5 gives some generic competencies that span each of these.

Box 1.Clinical leadership

• Provides leadership for evidence-based practice for a range of conditions and specialties
• Promotes health, facilitates self-care management, optimises patient engagement and progression to higher levels of care and readmissions
• Acts as a resource person, preceptor, mentor/coach, and role model demonstrating critical and reflective thinking
• Acts 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
• Analyses organisational systems for barriers and promotes enhancements that affect client healthcare status
• 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
• Acts as a liaison with other health agencies and professionals, and participates in assessing and evaluating healthcare services to optimise outcomes for patients/clients/communities
• Collaborates with health professionals, including physicians, advanced practice nurses, nurse managers and others, to plan, implement and evaluate improvement opportunities
• Aligns practice with overall organisational/contextual goals
• Guides, initiates and leads the development and implementation of standards, practice guidelines, quality assurance, education and research initiatives

Source: adapted from Heinen et al, 2019

Box 2.Professional leadership

• Assumes responsibility for own professional development by education, professional committees and work groups, and contributes to a work environment where continual improvements in practice are pursued
• Participates in professional organisations and activities that influence advanced practice nursing
• Participates in relevant networks: regional, national and international
• Develops leadership in and integrates the role of the nurse practitioner within the healthcare system
• Employs consultative and leadership skills with intraprofessional and interprofessional teams to create change in health care and within complex healthcare delivery systems
• Participates in peer-review activities, eg publications, research and practice

Box 3.Health system leadership

• Contributes to the development, implementation and monitoring of organisational performance standards
• Lead an interprofessional healthcare team with a focus on the delivery of patient-centred care and the evaluation of quality and cost-effectiveness across the healthcare continuum
• Enhances group dynamics, and manages group conflicts within the organisation
• Plans and implements training and provides technical assistance and nursing consultation to health department staff, health providers, policymakers and personnel in other community and governmental agencies and organisations
• Delegates and supervises tasks assigned to allied professional staff
• Creates a culture of ethical standards within organisations and communities
• Identifies internal and external issues that may impact delivery of essential medical and public health services
• Possesses a working knowledge of the healthcare system and its component parts (sites of care, delivery models, payment models and the roles of healthcare professionals, patients, caregivers and unlicensed professionals)

Box 4.Health policy

• Guides, initiates and provides leadership in policy-related activities to influence practice, health services and public policy
• Articulates the value of nursing to key stakeholders and policymakers

Source: Heinen et al, 2019

Box 5.Generic competencies spanning the four domains

• Possesses advanced communication skills/processes to lead quality improvement and patient safety initiatives in healthcare systems
• Uses principles of business, finance, economics, and health policy to develop and implement effective plans for practice-level and/or system-wide practice initiatives that will improve the quality of care delivery
• Advocates for and participates in creating an organisational environment that supports safe client care, collaborative practice and professional growth
• Creates positive healthy (work) environments and maintains a climate in which team members feel heard and safe
• Uses mentoring and coaching to prepare future generations of nurse leaders
• Provides evaluation and resolution of ethical and legal issues within healthcare systems relating to the use of information, information technology, communication networks, and patient care technology

The findings presented in Boxes 1 to 5 provide a research-based scoping of the international literature to identify aspects of leadership competencies connected with advanced nursing practice ( Heinen et al, 2019 ). Revisiting the theoretical differences between leadership and management ( Kotter, 1996 ), it can be appreciated that many of these competencies are blurred, with both existing as part of advanced roles. The clinical, professional and health system domains dominate the number of competencies recorded, giving an idea of the weight given by nurses to different areas of leadership. Competencies relating to the health policy domain were minimal. This is supported by a study describing the leadership capabilities of a sample of 14 advanced practice nurses in Canada using a qualitative descriptive study ( Lamb et al, 2018 ). Two overarching themes describing leadership were identified: ‘patient-focused leadership’ and ‘organisation and system-focused leadership’. Patient-focused leadership comprised capabilities intended to have an impact on patients and families. Organisation and system-focused leadership included capabilities intended to impact nurses, other healthcare providers, the organisation or larger healthcare system. Figure 1 summarises the leadership themes and capability domains identified in Lamb et al's study (2018) .

These findings also support the theory that advanced nurses do not recognise their wide reach as a major leadership part of their roles. In addition, it should be stated that all advanced nursing roles have their own idiosyncrasies based upon the individual practitioner, the environment and organisational needs; there is no ‘one size fits all’.

Multiprofessional working, leadership and the ACP role

With a move in the UK to multiprofessional working, especially in England, and changes towards core advanced practice skills crossing professional boundaries ( HEE, 2021 ) ACPs need proactive skills in cementing their leadership roles within teams. Anderson (2018) advised that successful multiprofessional working needs the individual professional to know the ‘standpoint’ of other professionals to enable their own understanding of complex problems. Edwards (2010) cautioned that professionals may work together and share personal values, but rarely do they work inter-professionally. The ACP role is complex, requiring autonomy and leadership of self within various aspects of the roles required of the individual in distinctive settings, in addition to performing and leading in teams often with professionals from other specialties.

What overt leadership skills may assist in delivery multiprofessional integrated care? Writing from a UK primary care perspective, Swanwick and Varnam (2019) described a necessary shift from the traditional individualistic hierarchical leader, working within and for single teams, to collective leadership encouraging a compassionate and inclusive culture. De Meyer (2011) also advised providing responsible collaborative leadership using the skills of co-operation, listening, influencing, and flexible adaptation, in contrast to what he terms the traditional ‘command and control’ top-down hierarchical approach. It could be suggested that this ‘way of being’ is aligned with the core skills of nurses but these may not be recognised by them as ‘real’ leading.

To ensure the success of the ACP role across the four pillars framework ( HEE, 2021 ) requires that the educational pathway and role has clarity, consistency and standardisation ( Dover et al, 2019 ) so that everyone will feel that they are entering on a level playing field. The framework ( HEE, 2021 ) represents a step forward by providing an overarching structure to align practice and education and creating greater consistency across ACP workforce developments. As the framework is implemented, it will be imperative to have an evaluation of its impact ( Evans et al, 2020 ).

The ACP is tasked with operating at an autonomous advanced level across the four pillars of education, leadership, research and clinical practice, and to be competent in the core capabilities for each pillar. Understanding the ACP role as a level of practice rather than a specific role with the distinguishing feature of autonomy may add clarification. Leadership is a crucial part of the ACP role and advanced nurses therefore need to conduct themselves as leaders so that others can recognise that they embody these skills. Yet, the time has come for all nurses to demonstrate their leadership competencies, collectively as a profession and individually in all settings where they practice. If every nurse is recognised as a leader, the transition to advanced practice will be fluid, streamlined and less of big deal.

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Positive Leadership Behaviors Empower Teams and Effect Change

Wymer, Joshua A. DNP, RN, NEA-BC, FACHE

For more information, contact Dr. Wymer at [email protected] .

The author declares no conflicts of interest.

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