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.’
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
Source: adapted from Heinen et al, 2019
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)
Source: adapted from Heinen et al, 2019
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
Source: adapted from Heinen et al, 2019
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).
Figure 1. Advanced practice nurse leadership themes
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.
Conclusion
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.