DQ 1:
Following completion of this week’s readings, what is your understanding of leadership? Identify and explain at least 3-4 essential qualities generally considered most important in the literature for a nurse to be considered an effective leader (describe these qualities and how they contribute to the effectiveness of a nurse leader. Your responses should stem from assigned course reading, IHI Modules and assigned articles; as well as outside evidence-based sources). Make sure to address how the Quadruple Aim and the Future of Nursing 2020-2030 initiatives influence the role of the nurse leader in today’s healthcare environment. What considerations do nurse leaders need to be cognizant of that might not have been as critical 10 years ago?
What qualities do you feel a nurse leader should possess and why? Compare and contrast, provide scenarios or examples comparing good versus bad nursing leadership (feel free to use examples from personal experiences and observations without; anonymously of course) to illustrate the point of poor and ineffective versus good and effective nursing leadership. What did you learn from this experience and how does it help shape your understanding of your role as a potential and effective nursing leader? Are nurse managers the same as nurse leaders?
POWERPOINTS TO ACCOMPANY
Nurse Leadership and Management
Foundations for Effective Administration
Joyce J. Fitzpatrick, PhD, MBA, RN, FAAN, FNAP, FAANP(H)
Celeste M. Alfes, DNP, MSN, MBA, RN, CNE, CHSE-A, FAAN
Editors
Chapter 3: Nurse Manager and Leader
Competencies
Linda Q. Everett and Benjamin J. Farber
© Springer Publishing Company, LLC.
1
Learning Objectives
• Describe the meaning and relevance of nurse leader competency.
• Understand nurse leader competency within the broader context of healthcare leadership competencies.
• Differentiate frameworks for nurse leader competencies.
• Critique the similarities and differences among frameworks for nurse leader competencies.
• Investigate emerging competencies that will be required in the future.
© Springer Publishing Company, LLC.
2
Leadership Competencies
• Historically, most literature on nursing competencies has focused on clinical care
• Successful leadership requires competency in areas such as quality and safety, finance, legal, human
resources, staff engagement, and patient and family satisfaction
• The current standard for nurse leader competencies:
• American Organization for Nursing Leadership (AONL)
– Nurse Executive Competencies (NEC)
– Nurse Manager Competencies (NMC)
• American Nurses Association (ANA)
– Nursing Administration Scope and Standards of Practice
© Springer Publishing Company, LLC.
3
AONL’s Five Domains of Nurse Executive Competencies
• AONL’s Five Domains:
•
•
•
•
•
Communications and relationship management
Professionalism
Leadership
Knowledge of the healthcare environment
Business skills and knowledge
• Traits that a chief nursing officer (CNO) must possess
• Super integrator
– Dynamic, driven, and determined
– Realistic
– Well-educated and experienced
• Additional nursing leadership frameworks to validate competencies
• Quality and Safety Education for Nurses (QSEN)
• American Academy of Colleges of Nursing (AACN)
• Institute of Medicine—enhanced skills: understanding of data, financial acumen, collaboration, innovation, and change
management
© Springer Publishing Company, LLC.
4
Nurse Manager Competencies
• AONL NMC—three domains:
• The Science—Managing the business; hard skills that can be studied or learned Professionalism
• The Art—Leading the people; soft skills learned over time through life and job experience Knowledge of the healthcare
environment
• The Leader Within—Creating the leader in oneself; personal and professional growth, career planning, personal journey,
and discipline
• QSEN Competencies (KSA)
• Knowledge
• Skills
• Attitude
• AACN Essentials
• 2021 The Essentials: Core Competencies for Professional Nursing Education
• Designed to bridge the gap between education and practice
© Springer Publishing Company, LLC.
5
Formal Nurse Executive Competencies
• Strategies to cultivate and develop leadership competencies
• Formal academic courses (self and peer assessments)
• Membership in professional associations
• Networking with peers and colleagues a key benefit to membership
• Manager and executive level leadership
• Interprofessional healthcare teams
• Advancements in sciences require nurse leaders to collaborate with other members of healthcare team
• Example: COVID-19 response required team efforts
• Mentoring
• Mentorship and coaching are extremely important in directing nurse leaders’ careers
• Considered a competency of nurse leadership
• Relationships can be formal or informal
© Springer Publishing Company, LLC.
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System Chief Nurse Executive
• Accountable for system wide and corporate leadership
• Reports to system president/chief executive officer (CEO)/chief operating officer (COO)
• Serves as boundary spanner across multiple facilities and care settings
© Springer Publishing Company, LLC.
7
Implications for Organizations
• Evidence-based professional competencies serve to guide talent management
• Learnings from 2020 to 2021 are applied to the healthcare organizations of tomorrow
• Emphasis on competencies related to nurse well-being and healthy work environments
© Springer Publishing Company, LLC.
8
Humane Competencies
• Diversity, equity, and inclusion (DEI)
• DEI programs are a vital competency for nurse managers and executives
• Healthcare inequities
•
•
•
•
Mismatch of nursing workforce and the patient population they serve
Lack of Black, indigenous, and people of color in nursing leadership
Lack of racial equity in nursing contributes to healthcare inequities
Leaders commit to building a culture that supports racial equity
© Springer Publishing Company, LLC.
9
Health Disparities and Social Inequities
• Nurse leaders need to identify and eliminate barriers that contribute to disparities
• Nurse leaders recognize role a patient’s circumstances play in their health
• Leaders need to influence policy makers
• Increase access
• Changes to the pay for performance (PFP) programs—consider social disparities when payments are calculated
© Springer Publishing Company, LLC.
10
POWERPOINTS TO ACCOMPANY
Nurse Leadership and Management
Foundations for Effective Administration
Joyce J. Fitzpatrick, PhD, MBA, RN, FAAN, FNAP, FAANP(H)
Celeste M. Alfes, DNP, MSN, MBA, RN, CNE, CHSE-A, FAAN
Editors
Chapter 2: Professionalism
Germaine C. Nelson
© Springer Publishing Company, LLC.
1
Learning Objectives
• Define professionalism, self-care, and mindfulness.
• Differentiate leadership and management behaviors that build professionalism within individuals, teams,
mentees, and organizations.
• Apply the elements of advocacy and support with individuals and groups with information to build
advocacy involvement and foundational precepts.
• Formulate individual and team strategies to engage in wellness, self-care and mindfulness practices.
© Springer Publishing Company, LLC.
2
Professionalism
• Standards of practice
• Promote health, prevent illness, restore health, alleviate suffering
• Nurse leaders enhance the maintenance of professional standards
– Maintaining competencies of leadership, professionalism, business skills and principles, relationship management,
knowledge of healthcare
• The nursing profession requires adherence to ethics, integrity, and accountability
• Engaging with ANA’s Center for Ethics and Human Rights
• Practicing skillful decision-making
• Creating an ethical culture
© Springer Publishing Company, LLC.
3
Organizational Role in Ethical Standards and Professionalism
• Mission and vision statement
• Compliance processes support the organization’s mission and vision
• Employee handbooks outline expected behaviors
• Nurse executive competencies dictate that nurse leaders:
• Uphold ethical principles and corporate compliance standards
• Hold staff and self accountable to comply with ethical standards
• Discuss, resolve, and learn from ethical dilemmas
© Springer Publishing Company, LLC.
4
Professionalism and Ethics at the Individual Level
• Continual assessment of one’s strengths,
weaknesses, opportunities, and threats (SWOT)
Figure 2.2. Flow for individual development of
ethics knowledge and competency.
(cont.)
© Springer Publishing Company, LLC.
5
Professionalism and Ethics at the Individual Level (cont.)
• Nurses need to be critically aware of codes of conduct directly linked to social media, publications,
and verbal dialogue (e.g., podcasts)
• Practice purposeful and deliberate posting
• Follow ANA guiding principles for social networking
• One’s professional image and reputation is maintained and curated daily
© Springer Publishing Company, LLC.
6
Advocacy
• Advocacy during the pandemic
• Available PPE
• Masking requirements
• ANA political action committee (PAC)
• Political engagement
• Nurses’ Day at the Capital
• Advocacy through membership
• Professional membership allows nurses to engage with peers on common interest
– Common clinical expertise
– Development and dissemination of research
– Drafting of position statements
• The nurse researcher’s role
– Conducting studies, participating in research, or participating in professional organizations that promote research is a
competency and goal when building professional advocacy
© Springer Publishing Company, LLC.
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Exemplary Professional Practice and Professionalism
• ANCC Magnet Criteria for Nursing Excellence
• The true essence of a magnet organization stems from professional exemplary practice within nursing
• Incorporates patients, patient-centered care, interprofessional collaboration practice, patient safety,
and autonomy into the organizational nursing practice
© Springer Publishing Company, LLC.
8
Equity, Social Justice, and Allyship
• Fairness, equality, and inclusion
• Racism declared a serious public health threat
• The George Floyd murder
• Health disparities brought to light during the COVID-19 pandemic
• The nursing profession is poised to address equity, social justice, and allyship
© Springer Publishing Company, LLC.
9
Cultural Humility, Inclusivity, and Access
• Providing care that is equitable and culturally competent
• Caring for patients as individuals and treating based on life experiences
• Never making care-related determinations based on appearance or presumed ethnic group affinity
• Nurse leaders must understand the community they serve
© Springer Publishing Company, LLC.
10
Healthcare Teams and Executive Presence
• Professionalism found in high-functioning executive triad (i.e., executive-nursing, executive-physician,
financial operations leadership) and dyad (nursing-physician) teams
• Committed to collaboration and coalition building
• Optimize strategy for positive patient, family, community engagement experience
• Engage the community
– Allowing the voice of the patient and the family to be heard
– Continuing investment in population health
• Executive presence
•
•
•
•
Ability to inspire others
Gravitas—leadership quality that conveys confidence and decisiveness
High level and consistent communication
Emphasis on building competencies, networking, and managing opportunities
© Springer Publishing Company, LLC.
11
Mentorship
• Identifying mentors, allies, and sponsors is key to professional development
• Mentors help navigate through challenging times
• Mentorships are bidirectional relationships
• Sustaining a successful mentoring relationship is enhanced by:
• Designing the alliance
• Getting to know one another
• Setting the agenda—SMART goals
© Springer Publishing Company, LLC.
12
Sponsorship
• Sponsors are typically in a position of influence or authority
• Sponsorship supports the individual and organization with succession planning
• Identifying and developing future leaders
• Succession planning is a key element to employee engagement and organization sustainability
© Springer Publishing Company, LLC.
13
POWERPOINTS TO ACCOMPANY
Nurse Leadership and Management
Foundations for Effective Administration
Joyce J. Fitzpatrick, PhD, MBA, RN, FAAN, FNAP, FAANP(H)
Celeste M. Alfes, DNP, MSN, MBA, RN, CNE, CHSE-A, FAAN
Editors
Chapter 1: Leading in Challenging Times
Angela S. Prestia
© Springer Publishing Company, LLC.
1
Learning Objectives
• Summarize the importance of perpetual readiness.
• Demonstrate understanding of the concept and complexities of courageous caring.
• Experiment with strategies to approach failed predictions and daily challenges.
• Create a mission critical checklist for daily use.
© Springer Publishing Company, LLC.
2
Leadership Character in Challenging Times
• The nurse leader readies themself as warrior
• Courageous caring; caring leadership
• A commitment to positive change and forward progress
• Mental and moral fortitude—“guts and nerves”
• Relentless commitment to those served
• Moral character
• Moral courage—willingness to take risk-laden action
• American Nurses Association
– Courageously caring nurse leaders are obligated to preserve the integrity of the profession
– Held to higher level of ethical standards
• Self-care—intentional practice of proper nutrition, hydration, physical and mental rest, exercise, and the expression of
gratitude
• Authentic presence
© Springer Publishing Company, LLC.
3
Authentic Presence
• Three elements of caring leadership comportment:
• How you act (67%)
• How you speak (28%)
• How you look (5%)
Table 1.1. Impactful Messaging
Messaging Type
Definition
Example
Truthful
Verify the facts knowing that they can be
fluid
“As of the end of quarter 1, HCAHPS scores for Nurse
Listened exceeded the target!”
Mindful
Consideration for the composition of the
audience
“I realize the majority of the ICU staff in attendance have over
10 years’ experience in the critical care specialty.”
Relevant
Messages that speak directly to the
individual or audience.
“I want to publicly thank the Emergency Department staff for
their performance during the recent Code Black.”
© Springer Publishing Company, LLC.
4
Preparing for Challenges
• Preparedness requires leadership investment
• Self-investment (e.g., advanced degrees, certifications)
• Developing a cache of resources to depend on in anticipation of future needs
• Awareness of political agendas and acknowledgement of political issues will assist in planning for their impact on healthcare
– Economy
– Racial injustice
– Tackling pandemics
– Climate change
(cont.)
© Springer Publishing Company, LLC.
5
Preparing for Challenges (cont.)
• The courageous caring leader consciously assimilates the aims of global healthcare think tanks
• Institute for Healthcare Improvement (IHI); the Quadruple Aim
• The Future of Nursing 2020–2030
• The nurse leader can proactively plan for challenging times by staying current on technological advances
• Knowledge of IT annual reports
• Participation in conferences
• Weekly/daily updates from the Chief Clinical Officer/Nurse Informaticist
© Springer Publishing Company, LLC.
6
Nurse Leadership Mission Critical Checklist
1. Committing to Evidence
• Avoiding emotional decision-making
• Using evidence to ground all practice
2. Preserving Patient Individuality
• Maintaining sight of quality patient care
• Making families and patients a part of nurse leaders’ presence and rounding
• Ensuring processes exist to secure living wills, advance directives
3. Preserving Staff Individuality
• Creating hope in staff, ensuring staff know they are “known and supported”
• Recognizing individuals’ value and contributions
(cont.)
© Springer Publishing Company, LLC.
7
Nurse Leadership Mission Critical Checklist (cont.)
4. Improving the Patient Experience—Quality and Safety
• Ensuring safe, effective, quality care
– Individualized and aligned with patient goals
• Providing and sustaining a healthy work environment
• Removing barriers to safe, quality care
– Workplace incivility
– Generational differences
– Lack of utilizing best practices
– Forgetting the centrality of the patient
• Accessing and leveraging data
– Limited access to data limits the nurse leader’s power to effect change
– Data requires reporting transparency
– Requires courageous acceptance of information
(cont.)
© Springer Publishing Company, LLC.
8
Nurse Leadership Mission Critical Checklist (cont.)
5. Communication
• Inviting dialogue that is free from negative personal emotion
• Addressing issues that are relevant with examples (data)
• Providing data to support discussion
6. Improving the Staff Experience
• Taking steps to help staff to discover and sustain joy and meaning in work
– Asking “What matters to you…” and not fearing the answer
– Identifying unique impediments to joy in the work within local context
– Encouraging shared responsibility in improving joy in work at all levels of the organization
– Using improvement science to test approaches to improving joy in the workplace
(cont.)
© Springer Publishing Company, LLC.
9
Nurse Leadership Mission Critical Checklist (cont.)
7. Healthcare Cost
•
•
Understanding and ensuring organization solvency
– Monies available to provide quality care to the community and meaningful work
Understanding and making decisions related to cost
– Census trends in development of staffing
– Agency staffing usage
– Antibiotic stewardship
– Capital expenditures
– Minor equipment changes
– Technology
– Robust retention strategies
8. Relationship Building
•
Participating in behaviors that build relationships
– Practicing self-care
– Creating space for reflection
– Networking
– Providing and seeking resources for emotional support
© Springer Publishing Company, LLC.
10
COMMUNICATION
KNOWLEDGE
LEADERSHIP
PROFESSIONALISM
BUSINESS SKILLS
Nurse Executive
Competencies
Suggested APA Citation: AONE, AONL. (2015). AONL Nurse Executive Competencies. Chicago, IL: AONE, AONL.
Accessed at: www.aonl.org
Accessible at: www.aonl.org/competencies
Contact: aonl@aha.org or (312) 422-2800
© 2015 American Organization of Nurse Executives (AONE), American Organization for Nursing Leadership (AONL). All materials contained in
this publication are available to anyone for download on www.aonl.org, for personal, non-commercial use only. No part of this publication may
be reproduced and distributed in any form without permission of AONL, except in the case of brief quotations followed by the above suggested
citation. To request permission to reproduce this material, please email aonl@aha.org.
2
AONL NURSE EXECUTIVE COMPETENCIES
©2015 AONE, AONL
OVERVIEW
N
urse Leaders in executive practice set
the vision for nursing practice in the
delivery of safe, timely, efficient, equitable
and patient-centered care. Working within
a collaborative and interprofessional
environment, the nurse in executive
practice is influential in improving the
patient experience of care (including quality
and satisfaction), improving the health of
populations and reducing the per capita cost
of health care.
The AONL Nurse Executive Competencies
detail the skills knowledge and abilities that
guide the practice of nurse leaders in executive
practice regardless of their educational
level, title or setting. The competencies are
captured in a model developed in 2004 by the
Healthcare Leadership Alliance1 that identify
the common core set of competency domains
for health care leadership: communication
and relationship management; knowledge
of the health care environment; leadership;
professionalism; business skills and principles.
Members include the American Organization for Nursing Leadership, The American College of Healthcare Executives, American Association for
Physician Leadership, Healthcare Financial Management Association, Healthcare Information and Management Systems Society, and Medical
Group Management Association.
1
Reliability and validity for the AONL Nurse Executive Competencies is established by periodic job analysis/role delineation studies. These
competencies are based on A National Practice Analysis Study of the Nurse Executive (2014).
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AONL NURSE EXECUTIVE COMPETENCIES
©2015 AONE, AONL
1
COMMUNICATION AND
RELATIONSHIP BUILDING
A. EFFECTIVE COMMUNICATION
Make oral presentations to diverse
audiences on:
»» Nursing
»» Health care topics
»» Organizational issues
Produce written materials for diverse
audiences on:
»» Nursing
»» Health care topics
»» Organizational issues
Facilitate group discussions
Demonstrate skill in interpersonal
communication
B. RELATIONSHIP MANAGEMENT
Build collaborative relationships
Exhibit effective conflict resolution skills
Create a trusting environment by:
»» Following through on promises and
concerns
»» Establishing mechanisms to follow-up on
commitments
»» Balancing the concerns of individuals with
organizational goals and objectives
»» Engaging staff and others in decisionmaking
»» Communicating in a way as to maintain
credibility and relationships
C. INFLUENCING BEHAVIORS
Assert views in non-threatening, nonjudgmental ways
Create a shared vision
Facilitate consensus building
Inspire desired behaviors and manage
undesired behaviors
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AONL NURSE EXECUTIVE COMPETENCIES
Achieve outcomes through engagement of
stakeholders
Promote decisions that are patient-centered
Apply situational leadership skills
D. DIVERSITY
Establish an environment that values
diversity (e.g. age, gender, race, religion,
ethnicity, sexual orientation, culture)
Establish cultural competency in the
workforce
Incorporate cultural beliefs into care delivery
Provide an environment conducive to
opinion sharing, exploration of ideas and
achievement of outcomes
E. COMMUNITY INVOLVEMENT
Represent the organization to non-health
care constituents within the community
Serve as a resource to community and
business leaders regarding nursing and
health care
Represent the community perspective in
the decision-making process within the
organization/system
Represent nursing to the media
Serve on community-based boards, advisory
groups, and task forces
F. MEDICAL/STAFF RELATIONSHIPS
Build credibility with physicians as a
champion for patient care, quality and the
professional practice of nursing
Confront and address inappropriate or
disruptive behavior towards patients
and staff
Represent nursing at medical executive
committee and other department/medical
staff committees
©2015 AONE, AONL
1
COMMUNICATION AND RELATIONSHIP BUILDING
Collaborate with medical staff leaders and
other disciplines in determining needed
patient care service lines
Collaborate with physicians and other
disciplines to develop patient care protocols,
policies and procedures
Collaborate to determine patient care
equipment and facility needs
Use medical staff mechanisms to address
physician clinical performance issues
Address and model appropriate conflict
resolution
Create opportunities for physicians and
nurses to engage in professional dialogue
5
AONL NURSE EXECUTIVE COMPETENCIES
G. ACADEMIC RELATIONSHIPS
Determine current and future supply and
demand for nurses to meet the care delivery
needs
Identify educational needs of existing and
potential nursing staff
Collaborate with nursing programs to
provide required resources
Collaborate with nursing programs in
evaluating quality of graduating clinicians
and develop mechanisms to enhance this
quality
Serve on academic advisory councils
Collaborate in nursing research and translate
evidence into practice
Collaborate to investigate care delivery
models across the continuum
Create academic partnerships to ensure a
qualified workforce for the future
©2015 AONE, AONL
2
KNOWLEDGE OF THE HEALTH
CARE ENVIRONMENT
A. CLINICAL PRACTICE KNOWLEDGE
Demonstrate knowledge of current nursing
practice and the roles and functions of
patient care team members
Communicate patient care standards as
established by accreditation, regulatory and
quality agencies
Ensure compliance with the State Nurse
Practice Act, State Board of Nursing
regulations, state and federal regulatory
agency standards, federal labor standards
and policies of the organization
Adhere to professional association
standards of nursing practice
Ensure that written organizational clinical
policies and procedures are reviewed and
updated in accordance with evidence-based
practice
Integrate bioethical and legal dimensions
into clinical and management
decision-making
Ensure protection of human subject rights
and safety in clinical research
B. DELIVERY MODELS / WORK DESIGN
Demonstrate current knowledge of patient
care delivery systems across the continuum
Describe various delivery systems and ageappropriate patient care models and the
advantages/disadvantages of each
Assess the effectiveness of delivery models
Develop new delivery models
Participate in the design of facilities
C. HEALTH CARE ECONOMICS AND POLICY
Understand regulation and payment issues
that affect an organization’s finances
Describe individual organization’s payer mix,
CMI and benchmark database
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AONL NURSE EXECUTIVE COMPETENCIES
Align care delivery models and staff
performance with key safety and economic
drivers (e.g., value-based purchasing,
bundled payment)
Take action when opportunities exist to
adjust operations to respond effectively
to environmental changes in economic
elements
Use knowledge of federal and state laws
and regulations that affect the provision of
patient care (e.g., tort reform, malpractice/
negligence, reimbursement)
Participate in legislative process on health
care issues through such mechanisms as
membership in professional organization
and personal contact with officials
Educate patient care team members on the
legislative process, the regulatory process
and methods for influencing both
Interpret impact of legislation at the state
and federal level on nursing and health care
organizations
D. GOVERNANCE
Use knowledge of the role of the governing
body of the organization in the following
areas:
»» Fiduciary responsibilities
»» Credentialing
»» Performance management
Represent patient care issues to the
governing body
Participate in strategic planning and quality
initiatives with the governing body
Interact with and educate the organization’s
board members regarding health care and
the value of nursing care
Represent nursing at the organization’s
board meetings
Represent other disciplines at the
organization’s board meetings
©2015 AONE, AONL
2
KNOWLEDGE OF THE HEALTH CARE ENVIRONMENT
E. EVIDENCE-BASED PRACTICE/OUTCOME
MEASUREMENT AND RESEARCH
Use data and other sources of evidence to
inform decision making
Use evidence for establishment of
standards, practices and patient care models
in the organization
Design feedback mechanisms by which to
adapt practice based upon outcomes from
current processes
Design and interpret outcome measures
Disseminate research findings to patient
care team members
Allocate nursing resources based on
measurement of patient acuity/care needed
Monitor and address nurse sensitive
outcomes and satisfaction indicators
F. PATIENT SAFETY
Support the development of an
organization-wide patient safety program
Use knowledge of patient safety science
(e.g., human factors, complex adaptive
systems, LEAN and Six Sigma)
Monitor clinical activities to identify both
expected and unexpected risks
Support a Just Culture (non-punitive)
reporting environment, supporting a reward
system for identifying unsafe practices
Support safety surveys, responding and
acting on safety recommendations
Lead/facilitate performance improvement
teams to improve systems/processes that
enhance patient safety
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AONL NURSE EXECUTIVE COMPETENCIES
G. PERFORMANCE IMPROVEMENT/METRICS
Articulate the organization’s performance
improvement program and goals
Use evidence-based metrics to align patient
outcomes with the organization’s goals and
objectives
Apply high reliability concepts for the
organization
Establish quality metrics by
»» Identifying the problem/process
»» Measuring success at improving specific
areas of patient care
»» Analyzing the root causes or variation
from quality standards
»» Improving the process with the evidence
»» Controlling solutions and sustaining
success
H. RISK MANAGEMENT
Identify areas of risk/liability
Facilitate staff education on risk
management and compliance issues
Develop systems that result in prompt
reporting of potential liability by staff at all
levels
Identify early warning predictability
indications for errors
Correct areas of potential liability
Ensure compliance by staff with all required
standards
©2015 AONE, AONL
3
LEADERSHIP
A. FOUNDATIONAL THINKING SKILLS
Address ideas, beliefs or viewpoints that
should be given serious consideration
Recognize one’s own method of decision
making and the role of beliefs, values and
inferences
Apply critical analysis to organizational
issues after a review of the evidence
Maintain curiosity and an eagerness to
explore new knowledge and ideas
Promote nursing leadership as both a
science and an art
Demonstrate reflective practice and an
understanding that all leadership begins
from within
Provide visionary thinking on issues that
impact the health care organization
D. SUCCESSION PLANNING
Develop a leadership succession plan
Promote nursing leadership as a desirable
specialty
Mentor current and future nurse leaders
Establish mechanisms that provide for early
identification and mentoring of staff with
leadership potential
Develop a workforce analysis plan and
implement strategies to ensure an adequate
and qualified workforce
E. CHANGE MANAGEMENT
Adapt leadership style to situation needs
Use change theory to implement change
Serve as a change leader
B. PERSONAL JOURNEY DISCIPLINES
Learn from setbacks and failures as well
as successes
C. SYSTEMS THINKING
Use knowledge of classic and contemporary
systems thinking in problem solving and
decision making
Provide visionary thinking on issues that
impact the healthcare organization
Recognize the contribution of mental
models on behavior
Promote systems thinking as an expectation
of leaders and staff
Consider the impact of nursing decisions on
the healthcare organization as a whole
Use resources from other paradigms
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AONL NURSE EXECUTIVE COMPETENCIES
©2015 AONE, AONL
4
PROFESSIONALISM
A. PERSONAL AND PROFESSIONAL
ACCOUNTABILITY
Hold self and others accountable for mutual
professional expectations and outcomes
Contribute to the advancement of the
profession
Participate in and contribute to professional
organizations
Demonstrate and promote leader and staff
participation in professional organizations
Promote leader and staff participation
in lifelong learning and educational
achievement
Achieve and maintain professional
certification for self
Promote professional certification for staff
Role model standards of professional
practice (clinical, educational and leadership)
for colleagues and constituents
C. ETHICS
Uphold ethical principles and corporate
compliance standards
Hold self and staff accountable to comply
with ethical standards of practice
Discuss, resolve and learn from ethical
dilemmas
D. ADVOCACY
Promote clinical perspective in
organizational decisions
Involve nurses and other staff in decisions
that affect their practice
Represent the perspective of patients and
families
Advocate for optimal health care in the
community
B. CAREER PLANNING
Coach others in developing their own career
plans
Seek input and mentorship from others in
career planning and development
Develop a personal and professional career
plan and measure progress
Solicit feedback about personal strengths
and weaknesses
Act on feedback about personal strengths
and weaknesses
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AONL NURSE EXECUTIVE COMPETENCIES
©2015 AONE, AONL
5
BUSINESS SKILLS
A. FINANCIAL MANAGEMENT
Develop and manage an annual operating
budget and long-term capital expenditure
plan
Use business models for health care
organizations and apply fundamental
concepts of economics
Interpret financial statements
Manage financial resources
Ensure the use of accurate charging
mechanisms
Educate patient care team members
on financial implications of patient care
decisions
Participate in the negotiation and monitoring
of contract compliance (e.g., physicians,
service providers)
B. HUMAN RESOURCE MANAGEMENT
Ensure development of educational
programs to foster workforce competencies
and development goals
Participate in workforce planning and
employment decisions
Use corrective discipline to mitigate
workplace behavior problems
Evaluate the results of employee
satisfaction/quality of work environment
surveys
Support reward and recognition programs to
enhance performance
Formulate programs to enhance work-life
balance
Interpret and ensure compliance with legal
and regulatory guidelines
Provide education regarding components of
collective bargaining
Promote healthful work environments
Address sexual harassment, workplace
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AONL NURSE EXECUTIVE COMPETENCIES
violence, verbal and physical abuse
Implement ergonomically sound work
environments to prevent worker injury and
fatigue
Develop and implement emergency
preparedness plans
Analyze market data in relation to supply
and demand
Contribute to the development of
compensation programs
Develop and evaluate recruitment,
onboarding, and retention strategies
Develop and implement an outcome-based
performance management program
Develop and implement programs to reeducate the workforce for new roles
C. STRATEGIC MANAGEMENT
Create the operational objectives, goals and
specific strategies required to achieve the
strategic outcome
Conduct SWOT and Gap analyses
Defend the business case for nursing
Utilize the balanced scorecard analysis to
manage change
Evaluate achievement of operational
objectives and goals
Identify marketing opportunities
Develop marketing strategies in
collaboration with marketing experts
Promote the image of nursing and the
organization through effective media
relations
©2015 AONE, AONL
5
BUSINESS SKILLS
D. INFORMATION MANAGEMENT
AND TECHNOLOGY
Use technology to support improvement of
clinical and financial performance
Collaborate to prioritize for the
establishment of information technology
resources
Participate in evaluation of enabling
technology in practice settings
Use data management systems for decision
making
Identify technological trends, issues and
new developments as they apply to
patient care
Demonstrate skills in assessing data
integrity and quality
Provide leadership for the adoption and
implementation of information systems
11
AONL NURSE EXECUTIVE COMPETENCIES
©2015 AONE, AONL
leadership /
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evidence & practice
Why you should read this article:
●● To enable you to outline the various types and characteristics of leadership
●● To understand the importance of effective nurse leadership and its effect on patient care
●● To identify ways to enhance your leadership skills and apply these in your everyday practice
Developing effective nurse leadership
skills
Denise Major
Citation
Major D (2019) Developing
effective nurse leadership
skills. Nursing Standard.
doi: 10.7748/ns.2019.e11247
Peer review
This article has been subject
to external double-blind
peer review and checked
for plagiarism using
automated software
Correspondence
denise.major@salisbury.nhs.uk
@denisemajor4
Conflict of interest
None declared
Accepted
9 August 2018
Published online
February 2019
Permission
To reuse this article or for
information about reprints
and permissions, contact
permissions@rcni.com
nursingstandard.com
Abstract
Leadership is a role that nurses are expected to fulfil, regardless of their job title and experience.
Nurses are required to lead and manage care as soon as they have completed their training. However,
the development of leadership skills and the associated learning can be challenging, especially for less
experienced nurses and those at the beginning of their careers. This article examines the importance of
effective leadership for nurses, patients and healthcare organisations, and outlines some of the theories
of leadership such as transformational leadership. It also details how nurses can develop their leadership
skills, for example through self-awareness, critical reflection and role modelling.
Author details
Denise Major, deputy director of nursing, Salisbury NHS Foundation Trust, Salisbury, Wiltshire, England
Keywords
clinical leadership, leadership development, leadership frameworks, leadership models, leadership skills,
transformational leadership
Optimal leadership is fundamental to the
successful provision of healthcare services
because of its effect on healthcare professionals
and patients. Optimal leadership contributes
to an engaged and positive staff culture, which
results in high levels of patient satisfaction and
enhanced outcomes (NHS Leadership Academy
2011, Gopee and Galloway 2014, Jonas et al
2017). Some newly qualified nurses consider
leadership to be the responsibility of senior staff
only; however, The Code: Professional Standards
of Practice and Behaviour for Nurses, Midwives
and Nursing Associates (Nursing and Midwifery
Council (NMC) 2018a) states that all nurses
‘should be a model of integrity and leadership
for others to aspire to’, which means that nurses
should be able to lead at any stage of their career
(Bally 2007, Chaffer 2016).
Healthcare settings are often fast-paced,
complex and high-pressure environments;
therefore, nurses require organisational and
communication skills that can be applied to
a range of scenarios. This means that nurse
leadership is required during every shift. Nurses
are required to make decisions, delegate, act as
role models and influence colleagues; however,
some nurses might be unintentionally influenced
by one leadership style early in their career.
Newly qualified nurses are just beginning
their leadership pathway and will have to
identify and develop a leadership style that is
suitable for them.
Importance of effective leadership
The level of leadership across healthcare systems
can have positive and negative outcomes, and
in the past decade there have been various
inquiries into suboptimal care. The Report
of the Mid Staffordshire NHS Foundation
Trust Public Inquiry (Francis 2013) identified
a failure to ‘tackle an insidious negative
culture involving a tolerance of poor standards
and a disengagement from managerial and
leadership responsibilities’. The suboptimal care
identified at Mid Staffordshire NHS Foundation
Trust, alongside ongoing negative coverage
in the media, threatened to undermine public
confidence in the nursing profession (Chaffer
2016). It should be noted that the challenges
identified at Mid Staffordshire NHS Foundation
Trust were not an isolated example of suboptimal
organisational and professional leadership.
For example, the Department of Health (DH)
(2012a) report Transforming Care: A National
Response to Winterbourne View Hospital
detailed the abuse of people with learning
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disabilities, which were attributed
to ‘a wider catalogue of failings at
all levels’.
It is widely recognised that
the complexity of organisational
structures such as healthcare
organisations commonly contribute
to failings in leadership (Chaffer
2016, Jonas et al 2017). Confusion
about accountability across roles,
rapid change and disagreement
about what constitutes optimal
leadership can result in a lack of
clarity around leadership (Bennis
and Nanus 1985, Jones and Bennett
2012). This lack of clarity can be
further compounded by unclear
organisational values and strategic
direction, as well as mixed messages
regarding acceptable behaviour
(Long 2017). To provide clarity
around values and behaviour, the
Francis (2013) report recommended
that: ‘The core values expressed
in the NHS Constitution should
be given priority of place and the
overriding value should be that
patients are put first, and everything
done by the NHS and everyone
associated with it should be
informed by this ethos.’
It is important that nurses develop
the ability to learn from failure
and consider how optimal practice
can be applied on a day-to-day
basis (Gopee and Galloway 2014,
Jonas et al 2017).
Nurses can use the questions in
Box 1 to determine whether there
Box 1. Questions that nurses
can use to identify clear and
effective leadership in their
organisation
»»Does your organisation have a culture
of learning? How can you identify this?
For example, is there transparency and
are lessons learned from incidents and
complaints, and do you feel confident to
raise concerns?
Do you see team-working across
professional groups? Is there a culture of
person-centred care? If so, in what way
can you describe these?
Can you find and articulate the corporate
objectives, values and vision of your
organisation?
Do you feel that the human resources
in your organisation – such as staff
health and well-being, management of
absence, learning and development, and
being listened to – are supportive and
understandable?
»»
»»
»»
62 / June 2019 / volume 34 number 6
is clear and effective leadership in
their organisation.
Leadership theories and
characteristics
The concepts of management
and leadership have distinct
characteristics, but are often used
interchangeably. In simple terms,
management is a process of ‘making
things happen’ and provides
order and consistency, resulting
in the direction of resources and
people to provide services (Wattis
and Curran 2011, Long 2017).
However, leadership reflects the
‘development of a shared vision’
and can be described as visionary,
innovative, values-based and
strategic (Wattis and Curran
2011). A leader should be able to
see the ‘bigger picture’ while also
focusing on individuals (Gopee
and Galloway 2014). However,
too much emphasis on either
management or leadership can be
harmful (Long 2017). For example,
a leader with a comprehensive plan,
but who attempts to implement
change without a vision, or who
fails to engage staff, is unlikely to
achieve successful change. Similarly,
an innovative leader who attempts
to implement change without
order and consistency is unlikely to
deliver their strategic vision. Both
of these scenarios will result in
unsatisfactory service provision and
disillusioned staff members.
Box 2 provides an overview of
some of the leadership theories
that have been developed, which
consider various leadership styles
and the characteristics of an
effective leader. Leadership theories
can assist nurses to question their
behaviour, whether leadership can
be taught, and whether particular
styles of leadership may be more or
less effective. Essentially, there is no
‘right’ or ‘wrong’ style of leadership
and when applied to the complex
scenarios that may be experienced
in healthcare settings, a mixture of
leadership styles may be required.
Transformational leadership
Transformational leadership
is commonly identified in the
literature as an effective approach
to nurse leadership (Daly et al 2014,
Paterson et al 2015). The qualities
of a transformational leader include
(Cope and Murray 2017):
»»Democratic – sharing
responsibilities with
their followers.
»»Target-orientated – setting clear
expectations for their followers.
»»Intellectually stimulating
– influencing followers to
develop new ideas.
»»Visionary – able to actively
promote and articulate a vision.
Jones and Bennett (2012) described
transformational leadership as being
‘concerned with engaging the hearts
and minds of staff. It aims to help
individuals and groups achieve
greater motivation, satisfaction and
a sense of achievement [starting
with] the development of a vision,
a view of the future that will inspire
potential followers.’
An important element of
transformational leadership, as
opposed to transactional leadership,
is that the transformational leader
is not required to be in a position
of power and is not dependent
on a hierarchy (Gopee and
Galloway 2014). In addition,
transformational leadership
aims to foster a culture of selfawareness and confidence, and
the empowerment of front-line
Box 2. Overview of
leadership theories
»»Trait theories – identify the
characteristics of successful leaders
and non-leaders. These theories debate
whether there are individuals who are
‘born leaders’
Functional theories – concentrate on the
function of the leader, rather than their
characteristics. These theories support
the development of leadership skills
through training
Style theories – examine the patterns
and styles of behaviour that the leader
exhibits when undertaking their role
(function) on a day-to-day basis. These
theories suggest that learning from
experience may result in changes to
style and behaviour. Examples include
‘authoritarian’, ‘democratic’, ‘permissive’
and ‘bureaucratic’ leadership
Contemporary theories – evolved
from earlier theories and incorporate
political and organisational factors.
Examples include ‘charismatic’,
‘connective’, ‘servant’, ‘transactional’ and
‘transformational’ leadership
»»
»»
»»
(Adapted from Gopee and Galloway 2014,
Swanick 2017)
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staff contributes to effective
leadership across organisational
boundaries. Compared with
other leadership styles,
transformational leadership is
regarded as having the most
positive effect on junior staff
(West et al 2015).
Care and compassion
In December 2012, the DH (2012b)
published Compassion in Practice:
Nursing, Midwifery and Care Staff:
Our Vision and Strategy, which
recognised that nurses are central
to healthcare provision across all
healthcare settings and at all stages
of health and illness. Central to
this strategy is the recognition
that the 6Cs – care, compassion,
competence, communication,
courage and commitment – are
fundamental to the philosophy of
nursing. The document stated that
each nurse should regard themselves
as ‘leaders in our care setting and
role model the 6Cs in our everyday
care of patients’ (DH 2012b).
West et al (2015) asserted
that organisations with effective
leadership tend to engender
positive patient experiences such
as respect, care and compassion.
The requirement for compassion
in leadership is further explored by
West et al (2017), who identified
compassion as having four
components, as described in Box 3.
The compassionate leader is able
to maintain effective relationships,
listen to colleagues, make
suggestions and be willing to learn
through critical reflection.
As well as requiring a systemswide approach to ensure effective
leadership across organisations,
leadership ‘at the bedside’ is an
important concept in the nurse’s
Box 3. Components of
compassion
»»Attending – paying attention to other
people and noticing their distress
»»Understanding – understanding what is
causing the other person’s distress
»»Empathising – relating to the other
person’s distress and having an empathic
response
Helping – taking thoughtful and
appropriate action to relieve the other
person’s distress
»»
(Adapted from West et al 2017)
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day-to-day practice, where they are
accountable for clinical decisions,
patient advocacy and the safe
provision of treatment (Timmins
2015). Larsson and Sahlsten (2016)
described ‘informal leadership’
as that which is not associated
with a professional position such
as ward leader or senior nurse,
but which still requires skills
in communication and conflict
resolution, as well as the ability
to learn from mistakes and
anticipate change (Daly et al 2014,
Sortedahl et al 2017). The informal
leader can develop a culture of
acceptance, support and trust within
their teams, which results in positive
behaviours and an ability to learn
among team members (Larsson and
Sahlsten 2016).
The nurse’s role is to advocate
for the patient’s best interests,
and this should be driven by
a sense of professionalism and
a commitment to person-centred
care. However, there is potential
for the nurse’s advocacy role to
contrast with the aims of the wider
organisation (Fast and Rankin
2017). For example, if the managers
of a healthcare organisation were
to propose a new model of care
without consulting the nursing staff,
the model of care could be based
on opinion or data which did not
fully reflect the local requirements
and experiences of patients. This
demonstrates why it is important
for nurses to speak up and use
their influence.
Reflection and self-awareness
Recent research into leadership has
concentrated on human interactions
and the personal qualities required
by effective leaders (Lake and King
2017, West et al 2017). These
personal qualities include self-belief,
self-awareness, self-management,
a drive for improvement and
personal integrity (NHS Leadership
Academy 2011). Effective leaders
also require emotional intelligence,
which can be defined as an
individual’s ‘ability to perceive,
understand and express emotion’
(Jones and Bennett 2012). Selfawareness is a vital element in
the development of emotional
intelligence and can be developed
through reflection (Weisinger 2000).
The concept of learning through
Key points
●● The Code: Professional Standards of Practice
and Behaviour for Nurses, Midwives and
Nursing Associates (Nursing and Midwifery
Council 2018a) states that all nurses ‘should be
a model of integrity and leadership for others
to aspire to’, which means that nurses should
be able to lead at any stage of their career
●● Leadership reflects the ‘development of
a shared vision’ and can be described as
visionary, innovative, values-based and
strategic (Wattis and Curran 2011). A leader
should be able to see the ‘bigger picture’ while
also focusing on individuals
●● Positive leadership role models can foster a
culture in which it is acceptable for junior
staff to raise concerns and ask for assistance,
which contributes to staff retention and
influences the delivery of safe and effective
care (Paterson et al 2015)
●● Strong and visible nurse leadership also
supports positive patient outcomes such
as reduced length of hospital stay and
increased confidence in the healthcare
system (Sfantou et al 2017)
reflection is well established
within pre-registration and postregistration nurse education,
training and practice (Jones and
Bennett 2012, Lake and King
2017). Revalidation was introduced
by the NMC in April 2016 and
focuses on reflective practice and
learning from experience (NMC
2018a). Reflective activities may
include critical consideration of
past clinical episodes, reading
clinical articles or attending study
days. These reflective exercises
can assist nurses to acknowledge
their limitations and identify their
strengths, which will assist the
‘everyday leader’ to become the
‘everyday learner’ (Bellack 2018).
Box 4 details a reflective exercise
that nurses can use to identify their
leadership characteristics.
The quality of the learning
that individual nurses derive from
reflection can vary and is linked to
an individual’s overall experience.
In the 1980s, Benner (1982) applied
the Dreyfus (1972) model of skill
volume 34 number 6 / June 2019 / 63
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acquisition to the development of
skills and knowledge in nurses. The
Dreyfus (1972) model examines
how learners develop skills through
instruction and practise and has
five skill levels: novice; advanced
beginner; competent; proficient;
and expert. The transition of the
newly qualified nurse from novice
to competent practitioner then
expert is complex and relies on the
individual recognising the necessity
to develop through reflection, as
well as the availability of formalised
learning and support from
colleagues (Benner 1982). In the
first two years of their professional
registration, the nurse is considered
to be at the levels of novice and/or
advanced beginner, which means
they have minimal experience of the
tasks required in clinical situations.
However, as their exposure to
clinical scenarios increases, the
individual begins to apply their
experience to their practice and
is able to become competent,
proficient and eventually expert
(Benner 1982).
For a newly qualified nurse,
taking the initiative and adopting
a leadership role may appear
challenging. However, they can
use simple reflective exercises,
such as those shown in Table 1,
to assist them to develop their
self-awareness and begin to
establish leadership skills.
Role modelling
Benner (1982) described the
importance of learning from others,
Box 4. Reflective exercise to
assist nurses to identify their
leadership characteristics
Take a moment to ask yourself which qualities
distinguish you as an everyday leader
Quickly name three adjectives that come
to mind when you think about describing
yourself
Consider whether your colleagues would
provide the same answers
What does this tell you about yourself
and how you are viewed by colleagues?
How do think colleagues experience
interactions with you?
How self-aware are you?
How do you react to feedback from
colleagues – is there always a reason
why they are not right?
and role modelling is one method
that nurses can use when they are
attempting to become an ‘everyday
leader’. The Code (NMC 2018a)
states that nurses must ‘act as a role
model of professional behaviour’
and ‘be aware at all times of how
your behaviour can affect and
influence the behaviour of other
people’. To support this, the NMC
published Future Nurse: Standards
of Proficiency for Registered Nurses
(NMC 2018b), in which there are
seven standards or ‘platforms’. One
of these platforms is ‘leading and
managing nursing care and working
in teams’, which involves nurses
providing leadership by ‘acting
as a role model for best practice
in the delivery of nursing care’
(NMC 2018b).
The attitudes and behaviours
of a senior nurse will be closely
observed and experienced by
members of the nursing team,
including nursing assistants and
volunteers. Complex healthcare
environments can be further
complicated by unexpected events
and an individual’s response to
these can influence those around
them (Price and Scowcroft 2012).
Furthermore, Price and Scowcroft
Table 1. Reflective exercise to assist nurses to develop their
self-awareness and leadership skills
Stage
1. Essential – caring for
the team
2. Proficient – recognising
underlying reasons for
behaviour
»»
»»
»»
»»
»»
»»
(Adapted from Bellack 2018)
64 / June 2019 / volume 34 number 6
(2012) suggested that individuals
are rarely aware of the influence
that they have on others; similarly,
Sortedahl et al (2017) explained
that nurses may not appreciate that
their behaviours are being observed
by junior staff such as healthcare
assistants and nursing students.
West et al (2017) described how
the behaviour of an individual
can ‘ripple’ through a team,
a concept that can be described
as ‘mood linkage’ or ‘visual
contagion’.
Bacur and Van Rensburg
(2016) found that nurses are
vital to professional development
and the integration of theory
and practice in the clinical
environment. A nurse’s positive
behaviour and professionalism
can have a significant effect on
nursing students and influence
their development. Nurses can
begin to gain the confidence of
team members by recognising
their contribution, which will
provide a positive environment for
feedback and direction (Larsson
and Sahlsten 2016). Positive
leadership role models can foster
a culture in which it is acceptable
for junior staff to raise concerns
Reflection on action
»»Do I notice negative or unsettling emotions in the team and
act to correct them?
»»Do my actions demonstrate that the well-being of my team is
important to me?
»»Do I undertake genuine acts of kindness for my team?
»»Do I understand the underlying reasons for my behaviour
and recognise its effect on the team?
»»Do I act with appropriate empathy, especially with
individuals who may be different to me?
»»Do I assist my colleagues to make the connection between
the way they feel and the quality of the service they provide?
3. Strong – providing
opportunities for mutual
support
»»Do I create a positive atmosphere for the team and patients
by caring for my own physical and mental health?
»»Do I create the conditions that assist my team to provide
mutual care and support?
»»Do I understand what motivates individuals and channels
their energy?
4. Exemplary – spreading
a caring environment
beyond one’s own
immediate area
»»Do I take positive action to make sure other leaders are
taking responsibility for the emotional well-being of their
team?
Do I share responsibility for colleagues’ emotional well-being
even when I may be a junior member of staff?
»»
(Adapted from NHS Leadership Academy 2013)
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and ask for assistance, which
contributes to staff retention and
influences the delivery of safe and
effective care (Paterson et al 2015).
Strong and visible nurse leadership
also supports positive patient
outcomes such as reduced length
of hospital stay and increased
confidence in the healthcare
system (Sfantou et al 2017).
Table 2 outlines some positive
role modelling behaviours that
nurses can incorporate into their
everyday practice.
Implications for practice
An individual’s behaviour can have
a significant influence on their
colleagues, regardless of their role
(Paterson et al 2015, West et al
2015, Sfantou et al 2017, Bellack
2018). Nurses are required to
develop insight into their own
leadership qualities during their
nursing training. However,
despite the publication of NMC
(2018c, 2018d) standards for preregistration and post-registration
education, further research is
required into the most effective
model for developing nurses’
leadership skills (Ross and Crusoe
2014, Larsson and Sahlsten 2016,
Bellack 2018).
Many free resources are
available to assist nurses to
develop their leadership skills,
such as online quizzes provided
by the Foundation of Nursing
Leadership (nursingleadership.org.
uk) and free-to-access courses on
subjects such as strategic thinking
and time management. Nurses
should also discuss with their
line manager any opportunities to
develop their leadership skills, such
as access to mentorship, coaching
and action learning (Jones and
Bennett 2012).
Write for us
Table 2. Positive role modelling behaviours
Behaviour
Frequency
Check in with your colleagues. How are they managing? Has their
workload changed because of an unpredicted incident or event?
Do they require assistance?
Daily
Take the lead in thanking staff for their hard work; emphasise the
positive outcomes of providing care as a team; acknowledge the
pressures of the shift
Daily
Acknowledge where individuals are feeling particularly stressed.
What is causing this and how can it be remedied?
Daily
Do not accept challenging behaviour in colleagues and discuss any
examples of this with them at an appropriate time
Daily
Look for effective role models and identify specific positive behaviours
they exhibit. How can you mirror and implement the same behaviours?
Routinely
Reflect on how you may come across to others – what are your stress
points and when do you feel you are most confident?
Routinely
Be brave – raise concerns and use your experiences to feedback issues;
ask for feedback on your practice
Routinely
The NHS Leadership Academy
(2011) Leadership Framework
includes four stages that indicate
a healthcare professional’s
development as a leader; for
example, stage 1 considers ‘own
practice/immediate team’ and
provides a starting point for nurses
to begin developing their leadership
role. These stages are further
supported by the NHS Leadership
Academy’s (2013) Healthcare
Leadership Model, which is
comprised of nine dimensions
aimed at leaders across all
healthcare settings and at all levels.
This document is freely available
and can serve as a reflective exercise
or as part of a structured leadership
development programme. The
NHS Leadership Academy provides
a free online training programme
(www.leadershipacademy.nhs.
For information
about writing
for RCNi
journals,
contact
writeforus@
rcni.com
For author
guidelines,
visit rcni.com/
writeforus
uk/programmes/the-edwardjenner-programme).
Conclusion
Leadership is an essential element of
the nurse’s role; however, developing
leadership skills can be challenging
for the newly qualified nurse. Senior
nurses and healthcare organisations
should not expect newly qualified
nurses to develop leadership skills
without support; therefore, clear
educational pathways for the
development of leadership skills are
required throughout nurses’ training.
Nurses and nursing students can
also access free resources that assist
them to enhance their leadership
skills through self-development and
reflection. The everyday nurse leader
is fundamental to the delivery of
safe and effective patient care across
healthcare systems.
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Influence Others with Integrity and Success.
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Call for papers
Nursing Standard is seeking CPD article
submissions from experienced or new authors
on a variety of subjects, including:
Continence
Communication
Infection control
IV therapy
Surgical complications
Wound care
Contact Evidence & Practice editor Tanya Fernandes
at tanya.fernandes@rcni.com
66 / June 2019 / volume 34 number 6
nursingstandard.com
Reproduced with permission of copyright owner. Further reproduction
prohibited without permission.
Leadership in Nursing: Qualities & Why It Matters
Practice & Advocacy
Retrieved from: Leadership in Nursing: Qualities & Why It Matters | ANA (nursingworld.org)
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Nursing Excellence
Ethics
ANA Official Position Statements
Leadership in Nursing: Qualities & Why It Matters
Nurse Staffing
Work Environment
Health Policy
Advocacy
Telehealth
Workforce
Healthy Nurse
APRN
Scope of Practice
Community Paramedics
State Law and Regulation
Barriers to RN Scope of Practice Panel
Medication Aides, Assistants, Technicians
IOM Future of Nursing Report
NAQC
Project Firstline
Innovation
Qualities & Leadership Styles
Strong leaders in nursing are vital to help navigate the constant evolution of health care. Nurse
leaders do more than balance costs, monitor productivity, and maintain patient and staff
satisfaction. They serve as role models and influence health care organizations at all levels. A
strong nurse leader motivates their colleagues, setting the tone for a safe, civil workplace with a
culture of high morale and job retention.
What Is a Nurse Leader?
A nurse leader is defined by their actions, and not always by a position of authority. Leaders in
nursing inspire and influence others to achieve their maximum potential. They use applied
leadership in nursing by drawing upon critical thinking skills to manage a team.
Nurse leaders take a broad view of how daily tasks impact the overall goals of the health care
organization. They communicate expectations to their team and motivate them to achieve
predetermined goals. Nurses can lead from various organizational areas if they project the
necessary leadership qualities to influence others.
Leadership Qualities in Nursing
A nurse leader role combines essential nursing, business, and leadership skills developed
through ongoing learning. They must be flexible enough to adapt to technological changes,
fluctuating payment methods, new treatment modalities, and regulatory and legislative
environments. Critical skills for effective nursing leadership include:
• Communication and Collaboration: These skills can reduce miscommunication, encourage
shared decision making, and provide a sense of working together toward common goals.
• Education and Quality of Practice: Continued professional development allows leaders in
nursing to keep pace with the ever-changing health care environment while striving for
excellence by supporting quality, evidence-based practice.
• Environmental Health and Resource Utilization: Leadership in nursing ensures that patient
care can be provided effectively in a safe and healthy environment while promoting wellness
among all health care staff.
• Ethics and Professional Practice Evaluation: Influential nurse leaders model ethical
practices to guide decisions, display honesty by being accountable for their actions, and
evaluate their adherence to professional practice standards. Learn more about the Code of
Ethics for Nurses.
• Professionalism and Leadership: Leaders in nursing build vital relationships and collaborate
with various health care teams on sensitive topics. Using critical thinking skills allows those in
nursing leadership roles to analyze decisions impacting the organization. They then clearly
explain the rationale in a manner that encourages staff support.
Other nursing leadership skills, such as displaying compassion and empathy, can assist the
nurse leader in developing interpersonal relationships and gaining respect in their role.
7 Leadership Styles in Nursing
Nursing leadership styles can impact job satisfaction, nurse retention rates, quality of care,
and patient outcomes. The nurse’s educational background, personality, and work environment
may influence their nursing leadership style. Each type of nurse leader role can be valuable
when utilized in the right setting.
• The Transformational nurse leader works to inspire nurses to achieve a greater vision by
helping with strength development. This nursing leadership style works well with mentoring.
• The Autocratic nurse leader makes quick decisions with little input from employees and
excels at task delegation. This nursing leadership style may be most effective in an emergency.
• A Laissez-faire leadership style puts faith in every facet of a well-oiled machine. This method
may work well with experienced teams or self-directed nurses.
• The Democratic nurse leader is collaborative and focuses on team success. This nurse leader
might excel in quality improvement roles but may not be effective in situations requiring
independent decisions.
• The Servant nurse leadership style focuses on employee development and individual needs.
This method works well with goal-driven environments or as a nurse educator.
• The Situational leadership style is the most adaptable since it analyzes the situation and
determines the appropriate approach. This nurse leader is flexible enough to modify their
approach based on the organization or individual’s needs. This style works well with nursing
students but may divert from the organization’s long-term goals.
• The Transactional nurse leader does well with short-term goals by focusing on efficiency and
performance. This task-oriented style reduces errors and works well with tight deadlines.
Examples of Leadership in Nursing
Projecting leadership skills in nursing that influences others can allow a nurse to lead without
being assigned a specific leadership position.
The aspiring nurse leader might:
• Seek out a mentor or become one
• Volunteer for committee roles
• Become involved in the community
• Take educational courses
• Stay current on the latest health care trends
• Get involved with public policy
A nurse aspiring for a nursing leadership role can get a certification or obtain additional
degrees specific to nursing leadership to increase their knowledge base and expand upon
professional development. But a title and the education aren’t enough to create an effective
leader. Nurses and other health care staff need to believe their contributions make a difference
in the organization.
Why Is Nurse Leadership Important?
Nurse leaders make a difference in workplace culture and drive positive changes in health care
legislation. When a team admires the qualities of their leader, it boosts morale and promotes a
psychologically safe workplace, which leads to higher job satisfaction and retention rates.
Influential leaders in nursing ensure that the organization’s vision is communicated to the
nursing staff while mentoring the nursing leadership of tomorrow.
COMMUNICATION
KNOWLEDGE
LEADERSHIP
PROFESSIONALISM
BUSINESS SKILLS
Nurse Executive
Competencies
Suggested APA Citation: AONE, AONL. (2015). AONL Nurse Executive Competencies. Chicago, IL: AONE, AONL.
Accessed at: www.aonl.org
Accessible at: www.aonl.org/competencies
Contact: aonl@aha.org or (312) 422-2800
© 2015 American Organization of Nurse Executives (AONE), American Organization for Nursing Leadership (AONL). All materials contained in
this publication are available to anyone for download on www.aonl.org, for personal, non-commercial use only. No part of this publication may
be reproduced and distributed in any form without permission of AONL, except in the case of brief quotations followed by the above suggested
citation. To request permission to reproduce this material, please email aonl@aha.org.
2
AONL NURSE EXECUTIVE COMPETENCIES
©2015 AONE, AONL
OVERVIEW
N
urse Leaders in executive practice set
the vision for nursing practice in the
delivery of safe, timely, efficient, equitable
and patient-centered care. Working within
a collaborative and interprofessional
environment, the nurse in executive
practice is influential in improving the
patient experience of care (including quality
and satisfaction), improving the health of
populations and reducing the per capita cost
of health care.
The AONL Nurse Executive Competencies
detail the skills knowledge and abilities that
guide the practice of nurse leaders in executive
practice regardless of their educational
level, title or setting. The competencies are
captured in a model developed in 2004 by the
Healthcare Leadership Alliance1 that identify
the common core set of competency domains
for health care leadership: communication
and relationship management; knowledge
of the health care environment; leadership;
professionalism; business skills and principles.
Members include the American Organization for Nursing Leadership, The American College of Healthcare Executives, American Association for
Physician Leadership, Healthcare Financial Management Association, Healthcare Information and Management Systems Society, and Medical
Group Management Association.
1
Reliability and validity for the AONL Nurse Executive Competencies is established by periodic job analysis/role delineation studies. These
competencies are based on A National Practice Analysis Study of the Nurse Executive (2014).
3
AONL NURSE EXECUTIVE COMPETENCIES
©2015 AONE, AONL
1
COMMUNICATION AND
RELATIONSHIP BUILDING
A. EFFECTIVE COMMUNICATION
Make oral presentations to diverse
audiences on:
»» Nursing
»» Health care topics
»» Organizational issues
Produce written materials for diverse
audiences on:
»» Nursing
»» Health care topics
»» Organizational issues
Facilitate group discussions
Demonstrate skill in interpersonal
communication
B. RELATIONSHIP MANAGEMENT
Build collaborative relationships
Exhibit effective conflict resolution skills
Create a trusting environment by:
»» Following through on promises and
concerns
»» Establishing mechanisms to follow-up on
commitments
»» Balancing the concerns of individuals with
organizational goals and objectives
»» Engaging staff and others in decisionmaking
»» Communicating in a way as to maintain
credibility and relationships
C. INFLUENCING BEHAVIORS
Assert views in non-threatening, nonjudgmental ways
Create a shared vision
Facilitate consensus building
Inspire desired behaviors and manage
undesired behaviors
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AONL NURSE EXECUTIVE COMPETENCIES
Achieve outcomes through engagement of
stakeholders
Promote decisions that are patient-centered
Apply situational leadership skills
D. DIVERSITY
Establish an environment that values
diversity (e.g. age, gender, race, religion,
ethnicity, sexual orientation, culture)
Establish cultural competency in the
workforce
Incorporate cultural beliefs into care delivery
Provide an environment conducive to
opinion sharing, exploration of ideas and
achievement of outcomes
E. COMMUNITY INVOLVEMENT
Represent the organization to non-health
care constituents within the community
Serve as a resource to community and
business leaders regarding nursing and
health care
Represent the community perspective in
the decision-making process within the
organization/system
Represent nursing to the media
Serve on community-based boards, advisory
groups, and task forces
F. MEDICAL/STAFF RELATIONSHIPS
Build credibility with physicians as a
champion for patient care, quality and the
professional practice of nursing
Confront and address inappropriate or
disruptive behavior towards patients
and staff
Represent nursing at medical executive
committee and other department/medical
staff committees
©2015 AONE, AONL
1
COMMUNICATION AND RELATIONSHIP BUILDING
Collaborate with medical staff leaders and
other disciplines in determining needed
patient care service lines
Collaborate with physicians and other
disciplines to develop patient care protocols,
policies and procedures
Collaborate to determine patient care
equipment and facility needs
Use medical staff mechanisms to address
physician clinical performance issues
Address and model appropriate conflict
resolution
Create opportunities for physicians and
nurses to engage in professional dialogue
5
AONL NURSE EXECUTIVE COMPETENCIES
G. ACADEMIC RELATIONSHIPS
Determine current and future supply and
demand for nurses to meet the care delivery
needs
Identify educational needs of existing and
potential nursing staff
Collaborate with nursing programs to
provide required resources
Collaborate with nursing programs in
evaluating quality of graduating clinicians
and develop mechanisms to enhance this
quality
Serve on academic advisory councils
Collaborate in nursing research and translate
evidence into practice
Collaborate to investigate care delivery
models across the continuum
Create academic partnerships to ensure a
qualified workforce for the future
©2015 AONE, AONL
2
KNOWLEDGE OF THE HEALTH
CARE ENVIRONMENT
A. CLINICAL PRACTICE KNOWLEDGE
Demonstrate knowledge of current nursing
practice and the roles and functions of
patient care team members
Communicate patient care standards as
established by accreditation, regulatory and
quality agencies
Ensure compliance with the State Nurse
Practice Act, State Board of Nursing
regulations, state and federal regulatory
agency standards, federal labor standards
and policies of the organization
Adhere to professional association
standards of nursing practice
Ensure that written organizational clinical
policies and procedures are reviewed and
updated in accordance with evidence-based
practice
Integrate bioethical and legal dimensions
into clinical and management
decision-making
Ensure protection of human subject rights
and safety in clinical research
B. DELIVERY MODELS / WORK DESIGN
Demonstrate current knowledge of patient
care delivery systems across the continuum
Describe various delivery systems and ageappropriate patient care models and the
advantages/disadvantages of each
Assess the effectiveness of delivery models
Develop new delivery models
Participate in the design of facilities
C. HEALTH CARE ECONOMICS AND POLICY
Understand regulation and payment issues
that affect an organization’s finances
Describe individual organization’s payer mix,
CMI and benchmark database
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AONL NURSE EXECUTIVE COMPETENCIES
Align care delivery models and staff
performance with key safety and economic
drivers (e.g., value-based purchasing,
bundled payment)
Take action when opportunities exist to
adjust operations to respond effectively
to environmental changes in economic
elements
Use knowledge of federal and state laws
and regulations that affect the provision of
patient care (e.g., tort reform, malpractice/
negligence, reimbursement)
Participate in legislative process on health
care issues through such mechanisms as
membership in professional organization
and personal contact with officials
Educate patient care team members on the
legislative process, the regulatory process
and methods for influencing both
Interpret impact of legislation at the state
and federal level on nursing and health care
organizations
D. GOVERNANCE
Use knowledge of the role of the governing
body of the organization in the following
areas:
»» Fiduciary responsibilities
»» Credentialing
»» Performance management
Represent patient care issues to the
governing body
Participate in strategic planning and quality
initiatives with the governing body
Interact with and educate the organization’s
board members regarding health care and
the value of nursing care
Represent nursing at the organization’s
board meetings
Represent other disciplines at the
organization’s board meetings
©2015 AONE, AONL
2
KNOWLEDGE OF THE HEALTH CARE ENVIRONMENT
E. EVIDENCE-BASED PRACTICE/OUTCOME
MEASUREMENT AND RESEARCH
Use data and other sources of evidence to
inform decision making
Use evidence for establishment of
standards, practices and patient care models
in the organization
Design feedback mechanisms by which to
adapt practice based upon outcomes from
current processes
Design and interpret outcome measures
Disseminate research findings to patient
care team members
Allocate nursing resources based on
measurement of patient acuity/care needed
Monitor and address nurse sensitive
outcomes and satisfaction indicators
F. PATIENT SAFETY
Support the development of an
organization-wide patient safety program
Use knowledge of patient safety science
(e.g., human factors, complex adaptive
systems, LEAN and Six Sigma)
Monitor clinical activities to identify both
expected and unexpected risks
Support a Just Culture (non-punitive)
reporting environment, supporting a reward
system for identifying unsafe practices
Support safety surveys, responding and
acting on safety recommendations
Lead/facilitate performance improvement
teams to improve systems/processes that
enhance patient safety
7
AONL NURSE EXECUTIVE COMPETENCIES
G. PERFORMANCE IMPROVEMENT/METRICS
Articulate the organization’s performance
improvement program and goals
Use evidence-based metrics to align patient
outcomes with the organization’s goals and
objectives
Apply high reliability concepts for the
organization
Establish quality metrics by
»» Identifying the problem/process
»» Measuring success at improving specific
areas of patient care
»» Analyzing the root causes or variation
from quality standards
»» Improving the process with the evidence
»» Controlling solutions and sustaining
success
H. RISK MANAGEMENT
Identify areas of risk/liability
Facilitate staff education on risk
management and compliance issues
Develop systems that result in prompt
reporting of potential liability by staff at all
levels
Identify early warning predictability
indications for errors
Correct areas of potential liability
Ensure compliance by staff with all required
standards
©2015 AONE, AONL
3
LEADERSHIP
A. FOUNDATIONAL THINKING SKILLS
Address ideas, beliefs or viewpoints that
should be given serious consideration
Recognize one’s own method of decision
making and the role of beliefs, values and
inferences
Apply critical analysis to organizational
issues after a review of the evidence
Maintain curiosity and an eagerness to
explore new knowledge and ideas
Promote nursing leadership as both a
science and an art
Demonstrate reflective practice and an
understanding that all leadership begins
from within
Provide visionary thinking on issues that
impact the health care organization
D. SUCCESSION PLANNING
Develop a leadership succession plan
Promote nursing leadership as a desirable
specialty
Mentor current and future nurse leaders
Establish mechanisms that provide for early
identification and mentoring of staff with
leadership potential
Develop a workforce analysis plan and
implement strategies to ensure an adequate
and qualified workforce
E. CHANGE MANAGEMENT
Adapt leadership style to situation needs
Use change theory to implement change
Serve as a change leader
B. PERSONAL JOURNEY DISCIPLINES
Learn from setbacks and failures as well
as successes
C. SYSTEMS THINKING
Use knowledge of classic and contemporary
systems thinking in problem solving and
decision making
Provide visionary thinking on issues that
impact the healthcare organization
Recognize the contribution of mental
models on behavior
Promote systems thinking as an expectation
of leaders and staff
Consider the impact of nursing decisions on
the healthcare organization as a whole
Use resources from other paradigms
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AONL NURSE EXECUTIVE COMPETENCIES
©2015 AONE, AONL
4
PROFESSIONALISM
A. PERSONAL AND PROFESSIONAL
ACCOUNTABILITY
Hold self and others accountable for mutual
professional expectations and outcomes
Contribute to the advancement of the
profession
Participate in and contribute to professional
organizations
Demonstrate and promote leader and staff
participation in professional organizations
Promote leader and staff participation
in lifelong learning and educational
achievement
Achieve and maintain professional
certification for self
Promote professional certification for staff
Role model standards of professional
practice (clinical, educational and leadership)
for colleagues and constituents
C. ETHICS
Uphold ethical principles and corporate
compliance standards
Hold self and staff accountable to comply
with ethical standards of practice
Discuss, resolve and learn from ethical
dilemmas
D. ADVOCACY
Promote clinical perspective in
organizational decisions
Involve nurses and other staff in decisions
that affect their practice
Represent the perspective of patients and
families
Advocate for optimal health care in the
community
B. CAREER PLANNING
Coach others in developing their own career
plans
Seek input and mentorship from others in
career planning and development
Develop a personal and professional career
plan and measure progress
Solicit feedback about personal strengths
and weaknesses
Act on feedback about personal strengths
and weaknesses
9
AONL NURSE EXECUTIVE COMPETENCIES
©2015 AONE, AONL
5
BUSINESS SKILLS
A. FINANCIAL MANAGEMENT
Develop and manage an annual operating
budget and long-term capital expenditure
plan
Use business models for health care
organizations and apply fundamental
concepts of economics
Interpret financial statements
Manage financial resources
Ensure the use of accurate charging
mechanisms
Educate patient care team members
on financial implications of patient care
decisions
Participate in the negotiation and monitoring
of contract compliance (e.g., physicians,
service providers)
B. HUMAN RESOURCE MANAGEMENT
Ensure development of educational
programs to foster workforce competencies
and development goals
Participate in workforce planning and
employment decisions
Use corrective discipline to mitigate
workplace behavior problems
Evaluate the results of employee
satisfaction/quality of work environment
surveys
Support reward and recognition programs to
enhance performance
Formulate programs to enhance work-life
balance
Interpret and ensure compliance with legal
and regulatory guidelines
Provide education regarding components of
collective bargaining
Promote healthful work environments
Address sexual harassment, workplace
10
AONL NURSE EXECUTIVE COMPETENCIES
violence, verbal and physical abuse
Implement ergonomically sound work
environments to prevent worker injury and
fatigue
Develop and implement emergency
preparedness plans
Analyze market data in relation to supply
and demand
Contribute to the development of
compensation programs
Develop and evaluate recruitment,
onboarding, and retention strategies
Develop and implement an outcome-based
performance management program
Develop and implement programs to reeducate the workforce for new roles
C. STRATEGIC MANAGEMENT
Create the operational objectives, goals and
specific strategies required to achieve the
strategic outcome
Conduct SWOT and Gap analyses
Defend the business case for nursing
Utilize the balanced scorecard analysis to
manage change
Evaluate achievement of operational
objectives and goals
Identify marketing opportunities
Develop marketing strategies in
collaboration with marketing experts
Promote the image of nursing and the
organization through effective media
relations
©2015 AONE, AONL
5
BUSINESS SKILLS
D. INFORMATION MANAGEMENT
AND TECHNOLOGY
Use technology to support improvement of
clinical and financial performance
Collaborate to prioritize for the
establishment of information technology
resources
Participate in evaluation of enabling
technology in practice settings
Use data management systems for decision
making
Identify technological trends, issues and
new developments as they apply to
patient care
Demonstrate skills in assessing data
integrity and quality
Provide leadership for the adoption and
implementation of information systems
11
AONL NURSE EXECUTIVE COMPETENCIES
©2015 AONE, AONL
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