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Journal of Nursing Management, 2017, 25, 77–81

Commentary

Building leadership capacity in advanced nurse practitioners – the role of organisational management

Correspondence Naomi Elliott School of Nursing and Midwifery Trinity College Dublin, the University of Dublin 24 D’Olier Street Dublin 2, DO2 T283 Ireland E-mail: naomi.elliott@tcd.ie

ELLIOTT N. (2017) Journal of Nursing Management 25 , 7781 Building leadership capacity in advanced nurse practitioners the role of organisational management

Aim To highlight the organisation-level management’s role in building leadership capacity in advanced nurse practitioners and the need for appropriate supports to increase their becoming leaders. Background Little is published about the role of organisation-level management in building leadership capacity and in developing the next generation of nurse leaders. In times of economic constraint, organisations need to focus their efforts on targeted leadership initiatives. Advanced nurse practitioners are ideally positioned to act as leaders both within and beyond the health care organisation. Evaluation From the available research evidence, several support structures and mechanisms are identified as enablers for advanced nurse practitioners to enact their leadership role. Conclusion Health care organisations need to include building leadership capacity as a priority in their strategic plan and take action to build-up the level of advanced nurse practitioner leadership. Implications for nursing management Nurse executives have a vital role in influencing the organisation’s strategic plan and making a business case for prioritising leadership capacity building within advanced nurse practitioners. A challenge for nurse executives faced with competing service and leadership development demands, involves strategic decision-making regarding whether the advanced nurse practitioner’s role is limited to service delivery or its potential in leading health care reforms is realised.

Keywords : advanced nurse practitioner, clinical leadership, leadership capacity, nurse consultant, organisational management

Accepted for publication: 20 September 2016

Introduction

Building leadership capacity is not a new concept to nursing or health care management (Ferguson & Donaho 1999, Alleyne & Jumaa 2007, Jooste & Cairns 2014, West et al. 2015). As the demand for health care reform is increasing rapidly, the need to develop leaders who can respond by innovating and improving health care practice is escalating, and build- ing leadership capacity has become a priority. Within nursing, advanced nurse practitioners are ideally posi- tioned to act as leaders both within and beyond the health care organisation (Delamaire & Lafortune

DOI: 10.1111/jonm.12444 ª 2016 John Wiley & Sons Ltd

2010), however, missing in the leadership literature is a focus on the role of organisation-level management in building leadership capacity and enabling advanced nurse practitioners to enact their leadership role. Previous leadership development initiatives associ- ated with established international and national insti- tutes, such as the International Council of Nurses [ICN]-Burdett Global Nursing Leadership Institute (http://leadership.icn.ch/gnli/), American Academy of Nursing [AAN] Institute for Nursing Leadership (http:// www.aannet.org/nurse-leaders), National Health Ser- vice [NHS] Leadership Academy (http://www.leader shipacademy.nhs.uk/), and Health Services Executive

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Commentary

[HSE] National Leadership and Innovation Centre (http://www.hse.ie), have supported leadership develop- ment in nursing over the decades. Whilst progress has been made most notably in the areas of leadership edu- cation and training across all grades of nurses, the chal- lenge for future leadership development is to build leadership capacity and to recognise the role that organ- isation-level management has in developing advanced nurse practitioners as leaders. For executive-level nurses, working in complex and business orientated health care organisations creates challenges arising from competing demands; such as between the need for building leadership capacity in advanced nurse practitioners and the service demand for increased access to quality clinical services and reduced waiting time for growing numbers of patients. Numerous studies have identified heavy clinical work- load as a major barrier to leadership insofar as the time available for advanced nurse practitioners’ lead- ership activities is constantly being eroded by clinical service demands (Guest et al. 2004, Woodward et al. 2005, DiCenso & Bryant-Lukosius 2010, Simmons 2010, Chang et al. 2012, Higgins et al. 2014). What is missing in the leadership literature is a discourse on the role of organisational management in building leadership capacity and importantly, what support structures and mechanisms need to be included in the leadership development programme for advanced nurse practitioners.

Key differences between leadership capacity and leadership capability

Although leadership capacity and leadership capability are inter-related (Severinsson 2014), there are subtle yet important differences that have implications for organisational management. For Weiss and Molinaro (2005), leadership capacity involves organisation-level systems and practices to build up the number and level of leaders, whereas leadership capability focuses on the development of individual-level leadership skills, abilities and competencies through education programmes. In nursing, a trend in leadership develop- ment has been to focus on the individuals’ skills and behaviours as described by the various leadership the- ories, for example, transformational leadership (Bass & Avolio 1994) or situational leadership (Hersey et al. 2012). More recently, research evidence is begin- ning to emerge that shifts the focus from the individ- ual to the workplace context and identifies organisation-level factors as a major influence on the nurse’s ability to enact leadership (Simmons 2010,

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Higgins et al. 2014, Elliott et al. 2016). Findings from a scoping review of the research evidence on barriers and enablers to leadership enactment in advanced practice contexts (Elliott et al. 2016), point to organi- sation-level gaps in leadership development and the need for leadership capacity building strategies in order to build up both the number and level of nurse leaders within organisations.

Building leadership capacity in advanced nurse practitioners

An essential of any programme for leadership develop- ment is that executive directors include building lead- ership capacity as one of the priorities within the organisation’s strategic plan (Weiss & Molinaro 2005). The goal of building up the number and level of nurse leaders is not a short-term goal but requires a long-term strategic approach and a sustained commit- ment from the organisation in the form of providing appropriate support structures and resources that will continue to support nurse leaders beyond the initial start-up either of new leadership posts or new practice development projects. In countries such as the UK and the USA, considerable investment has already been made in the areas of developing leadership education courses and competency guidelines (NHS Leadership Academy 2011, American Association of Colleges of Nurses 2013), which serve to increase the leadership ability of individual nurses across all grades. However, the Center for Creative Leadership (2016) in a White Paper on Addressing the Leadership Gap in Health- care, argues that in times of economic constraint health care organisations cannot afford to pour resources into generalised leadership development but instead need to focus their efforts on targeted leader- ship initiatives. Whittle et al. (2012) discuss how organisations that are constituted from a ‘hierarchy of capacities’ (p.15) should consider adopting a frame- work for capacity building that reflects the hierarchies. In nursing, whilst leadership development is relevant across all grades of nurses, there is a general consen- sus within the international nursing profession that the advanced nurse practitioner/nurse practitioner/ nurse consultant role represents the highest grade of clinical leadership in nursing (Delamaire & Lafortune 2010). Within policy guidelines on the advanced nurse practitioner/nurse practitioner/nurse consultant roles, leadership is identified as a core dimension of the role alongside clinical practice, education and research (e.g. Canadian Nurses Association 2008, National Council for the Professional Development of Nursing

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and Midwifery 2008, The Scottish Government 2010, Nursing and Midwifery Board of Australia 2014). As such, advanced nurse practitioners are ideally posi- tioned to act as clinical and professional leaders inso- far as they have clinical expertise in their area of specialist practice and are educated, at a minimum to Master’s degree which usually includes change man- agement and research projects. The organisation’s strategic plan for leadership development, therefore, should include a focus on building leadership capacity within advanced practitioner-level nurses and put in place appropriate support structures and mechanisms that will enable them to fulfil their potential as leaders.

Support structures and mechanisms for building leadership capacity

The process of building leadership capacity in a mul- ti-profession, multi-layer health care organisation is complex. The literature on leadership development abounds with recommendations for ‘best-practice’, however, it is important to identify supports that are appropriate and relevant to the advanced practi- tioner’s context. Evaluation research on the advanced nurse practitioner role provides a useful evidence-base for exploring which supports are considered appropri- ate in advanced practitioner contexts. From the avail- able research evidence, a number of support structures and mechanisms that facilitate advanced nurse practitioners to enact their leadership role are identified that may help organisations to build leader- ship capacity and advance the level of nurse leaders. They include:

Defined leadership role. Having clarity on the advanced nurse practitioner’s role and function both in nursing and across the multi-disciplinary team, so that their leadership role is clear and they are iden- tified as leaders of practice development initiatives within the health care organisation (Manley et al. 2008, Simmons 2010, Franks 2014); Director-level accountability . Having the advanced nurse practitioner’s position within the management structure of the organisation at the level of report- ing to a director, means they are in a position with direct access to executive decision-makers and bud- get-holders, are accountable for achieving their per- formance targets and for demonstrating outcomes relating to improved quality of patient care delivery, evidence-based innovation and practice development (Mullen et al. 2011, Bahouth et al. 2013);

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Commentary

Leadership mentoring. Having mentors in the form of ‘leadership brokers’ to guide advanced nurse practitioners on using/ developing the particular skill-sets that are needed for successful implementa- tion of innovation and practice changes in multi-dis- ciplinary and business-orientated health care organisations (Donald et al. 2011, Franks 2014, Leggat et al. 2015). Leadership mentoring in the form of advising advanced practitioners on effective ways of raising their profile in arenas external to the organisation and establishing alliances with national and international centres of excellence (Abbott 2007, Begley et al. 2014);

Membership of strategic committees. Being nomi- nated by organisation-level management on to clini- cal and strategic committees at local, national and international levels, so that advanced nurse practi- tioners can impact decision-making regarding ser- vice delivery and are visible as leaders beyond their immediate clinical practice area (Donald et al. 2011, Higgins et al. 2014);

Networking . Providing support for networking to enable advanced nurse practitioners build up strate- gic alliances within and external to the workplace organisation, so that they can collaborate with others to act as change agents and address key issues in advancing practice (DiCenso & Bryant- Lukosius 2010, Simmons 2010, Helen & Michelle 2012, Higgins et al. 2014);

Formal health care–university links. Establishing formal links with universities for research can increase the number of research applications by advanced nurse practitioners and success rates in research funding. The clinical research function of advanced nurse practitioners can add value through supporting evidence-based practice, and disseminat- ing best practice and innovation (Mullen & Gavin- Daley 2010);

Administration/clerical/information technology sup- port. Resourcing the advanced nurse practitioner’s clinical work by providing clerical/administration/ information technology support in order to free-up time for leadership, practice development and research activities (Guest et al. 2004, Donald et al. 2011, Gerrish et al. 2012, Hourahane et al. 2012).

Conclusion

Building leadership capacity requires a long-term strategic approach and a sustained commitment from the organisation in the form of providing appropriate

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support systems and resources. Given that advanced nurse practitioners are ideally positioned within health care organisations to act as clinical and pro- fessional leaders, the organisation’s strategic plan for building leadership capacity should include them as part of a targeted leadership development initiative. From the available research evidence, the support structures and mechanisms that health care organisa- tions can put in place to build leadership capacity in advanced nurse practitioners and to enable them to fulfil their potential as leaders include having: a defined leadership role, director-level accountability, leadership mentoring, membership of strategic com- mittees, networking, formal health care–university links, and administration/clerical/ information tech- nology support.

Implications for nursing management

Executive-level nurses have a vital role in influencing the organisation’s strategic plans, identifying key pri- orities and forward planning so that the organisation will be able to respond to future changes in health care delivery. Nurse executives are ideally positioned to make a business case for including leadership capacity building as a priority and focusing on the advanced practitioner-level nurse for targeted leader- ship development initiatives. The value of having this as a named priority in the strategic plan is that through the governance structures, the organisation is held accountable for implementing leadership capacity building and for making progress reports on leader- ship development targets as part of the organisation’s annual reports. The challenge for nurse executives involves strategic decision-making regarding whether the advanced nurse practitioner’s role is limited to ser- vice delivery or whether its potential as a ‘force majeure’ in leading health care reforms can be realised.

Source of funding

No funding was received for this study.

Ethical approval

Ethical approval was not required for this paper.

NAOMI ELLIOTT PhD, RGN, RNT Associate Professor, School of Nursing and Midwifery, Trinity College Dublin, The University of Dublin, Dublin, Ireland

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