Leadership as used in the literature is an ambiguous term and may cover a range of ideas and people in various roles. From a synthesis of the literature, it is recognized that leadership is an abstract concept that requires a context to give it more specific meaning; therefore, for the purpose of this review, it is defined, within an organizational context, as the influence of others by inspiration, encouragement and direction to willingly follow in the pursuit of objectives.
From an initial search of CINAHL and Medline online databases, over 9000 articles were retrieved on nursing leadership, highlighting its importance and challenges, with a number focusing on the development of leadership skills. A common proposition within this body of literature is that the role of leadership is to inspire, encourage and influence others in a manner that keeps them committed to the goals and values of the organization.1
Leadership in health care is seen to be important for high-quality care outcomes.2 In a qualitative study across 200 nursing homes, Pearson et al.3 identified the importance of leadership by senior nurses (referring to Directors of Nursing and Charge Nurses) on the outcome of quality care and life for care recipients. The senior nurse's leadership role was identified as pivotal in impacting high-quality care outcomes, and this proposition is supported over time by many authors, including Martin and Learmonth2 and Hewison and Morrell,4 who call for improvement in the preparation of nurses for leadership roles. The evidence also reflects that nursing leadership is an international concern, as recently identified by the International Council of Nurses in their Vision Statement for Nursing in the 21st century,5 requiring that nurses are equipped with the knowledge, strategies and strength to lead health services and populations through change for healthier futures. In terms of health workforce leadership, Gilmartin and D’Aunno identified that “leadership is positively and significantly associated with individual and group satisfaction, retention and performance”.6(p.394) Significantly, in the majority of these studies, authors agree that nursing leadership is seen to operate in complex, challenging and dynamically changing situations, affirming the need for effective leadership skills to meet these challenges.7 Nursing leadership is challenging, requiring a broad suite of capabilities and competences from the leader. Omoike et al.8 claim that the capabilities and competences of nurse leaders enable and empower nurses to operationalize leadership across a range of diverse health settings, where nurse leaders make the most effective use of all available resources to achieve positive outcomes for their patients and the organization where they work. This mirrors the findings of Martin et al.9 in a Swiss hospital-based study of clinical leadership competency among nurses, specifically seeking to measure leadership competency development. Although the nursing work environment is increasingly complex, with pressures from consumer expectations, advances in technology, pharmacology and medical sciences, along with changing service models and diminishing resources and the complexity of the work environment, call for diverse leadership skills.10
A paradigm for nursing leadership posed by Porter-O’Grady10 identified the need for relational leadership and the importance of emotional intelligence for the new age leader. In this paradigm, effectiveness elements of self-awareness, self-management, social awareness and relationship management were viewed as critical. “The leader is always dealing with people within the vortex and complexity of change movement. Even responding to critical events at the right time is fraught with the ebbs and flows of the next emerging stage of change”.10(p.110) Supporting these findings, Cummings11 undertook a systematic review of nursing leadership publications, which led to the assertion that traditional task-focused leadership is ineffective in achieving optimal outcomes; instead, what is needed is transformational and relational nursing leadership to achieve effective outcomes. This idea resonates with Porter-O’Grady's10 leadership paradigm. Hence, this systematic review will specifically focus on interventions for leadership skill development of nurses.
A number of studies have identified specific focus areas for nursing leadership development. Day et al.12 reviewed 25 years of research publications in a publication called The Leadership Quarterly and found that focus areas could be broadly categorized into either interpersonal or intrapersonal leadership phenomena. They also noted a distinction between leader development, classified as an individual growth process, and leadership development, which is an activity or process involving a group, cohort or multiple individuals collectively, especially in relation to skills. Roles of nursing leadership have evolved over the past three decades. In the 1980s, health services were led by administrators, and in the 1990s, the manager was the preferred role; now in the new millennium, “leader” is the role embodied by senior nurses. The senior nurse's role, over time, has grown from circumscribed clinical and managerial functions to a broader, more strategic and relational focus.2 Currently, no previous systematic review has been undertaken specifically focusing on nursing leadership skill development interventions; this systematic review will therefore provide scope and analysis on this topic. More specifically, although a lot of literature reports leadership development for nurses from undergraduate and postgraduate stages of career, this research is interested in identifying the effective interventions used to develop senior registered nurses, defined as directors of nursing, charge nurses, nurse executives and nurse administrators.
Leadership development interventions are reported in a number of healthcare organizations, established in an effort to develop a platform of increased capacity and the skills they require for succession, growth and change. Based on studies with the US Army, Michael et al.13 posed the question on whether leadership skills develop in relation to experience over time, and if so, what kinds of experiences are effective. The authors proposed a conceptual model for leadership skill development, comprising the four inter-related domains of personal characteristics, career development, training and assignment, and developmental issues. The findings of this study demonstrated that leadership performance is frequently dependent on the leaders’ ability to solve complex, ill-defined or novel problems, which again support the paradigm change to new age leadership posited by Porter-O’Grady.10
A number of recent publications highlight the growing trend in many countries toward systematic frameworks for nursing leadership development, signifying a trend toward a formal and structured approach for leadership development. Both Mortlock14 and Kumar15 report on the recent implementation of leadership development frameworks by the National Health Service (NHS) in the United Kingdom, a driving force in the development of leadership skills at all levels and among all disciplines within the health sector. The NHS approach to a leadership framework recognizes seven domains of leadership, including five core domains that involve collaborative contributions of demonstrating personal qualities, working with others, managing services, improving services and setting direction, and the remaining two domains that relate to individual roles of creating the vision and delivering the strategy. A strength of Kumar's15 work is identification of barriers and pitfalls related to leadership development in the healthcare setting. An important point made is that, regardless of the leadership development approach, the individual characteristics of the leader are central, and adoption of a generic approach to leadership skill development presents a risk of failure.
Recent approaches taken in Australia mirror this NHS initiative, with the implementation by the NSW Health Education and Training Institute (HETI) of the NSW Health Leadership Framework.16 This evidence-based framework also draws upon Canadian Health Service experience from their “Leads in a Caring Environment” leadership capability framework.17 For NSW health services, HETI has developed a nine-month leadership development program, called the “Clinicians and Executives Team Leadership Program”, which is designed to build individual, team and organizational capability. Another innovative program currently underway is the Clinical Leadership in Aged Care project that involves a structured intervention of education, mentoring and active learning exercises designed to develop leadership behaviors and skills among nurses in aged care settings.18
From this initial review of the literature, there is substantial and ongoing interest in developing effective leadership in health care; however, there is a gap in the literature surrounding the identification and measurement of effective interventions and very few experimental studies that compare interventions for leadership skill development among nurses. The leadership skills of senior nurses are acknowledged as playing a major role in organizational leadership and the health outcomes of care recipients3,11; therefore, this systematic review of the literature will benefit the health sector and service consumers through the identification and evaluation of evidence on effective interventions for leadership skill development of nurses. This new knowledge will enable better utilization of resources and enhance program development through identification of the most effective interventions for leadership skill development for nurses.
Types of participants
This review will consider studies that include nurses in, or preparing for, recognized leadership roles, including, but not limited to, directors of nursing, nursing unit managers, operational managers, directors, administrators, coordinators, supervisors and similar equivalent positions of leadership by nurses.
Types of intervention(s)
This review will consider studies that evaluate interventions, structured and non-structured, that aim to develop leadership skills among nurses. The comparator includes studies with no intervention. Non-structured interventions may include flexible programs that are not delineated by time, completion of specific components or pre-conceived goals, for example, some mentoring and coaching interventions may fall into this category.
This review will consider studies that include measures of leadership skill development outcomes of nurses, including intervention effectiveness measured using validated tools or through numerically rated observation scales, for example, the Multifactor Leadership Questionnaire, and inclusive of self-efficacy rating scales. Leadership skill development outcomes of primary interest include communication, relationship management, delegation, conflict resolution, problem solving, planning and decision making.
Types of studies
This review will consider both experimental and epidemiological study designs, including randomized controlled trials, non-randomized controlled trials, quasi-experimental, before and after studies, prospective and retrospective cohort studies, case control studies and analytical cross-sectional studies.
The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract and the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Third, the reference list of all identified reports and articles will be searched for additional studies. For reasons of comprehension, only studies published in English will be considered for inclusion in this review. All relevant studies published, without date limitation, will be considered for inclusion in this review.
The databases to be searched include:
Cochrane Central Register of Controlled Trials
ProQuest Dissertation and Theses A&I
Initial keywords to be used will be: nurse, leader, leadership, skill, intervention, development, education, training, approach, strategy, program, module, course, framework, system, competence, capability, mentor, coach, model, curriculum, method, management, manager, professional.
Assessment of methodological quality
Quantitative articles selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer.
Quantitative data will be extracted from articles included in the review using the standardized data extraction tool from JBI-MAStARI (Appendix II). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives.
Quantitative articles will, wherever possible, be pooled in statistical meta-analysis using JBI-MAStARI. All results will be subject to double data entry. Effect sizes expressed as odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be statistically assessed using the standard χ2 and also explored using subgroup analyses based on the different quantitative study designs included in this review. Where statistical pooling is not possible, the findings will be presented in narrative form, including tables and figures to aid in data presentation, wherever appropriate.
This systematic review is undertaken as part of studies toward the awarding of a Doctor of Philosophy degree.
Appendix I: MAStARI appraisal instruments
Appendix II: MAStARI data extraction instruments
1. Porter-O’Grady T. A different age for leadership, part 1: context, new content. J Nurs Adm
2003; 33 2:105–110.
2. Martin GP, Learmonth M. A critical account of the rise and spread of ‘leadership’: the case of UK healthcare. Soc Sci Med
2012; 74 3:281–288.
3. Pearson A, Hocking S, Mott S, Riggs A. Management and leadership in Australian nursing homes. Nurs Prac
1992; 5 2:24–28.
4. Hewison A, Morrell K. Leadership development in the English National Health Service: a counter narrative to inform policy. Int J Nurs Stud
2014; 51 4:677–688.
5. Nurses I. C. o. International Council of Nurses, 2013, LFC Vision, Mission & Key Strategic Aims [Internet]. See http://www.icn.ch/pillarsprograms/lfc-vision-mission-and-key-strategic-aims/
for further details. [Accessed 1 September 2014]
6. Gilmartin MJ, D’Aunno TA. Leadership research in healthcare: a review and roadmap. Annals
2007; 1 1:387–438.
7. Macphee M, Skelton-Green J, Bouthillette F, Suryaprakash N. An empowerment framework for nursing leadership development: supporting evidence. J Adv Nurs
2012; 68 1:159–169.
8. Omoike O, Stratton KM, Brooks BA, Ohlson S, Storfjell JL. Advancing nursing leadership: a model for program implementation and measurement. Nurs Adm Q
2011; 35 4:323–332.
9. Martin JS, Frei IA, Suter-Hofmann F, Fierz K, Schubert M, Spirig R. Evaluation of nursing and leadership competencies – a baseline for practice development. Pflege
2010; 23 3:191–203.
10. Porter-O’Grady T. A different age for leadership, part 2: new rules, new roles. J Nurs Adm
2003; 33 3:173–178.
11. Cummings GG. Nursing leadership and patient outcomes. J Nurs Man
2013; 21 5:707–708.
12. Day DV, Fleenor JW, Atwater LE, Sturm RE, McKee RA. Advances in leader and leadership development: a review of 25 years of research and theory. Leadersh Q
2014; 25 1:63–82.
13. Michael DM, Stephyen JZ, Francis DH, Jacobs TO, Edwin AF. Leadership skills for a changing world: solving complex social problems. Leadersh Q
2000; 11 1:11–35.
14. Mortlock S. A framework to develop leadership potential. Nurs Man
15. Kumar RDC. Leadership in healthcare. Anaesth Intensive Care Med
2013; 14 1:39–41.
16. Clarke E, Diers D, Kunisch J, et al. Strengthening the nursing and midwifery unit manager role: an interim programme evaluation. J Nurs Man
2012; 20 1:120–129.
17. Comack MT. A journey of leadership: from bedside nurse to chief executive officer. Nurs Adm Q
2012; 36 1:29–34.
18. Jeon YH. Innovation in aged care leadership: overcoming workforce and care quality issues? Aust Nurs Mid J
2014; 21 7:37.