Barriers and enablers to advanced practitioners’ ability to enact their leadership role: A scoping review

International Journal of Nursing Studies 60 (2016) 24–45

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Barriers and enablers to advanced practitioners’ ability to enact their leadership role: A scoping review Naomi Elliott a,*, Cecily Begley a,b, Greg Sheaf c, Agnes Higgins a a

School of Nursing and Midwifery, Trinity College Dublin, The University of Dublin, Ireland Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden c The Library of Trinity College Dublin, The University of Dublin, Ireland b

A R T I C L E I N F O

A B S T R A C T

Article history: Received 18 November 2015 Received in revised form 29 February 2016 Accepted 4 March 2016

Background: Advanced roles such as nurse practitioner, nurse consultant and advanced nurse or midwife practitioner are increasing across the world. In most countries, clinical practice, education, leadership and research are the four components that define the advanced practitioner’s role. Of these, leadership is perhaps the most important part of the role, but its study has largely been neglected. There is a risk that failure to identify and respond to barriers to enacting the advanced practitioners’ leadership role will limit the extent to which they can become strategic leaders for professional development, and jeopardise the long-term sustainability of the role. Objectives: To identify the barriers and enablers to advanced practitioner’s ability to enact their leadership role. Data sources: A search of the research literature was undertaken in electronic databases (PubMed, CINAHL, PsycINFO, ProQuest Dissertation and Theses, from inception to 4–6th June 2015), unpublished research in seventeen online research repositories and institutes, and hand search of 2 leadership journals (March/April 2010–4th June 2015). Review methods: Using pre-set inclusion criteria, the 1506 titles found were screened by two authors working independently. The 140 full text reports selected were reviewed by two authors separately and 34 were included, and data extracted and cross-checked. Any disagreements were discussed by the scoping team until consensus was reached. Using content analysis, the barriers and enablers relating to leadership enactment were sorted into themes based on their common characteristics, and using a Structure-Process-Outcome conceptual framework were categorised under the four structural layers: (1) healthcare system-level, (2) organisational-level, (3) team-level, and (4) advanced practitioner-level. Results: Thirteen barriers to, and 11 enablers of, leadership were identified. Of these a majority (n = 14) were related to organisational-level factors such as mentoring, support from senior management, opportunity to participate at strategic level, structural supports for the role, and size of clinical caseload. Advanced practitioner-level factors relating to personal attributes, knowledge, skills and values of the advanced practitioner were identified. Conclusions: Although building leadership capabilities at advanced practitioner-level and team-level are important, without key inputs from healthcare managers, advanced practitioners’ leadership enactment will remain at the level of clinical practice, and their contribution as change agents and innovators at the strategic level of service development and development of the nursing profession will be not be realised. ß 2016 Elsevier Ltd. All rights reserved.

Keywords: Advanced practitioner Barriers Enablers Leadership Leadership capacity Nurse consultant Nurse practitioner Scoping review

* Corresponding author at: School of Nursing and Midwifery, Trinity College Dublin, The University of Dublin, 24 D’Olier St, Dublin 2, DO2 T283, Ireland. Tel.: +353 1 8963106; fax: +353 1 8963001. E-mail addresses: [email protected] (N. Elliott), [email protected] (C. Begley), [email protected] (G. Sheaf), [email protected] (A. Higgins). http://dx.doi.org/10.1016/j.ijnurstu.2016.03.001 0020-7489/ß 2016 Elsevier Ltd. All rights reserved.

N. Elliott et al. / International Journal of Nursing Studies 60 (2016) 24–45

What is already known about the topic?  Advanced roles such as nurse practitioner, nurse consultant and advanced nurse or midwife practitioner are proliferating across the international healthcare workforce.  Leadership is one of the four components that define the advanced nurse or midwife practitioner’s role.  The leadership component of an advanced practitioner role, which ultimately impacts on future healthcare design and delivery, has largely been neglected. What this paper adds  This systematic scoping review outlines 13 barriers to, and 11 enablers of, advanced practitioners’ ability to enact their leadership role.  Healthcare leaders and policy-makers need to develop not only individual leadership capability in advanced practitioners, but also leadership capacity in their organisation.  The long-term sustainability of advanced practitioner roles depends on appropriate organisational support to enable these practitioners enact the leadership component of their role. 1. Introduction Innovative advanced roles such as nurse practitioner, nurse consultant and advanced nurse or midwife practitioner are proliferating across the international healthcare workforce, especially where they substitute for doctors, or are expected to lead practice development and improve healthcare service delivery (Delamaire and Lafortune, 2010). These roles correspond with the International Council of Nurses’ (ICN) broad definition of the nurse practitioner/advanced practice nurse as a registered nurse with expert knowledge, complex decision-making skills and competencies for advanced clinical practice, ‘‘the characteristics of which are shaped by the context and/or country in which s/he is credentialed to practice’’ (ICN, 2009:1). Role extension is valuable if it improves patient outcomes and service delivery, but the long-term sustainability of these roles depends on appropriate organisational support to enable advanced practitioners enact the leadership component of their role, deliver on practice innovation and maximise the outcomes expected of the role (Abbott, 2007; Hourahane et al., 2012; Manley and Titchen, 2012; Woodward et al., 2005). Role extension is defined as ‘‘the inclusion of a particular skill or area of practice responsibility that was not previously associated with the nurse’s role’’ (Daly and Carnwell, 2003:160). Few studies have focused on the leadership component of the advanced practitioner role; consequently, there is a lack of clarity regarding the factors that influence the advanced practitioner’s ability to act as leader. Although leadership is often represented as a generic concept, leadership is context-specific and needs to be understood in terms of its professional and organisational contexts and not just in terms of leader competencies, behaviours, attributes and values (Turnbull-James, 2011).

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There is general consensus within the international nursing/midwifery professions that leadership is one of the four components that define the advanced practitioner’s role, the others being clinical practice, education and research. In many countries, the advanced practitioner is considered a key leadership position of influence for innovation, improving clinical practice, healthcare delivery and advancing the nursing/midwifery professions (Delamaire and Lafortune, 2010). Tracy and Hanson (2014) comment on the ever-expanding range of leadership domains that now includes clinical leadership, professional leadership, systems leadership and health policy leadership, whilst acknowledging there is considerable overlap across these four areas. As the nature and scope of leadership at advanced practice level is contingent on policy and guidelines, leadership practice varies across the different jurisdictions and usually is determined by the professional and regulatory bodies where these roles exist. In Ireland, for example, Advanced Nurse or Midwife Practitioners are charged with responsibility for providing clinical leadership and professional leadership (National Council of Nursing and Midwifery [NCNM], 2008): ‘‘Professional and Clinical Leadership: ANPs/AMPs [Advanced Nurse Practitioners/Advanced Midwife Practitioners] are pioneers and clinical leaders in that they may initiate and implement changes in healthcare service in response to patient/client need and service demand. They must have a vision of areas of nursing/midwifery practice that can be developed beyond the current scope of nursing/midwifery practice and a commitment to the development of these areas. . .’’ (NCNM, 2008:7). In other countries including Australia, Canada, Scotland, United Kingdom and United States of America the leadership dimension of the role is embedded within national policy and competency standards for advanced practitioners (Canadian Nurses Association, 2008; National Organization of Nurse Practitioner Faculties, 2011; Nursing and Midwifery Board of Australia, 2014; Royal College of Nursing, 2012; The Scottish Government, 2010). A broad definition of the concept of clinical leadership in the context of nurse or midwife practitioner includes ‘‘activities supporting the development of practice in the service’’ whereas professional leadership refers to ‘‘activities supporting developments outside of the service at national or international level’’ (Elliott et al., 2013:1039). Countries are at very different stages of development and implementing new advanced practice roles in nursing and midwifery (Delamaire and Lafortune, 2010). The process of introducing new roles within established healthcare systems is complex, and the ongoing development of advanced practice roles is reported across a number of countries (Andrega˚rd and Jangland, 2015; Buchan and Calman, 2005; Delamaire and Lafortune, 2010; Hain and Fleck, 2014; Heale and Rieck Buckley, 2015; Kleinpell et al., 2014; Mullen et al., 2011; New South Wales Department of Health, 2007; Pulcini et al., 2010; Sangster-Gormley et al., 2011). An international trend within this literature has been to focus on clinical practice,

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regulation and education issues (Pulcini, 2014). The leadership component of an advanced practitioner role, which ultimately impacts on future healthcare design and delivery, has largely been neglected. Rare exceptions to this are found in reports from evaluation studies conducted in the UK, Ireland and Canada, which included the leadership role, and identified barriers relating to a lack of supports for advanced practitioners to enable them function as leaders (Begley et al., 2010; DiCenso and Bryant-Lukosius, 2010; Donald et al., 2011; Guest et al., 2004; Hourahane et al., 2012). There is a risk that failure to identify and respond to barriers will limit the extent to which advanced practitioners can fulfil their role as innovators of practice development and strategic leaders for professional development, and jeopardise the longterm sustainability of the role. In the United States, which has a long tradition of advanced practice in nursing, the boundaries between nurse specialist and nurse practitioner roles are becoming increasingly blurred to the extent that a merger of both roles is considered (Cronenwett, 2012). In countries such as Ireland and Scotland with more recent experience of developing nurse/midwife consultant and advanced nurse/ midwife practitioner roles, national policy provides clarity on the leadership component of the role by differentiating it from other clinical nurse or midwife specialist roles (NCNM, 2008; The Scottish Government, 2010). Whilst nurses and midwives across all levels of the career trajectory participate as leaders (Cummings et al., 2010), there is a tacit expectation among policy-makers that those at consultant or advanced practitioner level have additional responsibility for practice innovation and strategic professional development. Furthermore, there is an expectation that when newly appointed advanced practitioners have had time to consolidate their roles and implement change projects, they will be able to demonstrate and account for their leadership outcomes as part of their job performance evaluation (Begley et al., 2014; Carryer et al., 2007; Manley and Titchen, 2012). This highlights the need to support advanced practitioners in their leadership roles, so that in time they will be in a position to demonstrate their leadership outcomes and contribution to improving healthcare delivery and advancing the nursing and midwifery professions. Evidence that advanced practitioners, even those new to the role, engage in leadership activities is well documented (Elliott et al., 2013; Franks, 2014; Gerrish et al., 2012; Martin-Misener et al., 2015; Sangster-Gormley et al., 2012). However, Guest et al. (2004) in their national evaluation in the UK report that newly appointed nurse, midwife and health visitor consultants were left to cope without ongoing support after the initial start-up of their posts. Within the health services management research literature, there is a growing awareness that successful initial implementation of innovations does not always result in long-term or sustained change (Martin et al., 2012). A systematic review of 125 studies identified the factors influencing the sustainability of new programmes and innovations in healthcare settings (Wiltsey Stirman et al., 2012). Findings showed that organisational context, capacity, processes and interactions, and components of

the new programme or practice itself, are key factors that impact on sustainability and what happens after the initial implementation (Wiltsey Stirman et al., 2012). Whilst previous research provides valuable insight into the challenges involved in sustaining changes, little is known about sustainability within the context of advanced practitioner roles (Considine and Fielding, 2010). The future development of these roles is at a critical juncture; if these skilled practitioners are to succeed as clinical and professional leaders then the barriers to, and enablers of leadership need to be identified so that appropriate mechanisms to sustain this aspect of the role can be put in place. A conceptual framework on nurse practitioner role enactment in acute care developed by Kilpatrick et al. (2013) provides some insight into the complex nature of role enactment and how it is affected by contextual structures such as the health care system, organisation, team, advanced practitioner and patient characteristics. Elliott et al.’s (2014) leadership outcome-indicators also highlight the complex nature of the leadership role and the contribution that clinical specialists and advanced practitioners make to healthcare. Both of these frameworks highlight further the context-sensitive nature of role enactment and support the relevance of identifying the barriers and enablers to advanced practitioners’ abilities to enact the clinical and professional leadership dimensions of their role. Evaluation research following implementation of new advanced practitioner roles provides a valuable resource for a scoping review to map out what is known about the barriers and enablers to the leadership component of the advanced practitioner role. This scoping review is timely as organisational leaders and policy-makers need access to evidence-based information to inform decision-making on the future development of nurse or midwife practitioner roles including what is needed to support the nurse/ midwife practitioners so that they can enact their leadership role to maximum effect within the health service. The aim of this scoping review, therefore, is to identify the barriers and enablers to advanced practitioners’ ability to enact their leadership role. 2. Methods Using Arksey and O’Malley’s (2005) methodological framework, a systematic and comprehensive scoping study was undertaken to review the research literature on the barriers and enablers that influence the advanced practitioner’s leadership role within healthcare and clinical settings. This review matches the third of the four types of review identified in Arksey and O’Malley’s (2005) typology of scoping reviews, in that it aims to summarise and synthesise available research evidence, and disseminate findings for policy makers, organisational managers and advanced practitioners who otherwise lack time and resources to undertake such work themselves. A key limitation of scoping review methodology is that there is no formal assessment of the quality of research studies. For Bostro¨m et al. (2011) this limits the value of scoping reviews for making recommendations for clinical practice

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and policy. However, others counter-argue that an advantage of not conducting quality appraisal is that a greater range of study designs and methodologies are included (Njelesani et al., 2011); and that it is consistent with the definition and primary purpose of scoping studies, which is to map the literature, identify knowledge and research gaps, and identify types and sources of evidence to inform practice, policy-making, and research (Daudt et al., 2013). Although no judgement was made on the quality of research papers, in line with recommendations for enhancing the methodology of scoping reviews (Daudt et al., 2013; Levac et al., 2010; Pham et al., 2014), other quality measures were included in the design of this scoping review. These included selecting project team members with expertise in the subject area and in systematic review methodology, clarification and definition of concepts in the research question, and having predetermined procedures whereby the review was carried out independently by two researchers, ratings were crosschecked and consensus meetings held to discuss any discrepancies or uncertainties. This ensured there was final agreement on the papers that met the inclusion criteria for this scoping review, and on the findings that were generated from the data analysis. In addition, the use of transparent and rigorous methods to identify and map literature relevant to the research question, and detailed information on the iterative process of the scoping review (see Fig. 1), enables readers to evaluate the quality and completeness of the data set. 2.1. Search strategy and data sources The search strategy included electronic databases supplemented by additional searches to identify published and unpublished research relevant to the question. The core electronic databases (which were searched from their inception until 4th June 2015, the date the search was conducted on), included PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature) and PsycINFO. A search of the ProQuest Dissertation and Theses database was carried out on 6th June 2015. The search strategy was developed by the project team, which included a librarian with expertise in Webbased information systems, systematic review methodology, and nursing and midwifery subject collections. The core search terminology, based on terms linked to leadership and advanced practice role nomenclature, is derived from Pulcini et al’s (2010) survey and from the appropriate international nursing organisations; for example, literature from the Royal College of Nursing (RCN) in the United Kingdom, and the Nursing and Midwifery Board in Ireland (NMBI), was examined for additional terms. Appropriate thesaurus terms were used to supplement keywords and tailor the search to the individual database. For example, the following search was performed in PubMed: ((‘‘Advanced Practice Nursing’’[MeSH Term] OR ‘‘Nurse practitioner’’ OR ‘‘nurse practitioners’’ OR ‘‘Nurse consultant’’ OR ‘‘nurse consultants’’ OR ‘‘Midwife practitioner’’ OR

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‘‘midwife practitioners’’) OR ((‘‘advanced practice’’ OR ‘‘advanced practitioner’’ OR ‘‘advanced practitioners’’) AND (‘‘nurses’’[MeSH Terms] OR nurse[tiab] OR nurses[tiab] OR midwife[tiab] OR midwives[tiab]))) AND (leadership[tiab] OR leader[tiab] OR leaders[tiab] OR ‘‘leadership’’[MeSH Term]). Searches were limited to publications in the English language. To ensure that the review of relevant research was as comprehensive as possible, an additional search of the grey literature for relevant research reports was carried out on the same date (4th June 2015) in the following online research repositories, databases and institutes: Cochrane Library http://www.cochranelibrary.com/; Open Grey (http://opengrey.eu/); Joanna Briggs Institute (JBI) Library of Systematic Reviews (http://joannabriggs.org); Organisation for Economic Co-operation and Development (OECD) (http://www.oecd.org/); ICN-Burdett Global Nursing Leadership Institute (http://leadership.icn.ch/); ICN Nurse Practitioner/Advanced Nursing Practice Network (http:// international.aanp.org/); American Nurses Association Leadership Institute (http://www.ana-leadershipinstitute. org/); American Association of Nurse Practitioners (AANP) (http://www.aanp.org/); National Health Service Leadership Academy (http://www.leadershipacademy.nhs.uk/); Royal College of Nursing (http://www.rcn.org.uk/); Canadian Foundation for Healthcare Improvement (http://www. cfhi-fcass.ca/); Canadian Nurse Practitioner Initiative (CNPI) (http://apntoolkit.mcmaster.ca/); Canadian Association of Advanced Practice Nurses (CAAPN) (http://caapn-aciipa. org/); Australian College of Nurse Practitioners (http://acnp. org.au/); Nursing and Midwifery Board of Ireland (NMBI) (http://www.nursingboard.ie/); Irish Association of Advanced Nurse and Midwife Practitioners (http://www. iaanmp.com/); and Lenus – the Irish Health Repository (http://www.lenus.ie/hse/). An additional hand search was performed in key international journals, namely Nursing Leadership (from April 2010 to 4th June 2015) and the Australian Journal of Advanced Nursing (from March 2010 to 4th June 2015). The reference lists of the most relevant articles were also searched to identify any research papers specifically about nurse or midwife practitioner leadership. 2.2. Inclusion criteria Research studies about nurses and midwives working in advanced practice roles in all care settings such as hospital, community or public health care were included. Research was defined as any form of systematic enquiry, including mixed methods, action research, systematic review and meta-synthesis. Literature reviews, discussion papers and editorials were excluded. All qualitative research designs were eligible, including descriptive evaluation and case study which examined the contexts in which the nurse practitioners worked and provided multiple perspectives from key stakeholders such as senior nursing management, medical consultants, interdisciplinary team members, other nursing grades and student nurses. All quantitative designs were eligible for inclusion provided that the study generated evidence on a leadership dimension of the nurse practitioner’s role. However,

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N. Elliott et al. / International Journal of Nursing Studies 60 (2016) 24–45

Fig. 1. Flowchart of paper/report selection process.

clinical trials or intervention studies and those concerned solely with clinical outcomes and comparing nurse with medical practitioner care delivery were excluded. Although the ICN’s (2009) definition of nurse practitioner was used, it was also necessary to consider additional titles that are used in different jurisdictions and regulatory bodies internationally. Titles such as ‘nurse or midwife consultant’, for example, used in the United Kingdom and ‘advanced nurse or midwife practitioner’ which is used in Ireland were included. Studies that were concerned solely with clinical nurse and midwife specialist or clinical nurse and midwife leader roles were excluded, although role boundaries are blurred in some countries. Lowe et al. (2012) assert that it is time to recognise the differences in roles, to provide role definition and clarity, which ultimately would improve international standards of nursing/midwifery titles and scopes of practice. Studies that examined nurse or midwife practitioner leadership in terms of the two widely recognised

components of clinical leadership and professional leadership were included (Canadian Nurses Association, 2008; Elliott et al., 2013; International Council of Nurses, 2009; National Organization of Nurse Practitioner Faculties, 2011; Nursing and Midwifery Board of Australia, 2014; Royal College of Nursing, 2012). Studies that identified the barriers and enablers, and examined their impact on enabling nurse or midwife practitioners enact their clinical and professional leadership roles were accepted. 2.3. Screening Following the removal of duplicates, a two-stage screening process was used to assess the relevance of research studies identified in the search. For the first stage of screening, only titles and abstracts were reviewed to exclude studies that did not meet the inclusion criteria. Two researchers independently reviewed all titles and abstracts, and agreed the selection of studies for full-text

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retrieval. In the second stage, full-text articles were assessed by two researchers independently and agreed as eligible for inclusion in the next stage of data extraction. A separate chart was developed for all excluded papers noting key reasons for their exclusion. Any discrepancies about inclusions and exclusions which arose during the selection process were discussed within the research team and resolved by consensus. 2.4. Data extraction and analysis A data extraction framework was developed by the scoping team to ensure that the process of data extraction was standardised between the reviewers. For all included studies and research reports, the following information was recorded:        

Author(s). Year of publication. Country. Practice context. Research purpose/aim. Research design and methods. Study participants. Findings/results data relating to barriers and enablers to leadership role enactment.

Using the agreed data extraction framework, two team members completed and cross-checked each data extraction. Any inconsistencies were discussed at team meetings and agreement was reached. Using content analysis, the barriers and enablers that related to leadership enactment were sorted into themes based on their common characteristics. Using Donabedian’s (1988) StructureProcess-Outcomes conceptual framework as adapted by Kilpatrick et al. (2013), the themes were categorised. However, only the structural component of the framework comprising the healthcare system, organisation, team and nurse practitioner levels were relevant in this analysis of the barriers and enablers to advanced practitioner leadership role enactment. 3. Results 3.1. Search results The electronic databases search yielded 1450 titles and abstracts. PubMed (n = 744), CINAHL (n = 397), PsycINFO (n = 200) and ProQuest Dissertations and Theses (n = 109). The search of online research repositories, databases and institutes for grey literature yielded 34 reports, and the hand search of key journals and references lists identified a further 22 papers. Fig. 1 provides a flow chart summarising the search strategy and study selection process. Following the removal of duplicates, the remaining 1387 titles and abstracts were reviewed using the inclusion and exclusion criteria, and 140 full texts were retrieved for screening. Some authors had multiple manuscripts published from single studies and were included if additional data relating to the leadership barriers and enablers were reported. Following review of the 140 full texts, 106 were excluded as they did not report

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data on barriers or enablers to leadership, reported on leadership tool development, role development, curriculum development, were not related to advanced practitioner, were literature reviews, opinion pieces, repeat papers or full text was not available (see Fig. 1). The final 34 papers/reports comprise a diverse range of research designs; 10 employed a mixed method design, five employed a multi-method design, five employed a qualitative design (two qualitative descriptive, one phenomenology, one ethnography, one cross-sectional qualitative), three employed a case study design, four employed a survey design, three employed an action research design (one action learning, one participatory action research, one co-operative inquiry), three employed a systematic review, synthesis or scoping review design, and one employed a pre-post longitudinal intervention research design. The methodological details of included studies are presented in Table 1. Of the 34 included papers, published between 1985 and 2015, 16 were conducted in the United Kingdom, six in Ireland, four in Canada, four in the United States, two in Australia and New Zealand, one in Taiwan and one in Northern Ireland. See Table 2 for all details of included papers. 3.2. Barriers to advanced practitioner leadership role enactment From the analysis, the barriers and enablers were categorised under four structural layers: (1) healthcare system-level, (2) organisational-level, (3) team-level, and (4) advanced practitioner-level. The analysis identified several new and additional dimensions across the structural layers that were not included in Kilpatrick et al.’s (2013) framework (see Tables 3 and 4). As no patient-level barriers or enablers were identified in the scoping review of advanced practitioner leadership enactment, this structural layer was not reported. The 13 barriers were categorised under four structural dimension headings: (1) healthcare system-level: (i) lack of opportunity to work at strategic level, (2) organisational-level: (ii) large clinical caseload; (iii) lack of support from nursing or midwifery management, medical consultants, and clinical staff; (iv) lack of clarity/understanding of role including leadership and research role; (v) lack of clerical/administrative support; (vi) lack of authority/ position within organisation; (vii) insufficient resources (e.g. financial/information technology/library-databases access); (viii) lack of time/support for research, (3) team-level: (ix) lack of ‘critical mass’/lone position; and, (4) advanced practitioner-level: (x) lack of leadership skill development/education; (xi) lack of advanced practitioner (AP) leadership attributes; (xii) level of education; (xiii) time within role. As all references are listed in Table 3 and to enhance readability in the results sections, references are used only where appropriate. 3.2.1. Organisational-level barriers Organisational-level barriers (n = 7) were the largest category of barriers to advanced practitioner leadership enactment in the papers in this scoping review (see Table 3). Large clinical caseload was the most frequently

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Table 1 Methodological details of included studies (n = 34). Author and year

Research aim

Research design and data collection methods

Sample

Abbott (2007)

To explore the emerging role of nurse consultant in an English primary care settings.

Qualitative  Semi-structured interview

Bahouth et al. (2013)

To explore the experience of developing a centralised leadership approach to managing hospital-based Nurse Practitioners. To explore policymakers’ views on impact of specialist and advanced practitioner roles in Ireland. To report a study designed comparing the roles, responsibilities, and perceived outcomes of Clinical Nurse Specialists, Clinical Midwife Specialists, and Advanced Nurse Practitioners in Ireland. To produce a focused evaluation of the clinical services provided by clinical nurse and midwife specialists and advanced nurse and midwife practitioners in Ireland.

Multi-method  Questionnaire  Focus group interview

Nurse consultants (n = 4) Key stakeholders including managers, Directors or Assistant Directors, Joint commissioning officers, Project Director (n = 15) Nurse practitioner leaders (n = not given)

Begley et

al. (2014)

Begley et al. (2012)

Begley et

al. (2010)

Carryer et

al. (2007)

Chang et

al. (2012)

Department of Health and Social Services, 2005

DiCenso and Bryant-Lukosius (2010)

Doerksen (2010)

Donald et

al. (2011)

Franks (2014)

To draw on empirical evidence to illustrate the core role of nurse practitioners in Australia and New Zealand.

To compare nurse practitioners perceptions of required competencies and self-evaluated competencies in Taiwan To review the roles of the Nurse Consultants in post, with particular regard to the four core functions which exemplify their roles.

To develop a better understanding of advanced practice nursing roles, their current use, and the individual, organisational and health system factors that influence their effective integration in the Canadian healthcare system. To identify the professional development and mentorship needs of advanced practice nurses in a tertiary care hospital. To investigate the potential benefit of mentorship in assisting the advanced practice nurses to meet their identified professional development needs. To fully explore the integration of the nurse practitioner role in Canadian long term care (LTC) settings so the full potential of this role can be realised and timely access to quality care ensured for a growing population of LTC residents. To establish the contribution of nurse consultants to public health leadership agenda and understand the barriers precluding this.

Qualitative descriptive  Interviews Case study using mixed methods  Non-participant observation  Interviews  Questionnaire

A 3 phase, mixed method, sequential explanatory design  Delphi study  Non-participant observation  Interviews  Questionnaire  Documentary evidence Mixed method  Interviews  Analysis of published and grey literature, policy documents, nurse practitioner programme curricula. Survey  Questionnaire

Mixed-method  Questionnaire  Structured interview  Diary analysis  Focus groups  Structured meetings with policy-makers Decision support synthesis  Scoping review  Interview  Focus group interview

Mixed method  Questionnaire  Focus group interview

Executive leaders and policy makers in national organisations (n = 12) Advanced Practitioners and Clinical Specialists (n = 23) Clinicians (n = 21) Directors of Nursing/Midwifery (n = 13) Service users (n = 154) Nurse/midwife practitioner (n = 46) Clinical team members (n = 41) Director of Nursing/Midwifery (n = 28) Service users (n = 41) Nurse practitioners (n = 15)

Nurse practitioners (n = 374)

Nurse Consultants (n = 5) Key stakeholders including Chief Nurses of HSS Boards and Chief Nursing Officer (n = 300)

Scoping review articles (n = 468) Advanced Practice Nurses (n = 22) Key stakeholders (n = 40) INP/APNN conference attendees (n = 15) Nurse practitioners (n = 4) Advanced practice nurses (n = 14)

Multi-method  Questionnaire  Misener NP Job Satisfaction scale  Interviews

Nurse Practitioners (n = 37) Administrators and directors of care (n = 63)

Mixed method  Log of daily activities  Semi-structured interview

Nurse consultants (n = 4) Managers and service leaders (n = 6)

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Table 1 (Continued ) Author and year

Research aim

Research design and data collection methods

Sample

Franks and Howarth (2012)

To explore the role, key attributes and SWOT of nurse consultants specialising in safeguarding children. To identify factors that influence ability of advanced practice nurse to promote evidence-based practice among frontline nurses.

Mixed method  Log of daily activities  Semi-structured interview Multiple case study  Interview  Non-participant observation

To examine possible differences between master and non-mastered prepared paediatric nurse practitioners. To evaluate the impact of nurse, midwife and health visitor consultants on service delivery and patient care.

Survey  Questionnaire

Nurse consultants (n = 4) Managers and service leaders (n = 6) Advanced Practice Nurses (n = 23) Front line nurses and members of MDT approximately 10 per case study. Master’s and non-master’sprepared Paediatric Nurse Practitioners (n = 236)

To establish a rich picture of the nurse consultant role specialising in safeguarding children, in relation to their existing skills and perceived education needs. To identify factors that influence the leadership dimension of the role as part of larger study that aimed to evaluate the role and services of Clinical Specialists/Advanced Practitioners

Multi-method:  Semi-structured interview  Documentary analysis of job description and role specification Case study using mixed methods  Non-participant observation  Interview  Documentary evidence

To synthesise the evidence on the experiences of UK consultant nurses in implementing a new role in order to identify inhibitors and facilitators of role development. To examine the relationship of NP perceptions of the leadership climate in their organisations and self-reported formal and informal leadership behaviours. To examine perceptions of leadership by Master’s-prepared Nurse Practitioners and determine if they are providing leadership in practice. To identify contextual factors and challenges to role of the Acute Care Nurse Practitioner in Canada.

Systematic Review

Gerrish et al. (2012)

Glascock et al. (1985)

Guest et al. (2004)

Helen and Michelle (2012)

Higgins et al. (2014)

Hourahane et al. (2012)

Jones et al. (1990)

Joyce (2001)

Kilpatrick et al. (2010)

Leggat et al. (2015)

Manley and Titchen (2012)

To determine whether a formal mentoring programme assists nurse practitioner candidates to develop competence in their clinical leadership competencies. To enable Nurse Consultants and aspiring nurse consultants to become more effective through a programme of support which focused on developing expertise across the range of Nurse Consultant functions.

Multi-method evaluation  Interviews  Focus group  Questionnaire

Nurse consultants (survey n = 419) Nurse consultants (longitudinal panel interviews n = 32) Nurse consultants (leadership interviews n = 11) Nurse consultants (focus groups n = 22) Directors of Nursing/Midwifery (n = 11) Nurse consultants (n = 4) Key stakeholders (n = 6)

Clinical Specialists/Advanced Practitioners (n = 23) Multi-Disciplinary Team members (n = 21) Directors of Nursing/Midwifery (n = 13) Research articles (n = 11)

Survey  Questionnaire

Nurse Practitioners (n = 317)

Phenomenology  Interviews

Nurse Practitioners (n = 8)

Mixed methods  Scoping review  Individual interviews  Focus group interviews

Scoping review articles (n = 468) Clinical Nurse Specialist, Nurse Practitioner, physicians, educators, members of team, regulators, administrators and policy makers: Individual interviews (n = 62), and focus group (19 participants). Nurse practitioner candidates (n = 18) Senior nurses (n = 17)

Pre-post longitudinal intervention study  Leadership Practices Inventory Action learning-emancipatory action research  Action learning workshops  Interview  Reflective reviews

Nurse consultants (n = 10) Nurse consultant candidates (n = 7)

N. Elliott et al. / International Journal of Nursing Studies 60 (2016) 24–45

32 Table 1 (Continued ) Author and year

Research aim

Research design and data collection methods

Sample

Manley et al. (2008)

To explore how the leadership component of the Consultant Nurse for Older people role was reflected in day to day working.

Nurse consultants (n = 4) Action research facilitators (n = 5)

McIntosh and Tolson (2009)

To evaluate the extent to which nurse consultants fulfilled the 4 core functions of the role-including leadership.

Co-operative enquiry  Written accounts of leadership activity  Interpretative phenomenological analysis Multi-method  Semi-structured interviews  Focus group interviews  Documentary analysis

Mullen et al. (2011)

To evaluate the non-medical consultant role in the North West (10 year evaluation)

Mixed method  Literature review  Focus group interviews  Electronic questionnaire

Mullen and Gavin-Daley (2010)

To evaluate the non-medical consultant role in the North West (10 year evaluation)

Mixed method  Literature review  Focus group interview  Electronic questionnaire

National Council for the Professional Development of Nursing and Midwifery (2005)

To provide a preliminary evaluation of the role of the ANP that will guide the development of the role.

Mixed method  Literature review  Interviews

O’Keeffe et al. (2013)

To describe level of job satisfaction of ANP/AMPs.

Redwood et al. (2007)

To evaluate work of NC’s in NHS through key informant and nurse consultants. To provide descriptive accounts of new roles and their impact on practice along with a basis for recommendations and guidance for the future development of these roles. To develop an understanding of the implementation and development of the nurse consultant role.

Survey  Misener Nurse Practitioner Job Satisfaction Scale Case study  3608 feedback process  Interviews Participatory research  Semi-structured interviews

Redwood et

al. (2005)

Simmons (2010)

Woodward et al. (2005)

To explore the work of Nurse Consultants from their perspective and with particular reference to research aspects.

identified barrier (n = 14). Nine papers reported that large and increasing clinical caseloads impact on time available and limit opportunities for advanced practitioners to take on leadership activities or move forward on new ideas for clinical practice (Begley et al., 2010; Chang et al., 2012; DiCenso and Bryant-Lukosius, 2010; Gerrish et al., 2012; Guest et al., 2004; Higgins et al., 2014; National Council for the Professional Development of Nursing and Midwifery, 2005; Redwood et al., 2005; Woodward et al., 2005). Two papers reported that increased pressure for service delivery came in response to staff shortages (Simmons, 2010) and to physician demands (Kilpatrick et al., 2010).

Ethnography  Participant observation  In-depth interviews  Documentary analysis

Cross-sectional-qualitative  Unstructured interview

Nurse consultants (n = 4) Key stakeholders (n = 23) (managers, Directors of Nursing Services, Senior Nurse Managers, Director of Nurse Education) Non-medical consultants: nurses, midwives, health visitors, allied healthcare professionals and pharmacists (n = 95) Directors of Nursing (n = 6) Director/manager of nonmedical consultants (n = 25) Non-medical consultants: nurses, midwives, health visitors, allied healthcare professionals and pharmacists (n = 95) Directors of Nursing (n = 6) Director/manager of nonmedical consultants (n = 25) Advanced Nurse Practitioners (n = 8) Key stakeholders: medical doctors, nurse managers, patients and clinical nurse specialists (n = 17) Advanced Nurse/Midwife Practitioners (n = 47) Nurse consultants (n = 14) Key informants (n = not stated) Nurse consultants (n = 6) Key informants (n = 31) (academic colleagues, Directors of Nursing, clinical colleagues, line managers, students) Nurse Consultants (n = 6) Medical consultants, clinical nurses specialists, ward sisters and matrons (n = 11) Executive directors, senior directorate managers (n = 13) Nurse consultants (n = 10)

The high volume of clinical commitments impacted on the APs’ availability to undertake networking activities (Mullen and Gavin-Daley, 2010). From the national policy makers’ perspectives, a focus on clinical work limited the APs as visible leaders in nursing (Begley et al., 2014). In order to effect changes in clinical practice or service delivery at organisational level, advanced practitioners need support from key stakeholders. However, in 13 papers, lack of support from nursing management, medical consultants and clinical staff was identified as a barrier. Interprofessional tensions most notably with medical consultants (DiCenso and Bryant-Lukosius, 2010; Gerrish

Table 2 Findings related to barriers and enablers to Advanced Practitioner leadership enactment (n = 34). Author and year

Contex: country

Context: clinical setting

Barriers to leadership enactment

Enablers of leadership enactment

Abbott (2007)

England

USA

Begley et al. (2014)

Ireland

All disciplines

Begley et al. (2012)

Ireland

General Nursing Mental Health Intellectual Disability Children’s nursing Midwifery

Begley et al. (2010)

Ireland

General Nursing Mental Health Intellectual Disability Children’s nursing Midwifery

 Limited opportunity for cross boundary working. NCs managed within nursing hierarchies, expected to meet organisational objectives rather than advancing crossboundary work outside of the NC’s organisation.  Lack of formal reporting structure-interfered with ability of NP to effect changes related to patient care or practice. NP’s felt isolated, often unaware of strategic initiatives, practice and policy changes.  Focus on clinical work, not visible as leaders in nursing.  Lack of time and support for research.  Lack of support from policy makers.  Leadership not identified as Number 1 in job description, unlikely to be nominated onto committees as leaders by Director of Nursing.  Clinical/service provision is the main priority for Directors of Nursing and employers.  Lack of understanding of AP role by colleagues.  Fear of role blurring from other team members.  Role overload.  Large clinical/patient caseloads.  Single/lone postholders.

–

Bahouth et al. (2013)

Primary Care Learning disabilities Public health Child protection Intermediate care Academic medical centres

Carryer et al. (2007)

Australia and New Zealand. Taiwan

Multiple areas Multiple areas

Department of Health and Social Services, 2005

N. Ireland

Not identified

DiCenso and Bryant-Lukosius (2010)

Canada

Acute care Primary care

Doerksen (2010)

Canada

One general hospital

–

–

–

 Multiple APs in practice setting.  National accreditation requirements and reaccreditation procedures, involvement of senior managers in developing the standard of APs.  National study days and masterclasses.  Interpersonal skills and attributes. –  NPs with Master’s degree perform better in leadership and reform competence.

–

33

 Organisational, nursing and physician support.  Support from nursing leadership at regional level integrating the APN role, enacting policies that support and legitimise the role, and providing strong management support.  Networking support systems-opportunity for sharing and addressing common issues.  Mentorship especially for those new to APN role.  Professional development opportunities.  10/14 nurse consultants agreed that mentorship helps develop their publication and professional leadership role.

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Chang et al. (2012)

 Lack education on how to influence policy development.  Few clinical NP’s have opportunities to participate in decision-making, promotion and development of NP related affairs led by nurse academics, medical or nursing administration supervisors.  Increasing clinical caseload adversely affected leadership competence.  Most participants were college graduates (75.1%) or junior college graduates (14.8%), opportunities and competencies in leadership and reform are restricted.  Inadequate clerical support for administration aspects of role.  Lack of opportunity to work at strategic level.  Lack of leadership skill development programme.  Lack of managerial support.  Lack of administrative support.  Lack of networks, isolation.  Heavy clinical workload, prevents engagement in nonclinical role activities.  Physician resistance.  Inadequate representation at policy and decision making tables.

–

34

Table 2 (Continued ) Contex: country

Context: clinical setting

Barriers to leadership enactment

Enablers of leadership enactment

Donald et al. (2011)

Canada

Long term care settings

 Clerical support.  Data management support (access to databases, analysts and statisticians).

Franks (2014)

UK

Safeguarding children

Franks and Howarth (2012)

UK

Safeguarding children

Gerrish et al. (2012)

UK

Multiple hospital care settings Primary care

Glascock et al. (1985)

USA

Paediatric settings

 Lack of understanding in others about the worth of their role and by attitudes of other colleagues.  Lack of time for research and the lack of will by managers for them to spend time doing research.  Value of ANP roles is often misunderstood by managers.  Nurses come to roles in ad hoc ways, not fully prepared.  Lack of support/mentoring causes some nurses to flounder.  Lack of preparation for leadership and change agent role.  Lack of understanding and support of the role at organisational level–impacts on opportunity to place children’s needs high on health and social care agenda.  Heavy workloads prevented APNs from being able to role model or assist frontline nurses develop their practice.  Insufficient resources (e.g. IT/computer access).  Lack of time to keep up-to-date with the latest evidence.  Lack of support from medical staff, senior managers, ward managers, nurses to introducing evidence-based changes in care  Lack of access to libraries/resource centres.  Promoting evidence-based practice is a low priority of role. –

    

Guest et al. (2004)

UK

General Nursing Mental Health Learning disability Midwifery Health Visiting Community/primary care

Helen and Michelle (2012)

UK

Safeguarding children

 Lack of authority, support within management system to bring about improvement and change.  Increasing clinical workload –unable to craft an appropriate role or move forward on new ideas.  Lack of financial and staff support – unable to advance clinical innovation without enough staff and equipment.  Lack of basic administrative support.  Lack of leadership experience hindered effectiveness.

Participation on organisational committees. Facilitation of NP involvement in research. Mentorship from experts. Leadership opportunities. Clear job description, leadership at organisation and strategic level in job description, expected to contribute to the strategic and organisational delivery of services.  Good support and mentorship from senior colleagues – imperative to establishing nurse consultancy as a strong and effective role within healthcare organisations.

 APs able to formulate and operationalise policies and frameworks, connect services across a range of sectors.  APs able to establish networks and be a change agent at clinical/operational and strategic levels. –

 Master’s prepared NPs engaged in more leadership activities than non-master’s NPs.  Administration support – freed up time for NC’s to focus on key aspects of their role to bring about improvements and change.

 NC and other stakeholders viewed the role as pivotal in driving change at local and national level, perceived as experts to be consulted.

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Author and year

Ireland

General Nursing Mental Health Intellectual Disability nursing. Children’s nursing Midwifery

 Lone AP practitioner posts.  Large clinical caseloads coupled with a lack of time limited opportunities to take on leadership activities outside the immediate clinical context.

Hourahane et al. (2012)

UK

–

 The influence of others on the CN post e.g. yielding to doctor’s power.  Lack of clarity about the leadership function.  Shifting politics limits the enactment of leadership.  Organisational structure/arrangements can restrict the role – CN having a lack of control over the post direction.  Being traditionally managed, with lack of authority.  Lack of support through lack of resources.  Lack of organisational support/management/ administration.  Lack of support from medics.  Lack of clarity about the leadership and research functions of the role.  Confusion between the CN role and the Clinical Nurse Specialist role.  A job description that encompasses too much.  Being unprepared for the strategic element of the role.

Jones et al. (1990)

USA

Multiple specialties

Joyce (2001)

USA

Kilpatrick et al. (2010)

Canada

Adult Older person care, Family Midwifery Acute care settings

Leggat et al. (2015)

Australia

Not identified

 All leadership dimensions were predicted by at least one organisational climate dimension. Meeting organisational needs was predicted by the degree of risk taking supported and rewards given.  NP’s did not see self as leaders.  Competing demands.  Competing demands – physician demands to devote time to clinical component, whereas nurse administration want them to have time for leadership. –

 National framework for role development.  Multiple AP practitioners.  Nominated by Director of Nursing/Midwifery to represent organisation/specialty on internal/ external committees.  Mechanisms for sustaining leadership: availability of learning forums, platforms to showcase NP innovation and developments, opportunities to network and build strategic alliances.  Re-accreditation requirement to maintain a portfolio of professional and personal development to include evidence of ongoing leadership and clinical service delivery outcomes in their portfolio.  Personal attributes of the specialist/advanced practitioner.  The ability to influence.  The ability to lead; communication skills are essential.  Techniques of leadership and communications skills are essential with an ability to ‘propel’ agendas.  Having leadership strategies linked to patients, teams and the organisation.  Having evidence of leadership.  Having autonomy, flexibility and inclusion in senior decision making gives freedom to develop role.  Having freedom to work organisation-wide.  Support from peers and medics.  Organisational support: management/ administration.  Support from research and development.  The CN’s clarity of role stems from their expertise which makes them credible.  The clarity others have about the CN role and being able to differentiate the CN from other clinical roles particularly because of the leadership element of the role.  Managers were culture brokers and by influencing the dimensions of organisational climate managers may empower NP to exert both formal and informal leadership. –

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Higgins et al. (2014)

 Communication that clearly articulates the leadership dimension and expectation aids role implementation.  Formal mentoring programme – pairing experienced nurse practitioners and senior nurses with nurse practitioner candidates, assists NPCs to develop leadership skills.

35

36

Table 2 (Continued ) Author and year

Contex: country

Context: clinical setting

Barriers to leadership enactment

Enablers of leadership enactment

Manley and Titchen (2012)

UK

General nursing Midwifery Mental Health Paediatrics Intermediate care Community Public Health Child Protection

–

Manley et al. (2008)

UK

Older person care

Organisations did not:  know how to use NCs and did not value them  have role clarity – role not embedded into organisational culture  know how to support and develop NCs  accord them the same status as other consultants. –

McIntosh and Tolson (2009)

UK

Primary care

Mullen et al. (2011)

UK

Acute care Primary care Mental health Specialist services

Mullen and Gavin-Daley (2010)

UK

Nursing Midwifery Health visitor Pharmacists Allied Healthcare Professionals

 Some NMCs 18% (n = 17) did not appear to undertake any networking activities. A small number of NMCs 5% (n = 5) said they had not got the time, were exhausted, were not supported by their director or manager and/ or could not network due to clinical commitments.  Time within role – it took the majority of NMC up to 2 years to become established in the role, and a significant number took 4–5 years to get established.

National Council for the Professional Development of Nursing and Midwifery (2005)

Ireland

General Nursing Primary care Neonatology

 Clinical work expanding – less time available for other aspects of the role, thus influencing their ability to fulfil all elements of the role.  Lone NP post – difficult to take time away from the clinical work to attend to other aspects of the role.  Inadequate access to secretarial services – for clinically related work and educational and research activities.

O’Keeffe et al. (2013)

Ireland

Cross discipline Multiple specialists

Redwood et al. (2007)

UK

Acute care Mental health

 Lack of opportunity to secure resources – including secretarial support and funding for services to bring about change in practice.  Lack of support by management for leading research.  Lack of support from management.  Lack of a ‘critical mass’ of postholders regionally and nationally.  Organisational barriers hindered transformational style leadership endeavours.  Lack of personal attributes.

 Presence of personal attributes – ability for strategic thinking, have vision and education, research and evidence to be able to take forward change.

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 Resistance to change from other practitioners – who were longer/more established in clinical area.  Lack of understanding.  Resistance from staff and to organisational change.  Lack of appropriate administrative support.

Having explicit nursing expertise Role clarity Opportunities for networking across boundaries. Possessing attributes that enable them to act as leaders.  Internal support from colleagues.  Personal skills and behaviours.  External support from peers or networks/groups.  Previous experience and having worked in the trust before.  Understanding of the role within the organisation.  Impact of the role was greater when either line management and/or professional accountability were at the director level.  Formal links to universities – increased number of applications and success rate for research funding.  Majority of NMCs 89% [n = 85] were involved in regional expert groups and or networks and 76% [n = 72] participated in a variety of internal groups demonstrating their wider involvement in strategic decision making and working internally as a strategic contributor to policy and service development.  More than one NP working in an area.  Support from the multidisciplinary team and colleagues.  Support from nursing management – assisted planning service developments and time allocation. Nurse Managers had a role in garnering the support of the relevant agencies in terms of resources and co-operation, encouraging the NP and providing guidance on the relationship/ interface between NP role and overall service.  Master’s level education. –    

UK

Mental health Trust General hospital Trust

Simmons (2010)

UK

Acute National Health Service Trust

Woodward et al. (2005)

UK

General Nursing Mental Health

 Clinical demands competing with other leadership roles.  Lack of opportunity to work in advisory roles.  Lack of administrative support – NC’s spend time booking rooms, making appointments for meetings, taking minutes and writing letters on a regular basis.  Immature infrastructures – unclear how NC’s fit into organisation  Isolation – lone NC position.  Increased pressure for service delivery especially where there were staff shortages.  Research activity not a priority of strategic stakeholders.  Inadequate infrastructure support – need administrative support for clinical workload to free-up time for non-clinical work.  Inadequate infrastructure funding – to develop new nurse-led clinics and for professional development.  Professional sensitivities ‘politics’.  Lack of understanding about the leadership element of the role from Head of Nursing.  Lack of support from strategic stakeholders and clinical staff  Subservient relationship with medical consultants.  Excessive clinical workload and meeting government targets for waiting times – clinical work supersedes developmental work.  Role/job expectations not known.  Lack of authority to control decision-making, problems with access to decision-makers.

–

 Clear role boundaries-when in place NCs did not experience barriers associated with professional sensitivities.  Team support – teams that valued the NC and appreciated her expertise allowed/encouraged her to lead.  New NCs valued networking opportunities for support from other NCs in the Trust or external specialist network – helped develop strategic aspects of their role.

 Level of experience and Maser’s level education.

Key: AP, Advanced Practitioner; APN, Advanced Practice Nurse; CN Consultant Nurse; NC, Nurse Consultant; NP Nurse Practitioner; NMC, Non-Medical Consultant.

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Redwood et al. (2005)

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38

Table 3 Barriers to advanced practitioner leadership role enactment. Barrier

Number of papers

References

Healthcare system level [dimension: *healthcare and practice policy, *national and international guidelines] * Lack of opportunities to work at Abbott (2007); Begley et al. (2014); Begley et al. (2012); Chang et al. (2012); n=7 strategic level. Department of Health and Social Services (2005); DiCenso and Bryant-Lukosius (2010); Redwood et al. (2005). Organisational level [dimension: *workload, *support, *authority position, *resourcing, common understanding] * Large clinical caseload. n = 14 Begley et al. (2014); Begley et al. (2012); Begley et al. (2010); Chang et al. (2012); DiCenso and Bryant-Lukosius (2010); Gerrish et al. (2012); Guest et al. (2004); Higgins et al. (2014); Kilpatrick et al. (2010); Mullen and Gavin-Daley (2010); National Council for the Professional Development of Nursing and Midwifery (2005); Redwood et al. (2005); Simmons (2010); Woodward et al. (2005). * n = 13 Lack of support from nursing DiCenso and Bryant-Lukosius (2010); Donald et al. (2011); Franks (2014); Franks and management, medical Howarth (2012); Gerrish et al. (2012); Hourahane et al. (2012); Jones et al. (1990); consultants and clinical staff. Manley and Titchen (2012); McIntosh and Tolson (2009); Mullen et al. (2011); Mullen and Gavin-Daley (2010); O’Keeffe et al. (2013); Simmons (2010). Lack of clarity and n = 11 Begley et al. (2014); Begley et al. (2010); Franks (2014); Franks and Howarth (2012); understanding of leadership Gerrish et al. (2012); Hourahane et al. (2012); Manley and Titchen (2012); Mullen et al. and research role. (2011); O’Keeffe et al. (2013); Redwood et al. (2005); Simmons (2010). * Lack of clerical/administrative n = 11 Department of Health and Social Services (2005); DiCenso and Bryant-Lukosius support. (2010); Donald et al. (2011); Guest et al. (2004); Hourahane et al. (2012); Mullen et al. (2011); Mullen and Gavin-Daley (2010); National Council for the Professional Development of Nursing and Midwifery (2005); O’Keeffe et al. (2013); Redwood et al. (2005); Simmons (2010). * Lack of authority position Bahouth et al. (2013); Guest et al. (2004); Hourahane et al. (2012); Manley and Titchen n=6 within organisation. (2012); Simmons (2010); Woodward et al. (2005). * Insufficient resources (e.g. Donald et al. (2011); Gerrish et al. (2012); Guest et al. (2004); Hourahane et al. (2012); n=6 financial/IT/library access). O’Keeffe et al. (2013); Simmons (2010). *

Lack of time/support for research.

Team level [dimension: critical mass] Lack of ‘critical AP mass’/lone AP position.

n=4

Begley et al. (2014); Franks (2014); O’Keeffe et al. (2013); Simmons (2010).

n=6

Begley et al. (2010); DiCenso and Bryant-Lukosius (2010); Higgins et al. (2014); National Council for the Professional Development of Nursing and Midwifery (2005); Redwood et al. (2007); Redwood et al. (2005).

Advanced Practitioner level [dimension: personal characteristics, education] Lack of leadership skill n=6 development/education. Lacking AP attributes. n=3 Level of education. n=1 Time within role. n=1

Carryer et al. (2007); Department of Health and Social Services, (2005); Franks (2014); Franks and Howarth (2012); Helen and Michelle (2012); Hourahane et al. (2012). Chang et al. (2012); Joyce (2001); Redwood et al. (2007). Chang et al. (2012). Mullen and Gavin-Daley (2010).

* New/additional dimensions to Kilpatrick et al.’s (2013) conceptual framework. AP, Advanced Practitioner: IT, Information Technology.

et al., 2012; Hourahane et al., 2012; Simmons, 2010), and intradisciplinary tensions with frontline, experienced staff-nurses and clinical specialists (DiCenso and BryantLukosius, 2010; Gerrish et al., 2012; McIntosh and Tolson, 2009) and lack of support at organisational level (Franks and Howarth, 2012; Gerrish et al., 2012; Hourahane et al., 2012) were also factors that contributed to resistance to advanced practitioner-led changes in care and service delivery. Eleven papers reported that a lack of clerical or administration support for patient and clinical-related work reduced the APs’ time available for non-clinical leadership activities. Insufficient resourcing was also reported in the areas of data management support (Donald et al., 2011; Gerrish et al., 2012), funding (Guest et al., 2004; O’Keeffe et al., 2013; Simmons, 2010), and

computer/IT, library/resource access (Gerrish et al., 2012), which are all necessary to support the APs’ leadership role. Lack of clarity and understanding of the advanced practitioner role, including the leadership or research leader component of the role, was reported by 11 papers. In these studies, lack of understanding by managers or organisational leads of how advanced practitioners fit into the organisation as leaders (Simmons, 2010; Redwood et al., 2005), or their contribution to research (Franks, 2014; Simmons, 2010) were reported as barriers. Lack of authority and position within the organisation was reported in six papers. In these studies, lack of authority associated with being managed within traditional nursing hierarchies and not having a formal reporting structure to executive or director level organisational management (Bahouth et al., 2013; Guest et al.,

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39

Table 4 Enablers to advanced practitioner leadership role enactment. Enabler

Number of papers

Healthcare system level [dimension: *accreditation/re-accreditation policies] National accreditation and ren=2 accreditation requirements.

*

References

Begley et al. (2010); Higgins et al. (2014).

Organisational level [dimension: *network development, *mentoring, *support, *healthcare-university research links, *reporting structure, *resourcing/funding, common understanding] * n=9 Networking opportunities Begley et al. (2010); DiCenso and Bryant-Lukosius (2010); Franks and Howarth (2012); within organisation and with Helen and Michelle (2012); Higgins et al. (2014); Manley et al. (2008); Mullen et al. external groups. (2011); Mullen and Gavin-Daley (2010); Simmons (2010). * Mentoring/support from senior n=7 DiCenso and Bryant-Lukosius (2010); Doerksen (2010); Donald et al. (2011); Franks managers. (2014); Jones et al. (1990); Leggat et al. (2015); National Council for the Professional Development of Nursing and Midwifery (2005). n=5 Clarity in leadership role incl. at Franks (2014); Hourahane et al. (2012); Kilpatrick et al. (2010); Manley et al. (2008); organisation and strategic Simmons (2010). level. * n=3 Leadership opportunities/ Donald et al. (2011); Higgins et al. (2014); Mullen and Gavin-Daley (2010). participation in organisational committees. * Research support/links. n=3 Donald et al. (2011); Hourahane et al. (2012); Mullen and Gavin-Daley (2010). * Reporting structure at director n=1 Mullen et al. (2011). level. * Administration support. n=1 Guest et al. (2004). Team level [dimension: critical mass] Multiple APs.

n=3

Advanced Practitioner level [dimension: personal characteristics, education] Personal leadership attributes. n=7 MSc level education.

n=4

Begley et al. (2010); Higgins et al. (2014); National Council for the Professional Development of Nursing and Midwifery (2005).

Begley et al. (2010); Higgins et al. (2014); Hourahane et al. (2012); McIntosh and Tolson (2009); Mullen et al. (2011); Redwood et al. (2007); Woodward et al. (2005). Chang et al. (2012); Glascock et al. (1985); National Council for the Professional Development of Nursing and Midwifery (2005); Woodward et al. (2005).

* New/additional dimensions to Kilpatrick et al.’s (2013) conceptual framework. AP, Advanced Practitioner.

2004; Hourahane et al., 2012; Woodward et al., 2005) and having a subservient relationship to medical consultants (Hourahane et al., 2012; Manley and Titchen, 2012; Simmons, 2010) impacted on the advanced practitioner’s ability to influence strategic decision-making and provide leadership in developing healthcare/services. Lack of time for research or support by managers to carry out research activities which is necessary to support APs’ clinical leadership role was reported in four studies. 3.2.2. Healthcare system-level barriers Within the healthcare system-level category of barriers, lack of opportunity to work as leaders at strategic level was reported in seven papers. In these papers, lack of opportunities included: restrictions on cross-boundary working where APs were expected to meet organisational objectives (Abbott, 2007; Redwood et al., 2005); not being nominated onto committees as leaders or included as nurse representatives at policy and decision-making tables (Begley et al., 2012; Chang et al., 2012; DiCenso and Bryant-Lukosius, 2010); and not having a budget-holding or senior management responsibility (Department of Health and Social Services, 2005).

3.2.3. Advanced practitioner-level barriers Under advanced practitioner-level barriers six papers reported a lack of leadership skill development through mentoring or education programmes for advanced practitioners. In one paper, whilst advanced practitioners recognised that leadership was part of their role, they lacked knowledge on how to influence policy development (Carryer et al., 2007). Lack of preparation for leadership and change agent role (Franks and Howarth, 2012; Hourahane et al., 2012), lack of mentorship from senior colleagues (Franks, 2014) or lack of leadership experience (Helen and Michelle, 2012) were also reported as barriers to leadership enactment of APs. Three other barriers that were reported across four papers included not having master’s degree level education (Chang et al., 2012), insufficient time within role (Mullen and Gavin-Daley, 2010), and lacking advanced practitioner attributes such as: age/seniority (Chang et al., 2012); not seeing self as leader (Joyce, 2001); and lacking ability for strategic thinking or lacking vision (Redwood et al., 2007). 3.2.4. Team-level barriers Under team-level category barriers, lone or single advanced practitioner position was reported as a barrier

40

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to the advanced practitioner’s ability to enact leadership in six papers. 3.3. Enablers to advanced practitioner leadership role enactment From the analysis, the eleven enablers (see Table 4) were categorised under four structural headings: (1) healthcare system-level: (i) national accreditation and re-accreditation requirements, (2) organisational-level: (ii) networking opportunities within organisation and with external groups; (iii) mentoring and support from senior managers; (iv) clarity in leadership role including organisation and strategic level leadership; (v) leadership opportunities/participation in organisational committees; (vi) research support and links; (vii) reporting structure at director level; (viii) administration support, (3) teamlevel: (ix) multiple AP postholders, and (4) advanced practitioner-level: (x) personal leadership attributes; (xi) Master’s level education. 3.3.1. Organisational-level enablers Organisational-level (n = 7) was the largest category of enablers. Networking opportunities within the organisation and with external groups was the most frequently identified enabler to advanced practitioner leadership enactment across the 34 papers in this scoping review. Networking provided opportunities for advanced practitioners to build strategic alliances across boundaries and to act as change agents at clinical, operational and strategic levels (Franks and Howarth, 2012; Helen and Michelle, 2012; Higgins et al., 2014; Manley et al., 2008; Mullen et al., 2011; Mullen and Gavin-Daley, 2010; Simmons, 2010). Networking groups were reported as providing a support system for sharing and addressing common issues for advanced practitioners (DiCenso and Bryant-Lukosius, 2010). One study reported that networking opportunities in the form of advanced practitioner study days and masterclass events had a major impact on advanced practitioners in developing their role (Begley et al., 2010). In seven papers, mentoring and support from senior managers was reported as an enabler. One of these reported that a formal mentoring intervention with an action learning approach, whereby experienced nurse practitioners were paired with candidate nurse practitioners, resulted in significant improvement in selfreported leadership practices, assisted nurses to overcome barriers to clinical leadership and developed competence in clinical leadership (Leggat et al., 2015). Mentorship was identified as important especially for those new to advanced practice roles (DiCenso and Bryant-Lukosius, 2010) and to the establishment of a strong and effective advanced practitioner role within healthcare organisations (Franks, 2014). Five papers reported that having a clear leadership role description including responsibility at organisational and strategic level was important. Two papers found that role clarity supported advanced practitioners in their ability to articulate clearly to others what they could offer as leaders and set clear objectives for developing nursing practice (Hourahane et al., 2012; Manley et al., 2008). One paper

reported that where clear role boundaries were in place, advanced practitioners did not experience barriers associated with professional sensitivities (Simmons, 2010). Having opportunity to act as leader and participate in organisational committees was reported in three papers. One study showed that through participation in regional expert groups, networks and internal group, advanced practitioners demonstrated their wider involvement in strategic decision-making and contribution to strategic policy and service development (Mullen and Gavin-Daley, 2010). Having leadership opportunity was conditional on the advanced practitioner being put forward and nominated by the Director of Nursing/Midwifery to represent their organisation or specialty on internal and external committees (Higgins et al., 2014). Three papers reported that support for undertaking research (Donald et al., 2011; Hourahane et al., 2012) was an enabler; and having formal links to universities increased the number of applications by advanced practitioners and success rate for research funding (Mullen and Gavin-Daley, 2010). Two other enablers reported across two papers included; having a reporting structure whereby advanced practitioner had professional accountability at director level (Mullen and Gavin-Daley, 2010); and, having administration support that enabled advanced practitioners focus on leadership aspects of their role to improve practice and healthcare delivery (Guest et al., 2004). 3.3.2. Healthcare system-level enablers Within the healthcare system-level category of enablers, two papers reported that having national accreditation and re-accreditation standards, which require evidence of leadership as part of the advanced practitioner’s portfolio, was an enabler to leadership enactment (Begley et al., 2010; Higgins et al., 2014). 3.3.3. Advanced practitioner-level enablers Advanced practitioner-level enablers including personal attributes were reported in seven papers. In addition to their clinical expertise and knowledge of local contexts, the ability to lead teams in a process of implementing change (Higgins et al., 2014; Hourahane et al., 2012), to bring people from disparate professions together (McIntosh and Tolson, 2009), plus the attributes of political awareness (McIntosh and Tolson, 2009), strategic thinking and vision, (Redwood et al., 2007), and possessing high levels of selfconfidence and assertiveness (Woodward et al., 2005) were reported. Four papers identified that having advanced practitioners educated to master’s degree level was an enabler. Of these, one paper reported that master’sprepared paediatric nurse practitioners engaged in more leadership activities than those not educated to that level (Glascock et al., 1985). 3.3.4. Team-level enablers Under team-level category enablers, having multiple advanced practitioners in practice settings was reported as beneficial in three papers (Begley et al., 2010; Higgins et al., 2014; National Council for the Professional Development of Nursing and Midwifery, 2005).

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4. Discussion This scoping review provides a comprehensive overview of the research evidence on barriers and enablers to advanced practitioner leadership enactment in the international literature to date. Quality appraisal is not undertaken as part of a scoping review (Arksey and O’Malley, 2005), which can limit conclusions about the strength of evidence on barriers and enablers. However, the selection criteria employed in this scoping review were designed to include all relevant research in order to provide a broad evidence base on the leadership barriers and enablers in the advanced practitioner contexts. Publication and related biases associated with literature-based research can limit the validity of research synthesis and produce summaries that are based on incomplete sets of evidence (Ahmed et al., 2012; Song et al., 2010). In this scoping review, methods used to source research reports and minimise the risk of publication bias included extensive searches to locate unpublished studies or grey literature. This resulted in 11 unpublished research reports being included within the total set of papers (32%). The quality of the grey literature reviewed here was considered good as many were large-scale studies which took account of, and reported in sufficient detail, the advanced practitioner contexts in which the studies were conducted. Furthermore, more data were available in these unpublished reports when compared to the data available in peer-reviewed journal publications where research descriptions are, by necessity, limited by word count. It is also important to acknowledge the temporal context of data generation in these reports. Many of these studies (Begley et al., 2010; Department of Health and Social Services, 2005; DiCenso and Bryant-Lukosius, 2010; Donald et al., 2011; Guest et al., 2004; Mullen and Gavin-Daley, 2010; National Council for the Professional Development of Nursing and Midwifery, 2005; Redwood et al., 2005; Simmons, 2010) were carried out in a 5–10 year post-implementation period with the objective of evaluating the ‘new’ advanced practitioner role. The evaluations focused on aspects relating to integration within existing services, impact on clinical and organisational outcomes, and fulfilment of the clinical, research and leadership components of the role. Therefore, the available leadership data is fragmented, has varying levels of evidence and, overall, lacks the benefit of employing a theoretical framework on advanced practitioner leadership which would have supported a systematic research approach and contributed to a more cohesive body of evidence on advanced practitioner leadership enactment. Although Kilpatrick et al.’s (2013) framework provided an overall structure for categorising the review findings, the additional structural-level dimensions identified from this barriers-enablers analysis indicate the need for further work on expanding the structural-level dimensions to account for leadership role enactment. Furthermore, Gilmartin and D’Aunno (2007) recommend that leadership research adopts a broad perspective that includes not only the health sector but also integrates with the general leadership theory and knowledge in other sectors.

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An important finding from this scoping review is that the majority of barriers and enablers to advanced practitioner leadership enactment are organisational-level and associated with building leadership capacity as opposed to leadership capabilities as characterised by the individual’s traits, styles, and behaviours from leadership theories; for example, Transformational Leadership (Bass and Avolio, 1994; Kouzes and Posner, 2012) and Situational Leadership (Hersey et al., 2012). The concept of building leadership capacity is still evolving; however, subtle yet important distinctions between leadership capacity and leadership capability are beginning to emerge. For Weiss and Molinaro (2005), leadership capacity focuses on the organisation-level systems and practices to build up the number and level of leaders, whereas leadership capability is about the individual-level skills, abilities and developing leadership competency through education programmes. The barriers and enablers identified in this scoping review, including networking opportunities, mentoring and support from senior management, defined position of accountability at organisational and strategic level, opportunities to participate in organisational committees, administration support and clinical caseload management, imply that they are mainly organisational in nature. Exemplars that demonstrate the positive impact of organisational structure on the advanced practitioner’s ability to fulfil their role function, include Mullen and Gavin-Daley’s (2010) paper, which found that advanced practitioners with formal link arrangements with universities had more research applications and funding successes that those with informal or no links. This resulted in increased research activity and positively impacted on this component of the advanced practitioner’s clinical leadership. Higgins et al.’s (2014) paper provides another example whereby national reaccreditation structures and requirements for advanced practitioners to include evidence of leadership outcomes have a positive impact as both senior management and advanced practitioners share the common objective of being successful in the re-accreditation of the advanced practitioner post.The findings in this scoping review of international research, therefore, contribute to the evidence-base that the leadership functioning of advanced practitioners is contingent on whether or not the organisation has effective structures and processes in place for building advanced practitioner leadership capacity. Building leadership capacity is complex, requiring senior management to share leadership tasks and focus on developing leadership potential in those with less experience (Slater, 2008). In this scoping review, key enablers to leadership enactment were advanced practitioners having networking opportunities both within and between organisations, coupled with having the support from senior management to develop and be involved in those networks. Networks enabled advanced practitioners to acquire a ‘global’ view or perspective, thus facilitating them to act as change agents at clinical and strategic levels (Franks and Howarth, 2012; Helen and Michelle, 2012; Mullen and Gavin-Daley, 2010). Outside of nursing, leadership scholars and researchers assert that interorganisational and organisational networks are linked

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directly to leader effectiveness and impact on the organisation’s growth, survival and innovation (Kilduff and Balkundi, 2011). Networking enables individuals to acquire a particular type of power-knowledge and have access to others who control resources and business opportunities. Kilduff and Balkundi (2011) assert that the extent to which leaders are effective depends on the positions they have in the key networks both within and between organisations. Although the importance of networking to leader effectiveness is known, the findings from this scoping review suggest that networking is not always valued or supported by senior management or the organisations in which advanced practitioners work. Schein’s (1971:526) role innovation theory provides insight into the socialisation processes associated with new professional roles ‘‘. . .in large bureaucratically organized settings’’. According to Schein, for role innovation to be effective, professionals need to consider organisations as complex social systems and develop the skills of working with other disciplines in order to be able to intervene and initiate innovative change processes. Preparing nurses for leadership roles in increasingly complex business-orientated healthcare systems requires not only appropriate educational programmes but also support in developing skill-sets (i.e. understanding and appropriately intervening in organisational and political processes, balancing operational issues with strategic ones) that will enable nurses to become effective leaders initiating change in competitive environments and complex healthcare organisations (Huston, 2008; Machell et al., 2009). In this scoping review, senior management was identified as having a key role in enabling advanced practitioners to act as leaders through formal and informal mentoring, especially those new to the role or organisation and also by providing leadership opportunities through nominating advanced practitioners as representatives of the profession and/or organisation onto strategic committees, so that they are more visible as leaders in nursing to other healthcare professions. As such, senior management’s role as a ‘leadership broker’ is instrumental to the advanced practitioners’ ability to enact leadership. Unless advanced practitioners are given opportunities to work at strategic level and afforded positions of authority both within, and external to, the organisation, there is a risk that their visibility and leadership potential will be limited to individual patient and clinical arenas. Mentoring is effective in leadership development (Dziczkowski, 2013; Groves, 2007; Solansky, 2010; Stead, 2005; Tracy and Hanson, 2014); however, one cannot assume that senior managers are equipped to act as mentors to advanced practitioners, especially if they themselves have no experience of being mentored or any training on how to be effective mentors for others. From the general leadership and organisational theories, the Competing Values Framework (Quinn and Rohrbaugh, 1983) provides a useful framework for understanding how organisations function and deal with complexity (O’Riordan, 2015; Tong and Arvey, 2015). The Competing Values Framework identifies internal versus external values as a key factor of relevance to advanced practitioners who have to deal with competing demands

between thoseof the healthcare organisation and the profession. A key finding in this scoping review is that having large and increasing clinical caseloads coupled with a lack of clerical or administration support limits the time that advanced practitioners have available for leadership activities, including research. Evidence from studies outside the scoping review that measured the time advanced practitioners spend on their role functions, supports this finding. Results from a time-and-motion study of nurse practitioners working in an acute care setting in Canada (Kilpatrick et al., 2012), show that nurse practitioners spent 62–73% of their time on clinical activities and 4–16% on administration activities, with education, research and personal activities accounting for the remaining time spent. Another study of advanced practice nurses in a nephrology unit in Canada that measured how time was spent using a time documentation tool (Ridley et al., 2000) reports that an average of 72% was spent in clinical practice whereas only 2% of time was spent on professional leadership and publication activities. Whilst both of these were small-scale studies undertaken in acute health care settings in Canada, they do provide an objective measurement of advanced practitioner role activities. In the UK, policy guidelines on the nurse consultant’s time allocation state that it comprises 50% clinical and 50% non-clinical activities, however, numerous studies consistently report that service demands take priority over other aspects of the nurse consultant role (Guest et al., 2004; Mullen and Gavin-Daley, 2010; Simmons, 2010; Woodward et al., 2005). In a systematic review and metasynthesis of the effectiveness of nurse, midwife/allied health professional consultant role in the UK, Humphreys et al. (2007) report that they function at an operational level rather than at a strategic level, concluding that the emphasis placed on meeting service needs is an major concern as it leads to deficits in the other functions expected of the role. Furthermore, organisations where advanced practitioners were in single post-holder positions meant that they had sole responsibility for clinical work. These clinical responsibilities, coupled with a lack of peer-support and lack of ‘critical’ mass, added further constraints on the advanced practitioner’s ability to enact leadership. In considering future development of the leadership component of the role, the issue of competing values between organisational demands (Gilmartin and D’Aunno, 2007) (i.e. increasing patient numbers, reducing waiting lists, improved access, meeting performance targets within budgetary constraints) and the leadership role as envisioned by the profession (Canadian Nurses Association, 2008; National Council of Nursing and Midwifery, 2008; National Organization of Nurse Practitioner Faculties, 2011; Nursing and Midwifery Board of Australia, 2014; Royal College of Nursing, 2012; The Scottish Government, 2010), needs to be addressed. Understanding the context-specific nature of the advanced practitioner role (Hourahane et al., 2012; Kilpatrick et al., 2013; Simmons, 2010) is important in informing decision-making on future development of the role and identifying what supports are needed, so that they can enact their leadership role in pioneering innovative and improved healthcare practice. The context-specific nature of the role also highlights the importance of having

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advanced practitioner-sensitive outcomes and indicators (Elliott et al., 2014; Hickey and Brosnan, 2012; Kleinpell, 2013), so they can demonstrate their impact on patient outcomes, cost-effectiveness, service and professional developments when competing for limited resources in cost conscious times. 5. Conclusion Understanding the barriers and enablers to advanced practitioners’ leadership enactment derived from research evidence is necessary to advance the leadership dimension of the role, as well as ensuring that the long-term sustainability of the role is not jeopardised. Although limited by the absence of research that focuses specifically on the leadership dimension of the role this systematic scoping review provides further clarity on the structural factors that influence the advanced practitioner’s ability to act as leader. The analysis identified several new additional dimensions across the structural layers of Kilpatrick et al’s framework (2013). This highlights the need for further research expanding the structural-level dimensions to account for leadership role enactment. In future research, whilst some of the enablers and barriers might be considered mirror opposites of each other, this is not always the case, therefore they need to be considered as separate phenomena. A key insight from this scoping review is that leadership capacity is dependent on organisational-level strategies and supports. Although building leadership capabilities at individual and team-level are important, without key inputs from organisational-level healthcare managers there is a risk that the advanced practitioners’ leadership enactment will remain at the level of clinical practice, and their contribution as change agents and innovators at the strategic level of service development and development of the nursing and midwifery professions will never progress. Healthcare managers, therefore, need to consider both the enablers and barriers in their organisational strategy if they are to adopt the leadership roles advocated by the profession. Advanced practitioners themselves need to understand the complexities of leadership and organisational change within social and business-oriented systems, and recognise the impact of competing internal and external demands on healthcare systems. As role innovators, advanced practitioners also have a key role, through collaborative problem-solving with healthcare managers, in seeking to develop organisational structures and processes that build leadership capacity in healthcare settings. Conflict of interest: None declared. Funding: No external funding received. Ethical approval: Not required. References Abbott, S., 2007. Leadership across boundaries: a qualitative study of the nurse consultant role in English primary care. J. Nurs. Manag. 15 (7), 703–710. Andrega˚rd, A.C., Jangland, E., 2015. The tortuous journey of introducing the Nurse Practitioner as a new member of the healthcare team: a

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