Leadership and Management

Differentiating nursing leadership and management competencies

Bonnie Mowinski Jennings, RN, DNSc, FAAN Cynthia C. Scalzi, RN, PhD, FAAN James D. Rodgers III, BA, RN, BSN

Anne Keane, RN, EdD, FAAN, CRNP

As the foundation of evaluating content for nursing leadership and administration courses, leadership and management competencies were identified from a literature review of 140 articles published between 2000–2004. Similarities and differences among the competencies were assessed. A large intersection of common competencies was discovered, indicating a lack of discrimination between leadership and man- agement competencies. Arguably, this fusion ignores the different purposes served by leadership and man- agement. Alternately, the convergence of leadership and management competencies might reflect that traditional distinctions have narrowed. Nevertheless, ambiguity persists regarding essential leadership and management competencies and the way they are reflected in nursing curricula. If concerns about the work environment are to be remedied for patients and staff, nurse educators are urged to act quickly to identify requisite competencies and better align course content with them. This will better prepare nurse administrators to succeed in their arduous work.

Serious concerns exist about the paucity of nurseadministrators to create a work environment that isboth enriching to staff and safe for patients.1–4 The dearth of nurse administrators can be traced to 3 major forces. First, clinical careers are more highly valued than administrative careers.5–7 Second, too few nurse administrators are educationally prepared to assume the challenges of the role.1,8–10 Finally, the dramatic

Bonnie Mowinski Jennings is an Independent Health Care Consultant in Alexandria, VA. Cynthia Scalzi is an Associate Professor at the School of Nursing and the Wharton School, University of Pennsylvania, Philadelphia, PA. James D. Rodgers III is a Health Care Consultant for Neural Capital Management, LLC in New York, NY. Anne Keane is an Associate Dean for Academic Programs and Class of 1965 25th Reunion Term Professor in Nursing at the School of Nursing, University of Pennsylvania, Philadelphia, PA. Reprint requests: Dr. Bonnie M. Jennings, Editorial Board Member, Nursing Outlook, 6828 Lamp Post Lane, Alexandria, VA 22306. E-mail: [email protected]

Nurs Outlook 2007;55:169-175. 0029-6554/07/$–see front matter Copyright © 2007 Mosby, Inc. All rights reserved.

doi:10.1016/j.outlook.2006.10.002

changes resulting from restructuring efforts during the 1990s diminished the appeal of nurse manager and executive positions.11–15 Concurrently, however, calls are intensifying to fill a perceived leadership void in nursing and health care.16–31

These issues prompted the authors to review the content of nursing administration and nursing leader- ship courses at one university. As an initial step in the review, Websites were explored from schools of nurs- ing with administration and leadership programs. Based on information from the Websites, it was not clear how coursework for nursing leadership differed from coursework for nursing administration. This raised questions about the similarities and differences in lead- ership and management competencies and the curricu- lum that would best serve students in acquiring these competencies.

The central issue is not whether both pursuits are needed but, rather, whether a common curriculum can prepare individuals for both roles. Scoble and Russell32

noted that although leadership, management, and ad- ministration are used interchangeably, they are not synonymous. This view is consistent with the classic work of Bennis and Nanus33 who indicated that lead- ership and management are both important but pro- foundly different. According to Kouzes and Posner,34

leadership is based on relationships and helping people (and organizations) move toward achieving a vision. By contrast, management focuses on maintaining order, planning, organizing, coordinating resources, and at- tending to rules and details.34

If these assertions are correct, it becomes impor- tant to identify the competencies unique to leadership and management, as well as areas they share in common, to more appropriately guide educational endeavors. Competencies represent a cluster com- prised of knowledge, skills, attitudes, abilities, be- haviors, and other characteristics.35,36 The authors were particularly interested in competencies because of the underlying assumptions that: (1) training and education can improve competencies36 –39 and (2) competencies can be measured to evaluate effective-

ness.27,36 An analysis was, therefore, undertaken to

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Competencies abstract Jennings et al

identify similarities and differences between compe- tencies for nurse leaders and nurse managers. That analysis is reported in this article.

METHODS The Cumulative Index of Nursing and Allied Health Literature (CINAHL) and MEDLINE were used to identify the literature over 5 years—from 2000–2004. In CINAHL, “administration” is a subheading within the subject heading “management”. Information in the scope note suggested using both management and administration in the search. Thus, the major search words—leadership, management, and administration— were each combined with additional subject headings— competencies, knowledge, skills, abilities, characteris- tics, and attributes. This strategy identified 316 citations published in the English language. Of these articles, 53 were cited in both Medline and CINAHL searches yielding 263 unique publications.

The abstracts for each citation were assessed to refine the review. For example, 80 citations from the MEDLINE search were eliminated from this analysis because they were not relevant to the topic. The term management, for instance, was combined with many adjectives such as information management, quality management, disease management, and financial man- agement. Likewise, the administration search included articles about the administration of various drugs as well as the Health Care Financing Administration and the Food and Drug Administration. One article was published in 2 journals—with the appropriate copyright considerations addressed. Only the source where it was first published was counted for this review. Book reviews, recurring columns, letters to the editor, and unpublished dissertations were also omitted.

Although not an a priori decision, the authors also decided to exclude work conducted outside the US (n � 39). This choice was guided by several factors. First, questions exist regarding whether US principles of leadership and management can be extrapolated else- where, including to English-speaking countries.40 Even when individuals from different countries speak the same language, nuanced meanings may alter under- standing.41 Second, leadership and management com- petencies may differ depending on the country’s pre- vailing health insurance program. For similar reasons and to ensure consistency, articles published by US authors in international journals were also eliminated from the review.

While retrieving the remaining 127 articles, the authors located and included a few pertinent articles not reflected in the electronic literature searches (n � 10). In addition, one of the articles identified in the search was the most recent in a series of 4 articles with point and counterpoint perspectives. The 3 articles published prior to 2000 were added to this review because they

created the foundation for the article within the time-

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frame. This analysis was, therefore, based on a critical review of 140 publications.16–21,23–32,35,37–39,42–160

All 140 articles were independently evaluated by 3 of the authors who determined: (1) which competencies were addressed, and (2) whether the competencies were identified as pertaining to leadership or management. There was no attempt to judge the correctness of the characterizations. The authors then held a series of meetings during which they discussed their individual findings and talked through the few differences of opinion. All the differences were easy to reconcile and no articles were discarded. The analysis was therefore consensus-based.

FINDINGS A General Description of the Literature

Individuals from 16 disciplines authored these arti- cles, reflecting a widespread interest in leadership and management. The first author was most often a nurse (n � 67), followed by individuals in business (n � 19), medicine (n � 14), and health care management (n � 8). Authors from psychology, pharmacy, physical ther- apy, respiratory therapy, theology, and veterinary prac- tice (n � 1 each) also addressed competencies for leadership and management.

Most articles (n � 62) were published in nursing journals (44%), 30 in health care management journals (21%), 13 in business journals (9%), and 10 in medical journals (7%). The remaining articles were scattered among a variety of journal types such as quality care, public health, social work, health promotion, medical laboratories, fitness, and religious health care organiza- tions (n � 2 each). One article each was found in journals dedicated to infection control, military health care, dentistry, pharmacy, physical therapy, veterinary practice, and psychology.

Articles were published in 56 different journals with the Journal of Nursing Administration being the source of 23 articles (16%). The second most frequent places of publication were the Harvard Business Review and the Journal of Health Administration Education with 13 articles each (9%). Various clinical journals were also represented including Ambulatory Pediatrics and the American Journal of Surgery (n � 2 each) as well as the American Journal of Critical Care, the American Journal of Emergency Medicine, and Medical Surgical Nurse (n � 1 each). There was also one online journal in the collection.

Most of the articles were opinion-based (n�80, 57%). These ranged from more critical, scholarly com- mentaries to articles that were less analytical and only modestly supported by the literature. The remaining 60 articles (43%) used data in some way. Of these, 4 were reports of projects during which data were collected, 4 used data from previously conducted research such as in developing integrative reviews, and 52 were reports

of actual research. It was not possible to detect mean-

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Competencies abstract Jennings et al

ingful differences between the content of the opinion- based articles and those that were data-driven. Quanti- tative methods dominated the data-based articles, although 13 used qualitative methods and 3 used mixed methods.

A Description of the Competencies In this review, each competency mentioned in each

article was identified (n � 894), as well as whether the competency was addressed in relation to leadership or management. Some competencies, such as collabora- tion and team skills, were mentioned several times (n � 41). Other competencies, such as biostatistics, were mentioned only once. Leadership competencies (n � 581) were addressed more often than management competencies (n � 313), reflecting the current interest in leadership. When comparisons were made between leadership and management competencies, however, all but 32 competencies were mentioned in relation to both. Of these, 26 competencies were unique to leadership and 6 were unique to management. The large intersec- tion (n � 862) indicates a lack of discrimination between leadership and management competencies (see Figure 1). Despite this similarity, the tone of the literature suggested that leadership competencies were more highly valued.

Competency Categories Content analysis techniques were used to synthesize

the individual competencies into categories. Each of the 894 competencies was written on a 3 � 5 card. These were assessed by 2 of the authors who grouped similar competencies. Through this process, 36 categories emerged, 23 of which were common to both leadership

Figure 1. The intersection of leadership and management competencies.

and management.

Some competencies were easily clustered into cate- gories (eg, statements about vision and change). Others required thoughtful discussion to identify the central theme. For instance, “personal qualities” reflected 77 different characteristics such as risk-taking, courage, confidence, and creativity. Overall, the personal quali- ties highlighted the importance of knowing one’s self and developing a diverse and fluid repertoire. Self- knowledge serves many purposes such as enabling individuals to understand their values, beliefs, motiva- tions, and responses.129 It also allows individuals to wisely activate their own best characteristics for grap- pling with an array of organizational challenges, as well as assembling teams with complementary skills.24

The category “developing people” pulled together competencies such as mentoring, coaching, and devel- oping staff. These person-centered competencies in- volve reciprocal interactions that shape and prepare individuals to accomplish the organization’s mission. By comparison, the competencies in the “human re- sources management” category were more rule-bound and procedurally driven. They included competencies related to policies for hiring and firing, job descriptions, and labor relations.

The top 10 leadership and management categories were identified based upon the frequency counts of the competencies they represented. Most of the competen- cies, 746 of the 894, were accounted for in these 10 categories (85%). As shown in Table 1, the frequency with which the competencies were mentioned and their rank order varied between leadership and management. For example, the top 2 categories for both were “per- sonal qualities” and “interpersonal skills,” but their rank order was reversed. The top 10 leadership categories included “developing people” and “vision.” These cat- egories were also mentioned in management, but they ranked lower (17th and 18th, respectively). Conversely, although “human resource management” and “informa- tion management” were among the top 10 management categories, they ranked lower in the leadership catego- ries (11th and 17th, respectively). After the categories were finalized, it was discerned that they reflected 2 knowledge domains—some related to individual skills (eg, interpersonal, thinking) and some pertained to organizational skills (eg, management, business).

Competency categories shared by leaders and man- agers that had lower frequency counts (eg, high of 12, low of 1, mode of 2) included: offering incentives and rewards, developing a healthy work environment, being results-oriented, focusing on customers, sustaining or- ganizational and environmental awareness, improving quality, assessing technology, governance, delegating tasks and responsibilities, health policy, and law. Of note, developing a healthy work environment was mentioned only 6 times as a leadership competency and only 2 times as a management competency. This

reflects a poor fit between identified competencies and

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Competencies abstract Jennings et al

current needs to improve work environments as ad- dressed by the American Association of Critical Care Nurses,1 the American Hospital Association,2 the Insti- tute of Medicine,4 and the Joint Commission.3

For the remaining 13 categories, 9 were unique to leaders and 4 to managers. Examples of competencies associated only with leadership included using political skills and using power. Two leadership competencies stood out because they were unusual—remaining an independent thinker rather than a team player and serving as a symbol to represent the group. Competen- cies mentioned only in association to management concerned economics, biostatistics, epidemiology, and evidence-based practice. It was not clear why some of these competencies were limited to either leadership or management.

Competencies were most often portrayed in a posi- tive way, with little attention given to the shadow side of attributes. For instance, a passion for one’s work may have a negative effect if it overpowers others’ views.69

Similarly, collaboration was addressed more often than conflict, illustrating the tendency to ignore the tough work of both leadership and management. Heifetz and Linsky92 suggested that although conflict is potentially dangerous, it is necessary for change to occur. They underscored the importance of learning how to deal with people’s differences by letting conflicts surface.

The way in which conquering adversity shapes leaders also received limited attention. Effective lead- ership and management often develop from intense,

Table 1. Top 10 Competency Categ and Management

Rank Leadership

1. Personal qualities (147) 2. Interpersonal skills (100) 3. Thinking skills (55) 4. Setting the vision (36)* 5. Communicating (33) 6. Initiating change (32) 7. Developing people (25)*

8. Health care knowledge (clinical, technica business) (22)

9. Management skills (eg, planning, organizin (21)

10. Business skills (eg, finance, marketing) (17)

aNumber of times this competency was identified in the lite

*Unique to the top 10 Leadership Competencies.

**Unique to the top 10 Management Competencies.

even traumatic experiences that allow individuals to

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learn from failure and mistakes.20,48,76 In addition, some traits were paradoxical—personal humility and professional will; timidity and ferocity; shyness and fearlessness. These paradoxical combinations were found among individuals at the pinnacle of leader- ship.57

Competencies as Reflected in Educational Programs

Several of the articles in this review addressed educa- tional programs designed to develop leaders and managers in a number of different health care disciplines ranging from health care administration to veterinary prac- tice.17,31,32,38,39,43,45,63,80,83,102,110,119,121,123,127,138,140,160

Programs were also designed with the explicit purpose of developing leadership abilities among faculty mem- bers.17,118 The different disciplines notwithstanding, this collection of articles illustrated differences of opinion among stakeholders regarding the optimal coursework to achieve the desired competencies.

Relevant to nursing is a debate that surfaced about whether nursing administration programs will survive in the 21st century. This debate stimulated a point- counterpoint exchange that spanned 3 years.8,60,114,115

Although the authors offered different perspectives, they shared the belief that nursing administration pro- grams, as currently structured, will not position nurses to be successful leaders and managers in today’s health care environment. We, therefore, examined educational programs to develop nurse leaders and managers iden-

s for Leadership

gory (n)a

Management

Interpersonal skills (55) Personal qualities (54) Thinking skills (29) Management skills (eg, planning, organizing) (28) Communicating (24) Business skills (eg, finance, marketing) (23) Health care knowledge (clinical, technical, as

a business) (22) Human resources management (17)**

Initiating change (9)

Information management (9)**

reviewed.

orie

Cate

l, as a

g)

rature

tified in this review. They fell into 2 clusters.

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Competencies abstract Jennings et al

Programs in the first cluster were not conducted as part of traditional, degree-granting, educational programs. Of these, one was designed to improve beginning leadership competencies among baccalaureate nursing students.17 A central thesis of this program was that “Everyone—from staff nurse to chief nurse executive—should become a ‘workleader,’ which requires individuals to learn to effec- tively manage themselves as well as their relationships with others.”17 Another involved a research-based59 inter- active workshop designed to enhance charge nurse competencies.58 The workshop was structured to address 54 specific competencies in 4 categories—clinical/ technical, critical thinking, organizational, and human relations. At the other end of the career continuum, focusing on senior nurse leaders, was the Robert Wood Johnson Nurse Executive Program. Its curriculum com- prised 5 competencies—self-knowledge, interpersonal communication effectiveness, risk-taking and creativ- ity, inspiring and leading change, and strategic vision.24

Programs in the second cluster addressed graduate nursing curricula related to leadership and management. Of these, 2 opinion-based publications described re- vamping programs to better meet community needs by integrating leadership knowledge into various special- ties, including nursing administration.121,160 Details of these curricula, however, were not provided.

Research-based articles from the second cluster pro- vided more details about a desired curriculum for nursing administration programs.32,80,140 Some ques- tions were raised, however, based upon the groups recruited to delineate the desired content. In one in- stance, a survey of deans and program directors in- formed the content for master’s degree nursing admin- istration curricula.80 Such reports must be used cautiously because the point of view of practicing nurse administrators is missing. Input from practicing nurse executives and managers is especially important given Ackoff’s assertion that faculty isolation from current practice may reduce the relevance of content in man- agement education.70 Likewise, others have noted a tendency for faculty to teach what they know and what interests them, which may not be congruent with developing competencies for current and future admin- istrative practice.87 These beliefs suggest the need to be more inclusive when identifying stakeholders who can best inform course content. They may also help to explain why nurse managers indicated they often learned necessary competencies on the job rather than through formal education.102,140

The problems of selecting content based exclusively on the faculty perspective was overcome in a pair of studies that began by soliciting opinions about curric- ular content and key competencies aimed at preparing successful nurse administrators for the future from a convenience sample of an eclectic group of nurse leaders.32 These findings were used to create a ques-

tionnaire that was mailed to nurses in a variety admin-

istrative positions (eg, Chief Nurse Officers [CNOs], directors, nurse managers).140 Results from the mailed questionnaire were organized into 9 categories: (1) the business of health, (2) healthcare delivery systems, (3) health policy, law, and ethics, (4) human capital, (5) information systems, (6) leadership and management, (7) organizational theory and design, (8) quality man- agement, and (9) research.140 While grounded in the view of those with first-hand knowledge of nurse administrators’ needs, these categories nonetheless ver- ify the ambiguous terminology that impedes creating course content focused on developing specific compe- tencies.35,50 Of note, these categories are only modestly similar to those derived from the analysis reported here (see Table 1).

In addition, although the identification of these competencies by practicing nurse administrators al- lowed reality-based input, there was no attempt to identify competencies based on one’s career stage, role, or responsibilities. Competencies differ based on these considerations.27,110 This dynamic may be operational among nurse managers who rated the importance of graduate education lower than did nurse executives.103

Also not considered was how competencies might vary by setting. For instance, acute care facilities require a different set of competencies than those valued in long-term care.78,81,112 Likewise, skills suitable to rural settings77,142 may differ from those needed in urban areas. Although no curriculum can prepare individuals for all levels and all settings, educators would be wise to take these considerations into account. Educators would also be wise to consider the differences in clinical nurse leader roles72 and administrative nurse leader roles that might add to curricular confusion.

Competencies as Reflected by Professional Nursing Organizations

In 1997, the American Association of Colleges of Nursing and the American Organization of Nurse Ex- ecutives (AONE) identified core abilities and content for educating nurse administrators.161 These recom- mendations may now be obsolete based on 2 more contemporaneous documents, one from the American Nurses Association (ANA)162 and the other from AONE.163 The more recent AONE and ANA docu- ments were compared to competencies identified in this analysis.

The ANA standards for nurse administrative prac- tice162 group essential knowledge into 27 categories. These categories pertain to 2 levels of nurse adminis- trators, the executive level—CNOs, directors, deans, and associate deans—and the nurse manager level. Although leadership was mentioned as a responsibility of nurse administrators, it was not among the categories of essential knowledge. Interpersonal skills were also missing, although negotiation and conflict resolution

are specified. The absence of a category specific to

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Competencies abstract Jennings et al

communication was conspicuous because the ANA standards are predicated on a belief that vertical and horizontal communication is critical to success.

According to AONE, nursing leadership/management is a specialty that requires proficiency. In support of this belief, AONE organized competencies specific to nurse executives into a model comprising 5 categories: (1) communication and relationship management, (2) knowl- edge of the health care environment, (3) professionalism, (4) business skills and principles, and (5) leadership.163 It is noteworthy that the AONE model resulted from collab- oration among an interdisciplinary group of stakeholders interested in health care leadership (eg, American College of Healthcare Executives [ACHE], Healthcare Informa- tion and Management Systems Society [HIMSS], Medical Group Management Association [MGMA]). Each cate- gory is elaborated with sufficient detail so that it could be used to guide curriculum-development, although the nu- merous elements within each category pose a challenge to educators and students alike. It would be most useful if a similar effort could be conducted to identify competencies for first-line managers. It would also be helpful if a cadre of practicing nurse administrators could verify the fit between the stated competencies and their actual needs.

DISCUSSION Both educational programs and professional nursing organizations address numerous leadership and man- agement competencies, either directly or indirectly, in their curricular recommendations and standards state- ments. Questions arise, however, about the adequacy of these responses given the pace of change in today’s health care systems. In this analysis, leadership compe- tencies were addressed almost twice as often as man- agement competencies. Although this underscores the popularity of leadership, it belies the similarity between leadership and management competencies (see Figure 1). Of the 894 competencies found in the 140 articles reviewed, 862 were common to both leadership and management. This sizable intersection provides evi- dence to question whether previous distinctions be- tween leadership and management remain relevant.

Some may argue that the fusion of leadership and management competencies tends to ignore the different purposes served by each. Conversely, the convergence of leadership and management competencies might reflect a different dynamic. The dramatic changes that have altered the social context of health care may have influenced this evolution. Based on evidence from this review, the message for curriculum-development re- flects the need for an evolving educational paradigm, one that currently reflects the strong commonalities among leadership and management competencies.

Additionally, the educational paradigm needs to ensure that students are prepared with skills appropriate to the care delivery setting, societal demands, and their

career stage. Practicing nurse executives are challenged

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as well to design mechanisms to support individuals as they transition to first-line, midlevel, and executive administrative roles. An approach used by one univer- sity medical center to support 3 levels of leadership- training for nurses—emerging, operational, strategic— was described in a recent publication.164

To keep pace with the dynamic nature of health care, faculty must ensure that curricula adapt to changing conditions so nurse administrators are positioned for success in their challenging roles. To provide ongoing vision for thoughtful yet timely responses to these influ- ences, it would be beneficial to hold formal and frequent forums involving professional organizations, nurse educa- tors, nurse administrators, and students. High preference must be given to key competencies identified by the end-users—students and employers.

Educators are also challenged to sustain their own learning to keep pace with change. Lifelong learning is as important to nursing administration faculty members as it is to nurse leaders and managers in the clinical setting. However, consistent with concerns expressed by Ackoff,70 a nurse leader recently wrote “. . .many [faculty] have experienced an erosion in the relevancy of their knowledge and skills and, most importantly, their ability to imagine what could be—not what should be based on tradition.”165

Moreover, the vast array of competencies identified in this review verifies assertions that leaders and managers are expected to be all things to all people.19 It also corroborates the view that “the role of the nursing admin- istrator is expanding and the skill-set required is im- mense.”80 The complexity of the nurse administrator’s role is also evident in the competencies proposed by ANA162 and AONE.163 In addition, it has become too common for courses to be added to already heavy requirements without eliminating or consolidating ex- isting classes.

Ensuring a good fit between curricula and actual competencies needed for administrative practice has been difficult.37 Enthusiasm for leadership development must also build on coursework, such as financial and human resource management, that is essential to nurses who choose to become managers and nurse executives. Given concerns about the paucity of nurse administrators to create healthy work environments, it is essential for faculty to ensure that nursing administration curricula are commensurate with essential organizational and individu- als competencies. Meeting this goal will require regular conversations among representatives from all key stake- holder groups.

CONCLUSION Based on this analysis, the boundaries between nursing leadership and management competencies have nar- rowed. This narrowing blurs the differences tradition- ally noted between the 2, requiring new approaches to

conceptualizing curricula. The challenge for educators

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becomes one of examining and revising curricula to ensure that course content will help students acquire the competencies they need to succeed in contemporary administrative positions.

There must be thoughtful, deliberate consideration of these requisite competencies. Nurse educators, nurse ad- ministrators, employers, graduates and other stakeholders must unite to provide thoughtful direction for ongoing curricular discussions and decisions. The AONE163 and ANA162 have provided beginning frameworks in this regard. Further curricular decisions could benefit from “state-of-the-art” meetings designed to identify the impli- cations on the curriculum from changing social, financial, and health care policies. To maximize their productivity, such meetings need to attend to leadership and manage- ment competencies by settings, level of role responsibility, career stage, and changing social demands. Dialogues such as these will be futile if concrete or linear thinkers expect an exhaustive and complete curriculum as an outcome. However, these conversations could stimulate leading thinkers to understand critical points and content that will develop essential leadership and managerial skills, including critical thinking.

For almost 30 years, leaders in the field of nursing administration have repeatedly called for the development of curricula suitable to prepare nurse administrators for their arduous tasks.8–10,13,60,115,116 Perhaps the wide- spread concern about work conditions could have been avoided had these calls been heeded sooner. Although the past cannot be altered, its lessons can be used to build a future that better prepares nurse administrators to deal with the complex challenges that abound.

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