REVIEW ARTICLE

Strategies for the development of nurses' leadership in health services: a scoping review

Gabrielle Porfírio Souza1, Rebeca Iwankiw Lessa Beltran1, Karla Crozeta Figueiredo1, Tatiane Herreira Trigueiro1, Carolina Poite de Siqueira1, Thaiane Almeida da Silva Pol1, Alda Souza Figueredo1

1 Federal University of Paraná, Curitiba, PR, Brazil

ABSTRACT

Objective: to map the strategies for developing the leadership competence of nurses in health services. Method: a scoping review was developed as proposed by the Joanna Briggs Institute. The following inclusion criteria were established: scientific articles originating from primary and secondary sources, experience reports, case studies, and reflection articles with full content available, with no language or date restriction, which described strategies for the development of nurses' leadership competence, in health services. Results: twelve articles made up the sample, which presented as strategies the leadership development programs, programs focused on succession planning, mentoring and coaching processes, and innovation. Conclusion: it was observed that, although studies recognize nursing leadership as an essential competence for the professional practice of nurses, few have approached development strategies, especially in health services.

Descriptors: Leadership; Nurses; Health Services.

INTRODUCTION

Over the years, the organization of work has changed. Technological advances and social and cultural changes have enabled different ways for people to relate(1). Furthermore, the provision of complex care and the shortage of nursing professionals have been a reality in health systems(2). Identifying aspects that favor nursing leadership minimize the consequences of an overloaded system(2).

In this sense, nursing is seen as a crucial profession for the health system, as it directly collaborates with implementing and, consequently, maintaining health policies(3).

Nursing leadership, when performed effectively, motivates and encourages the development of a successful scenario, whether in direct patient care or in a management context. Thus, nursing leadership must be encouraged and promoted in all contexts, from the clinical setting to administration, education, policy, and research(4,5).

Leadership is a fundamental competence in team management that can be developed. In times of volatility, uncertainty, complexity, and ambiguity (VUCA), it is necessary for the individual to seek continuous professional updating to be strategic for his institution and to be active in the job market(6). The result of the nursing work depends, among other factors, on a harmonious environment, group motivation, and the appreciation of interpersonal relationships, influencing the productivity and effectiveness of care(7).

In addition, the presence of nurses who exercise leadership provides opportunities to construct spaces for support and guidance through the relationship they develop with the team, patients, and family members. Therefore, the leader's performance is essential to favor the implementation of the mission, values​, and principles established by management(8). In addition, the leadership style varies according to the leader's personality and way of acting(9).

Nowadays, the maintenance of traditional leadership development methods is questioned(10). Employing innovative and creative means of teaching-learning contributes to the formation and improvement of the practices of leaders. In this sense, changes have been necessary for the training process of nurses starting from the university years(11).

In summary, nursing leadership directly influences the definition of results for health institutions and patient care outcomes, reinforcing the need to understand how leadership practices can be developed(2).

The concern in carrying out this study arose from the need to identify new possibilities for leadership development strategies, especially in the current crisis scenario resulting from the Covid-19 pandemic and increased demand for health services. For this reason, this scoping review aimed to map the strategies for developing the leadership competence of nurses in health services.

METHODS

This is a scoping review conducted according to the method proposed by the Joanna Briggs Institute (JBI)(12). The present scoping review was registered in the Open Science Framework (OSF) platform (DOI: 10.17605/OSF.IO/32AJW)(13) and followed the recommendations proposed by the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR)(14).

For the construction of the research question, the PCC (Population, Concept, and Context) strategy was used, which allows the creation of an overview of the theme to be studied, favors the construction of the study question, and help the researchers carry out the search and prioritize inclusion and exclusion criteria(12). Based on the definition of the Population (Nurses), the Concept (Strategies for the development of leadership competence), and the Context (Health services), the following research question was created: Which strategies are used for the development of the leadership competence by nurses in health services?

The data collection took place between April 23 and May 13, 2021, in the PubMed/MEDLINE, and Scientific Electronic Library Online (SciELO) databases, through the Virtual Health Library (VHL) portal, in the Latin American and Caribbean Health Sciences Literature (LILACS) database, and in the Nursing Database (BDENF) through the portal of the Coordination for the Improvement of Higher Education Personnel (CAPES), and in Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, and Scopus. The choice of databases was based on the quantity of indexing of primary articles in the health area.

The following Health Sciences Descriptors (DeCS) and Medical Subject Headings (MeSH) were used: Nurses, Leadership, Health Services, Professional Competence, and Leadership and Governance Capacity, which, combined with Boolean operators, resulted in the search strategy shown in Figure 1, which was tested and applied in all the databases mentioned earlier.

Figure 1 - Search strategy. Curitiba, PR, Brazil, 2021

Source: Prepared by the authors, 2021.

Studies originating from research from primary and secondary sources, experience reports, case studies, and reflection articles, with full content available, were included with no language or date restriction, if they describe strategies for developing the leadership competence aimed at nurses working in health services. Studies of construction and validation of instruments, cross-cultural adaptation, construction of short forms, and letters to the editor were excluded.

The selection of studies included in the review took place in three stages: 1) Removal of duplicates; 2) Title and abstract screening; and 3) Full-text analysis: the studies selected in the previous step were read in full format by two reviewers, independently (GPS, RILB), and selected based on the inclusion and exclusion criteria. The discrepancies were resolved by the decision of a third reviewer (TAS).

In addition, a search was carried out in the reference lists of the included studies to identify potential articles that fit the criteria of this review. In this search, one study was included.

In the data extraction stage, the information from the studies included in the research was organized in a table prepared by the researchers using Office Microsoft Word® version 2010.

RESULTS

A total of 899 studies and one study from the grey literature were identified, totaling 900 studies. Of these, 357 duplicate studies were withdrawn. Subsequently, by screening the titles and abstracts of 543 studies, 504 were eliminated because they did not meet the established criteria or did not describe strategies for developing nursing leadership in health services, and 39 went on to the second phase of analysis – the full-text reading. After a complete reading, studies were excluded for not describing strategies used in leadership development, and thus, 12 articles were included in this review. The search and selection process is presented in the PRISMA-ScR flow diagram (Figure 2).

Figure 2 - PRISMA-ScR flow diagram. Curitiba, PR, Brazil, 2021

Source: Adapted from Tricco et al., 2018.

The 12 articles in this review were published between 1996 and 2019, and 2006 and 2018 had the highest number of publications, with three studies each (25%). Regarding the country of origin of the studies, there was a predominance of publications originating in the United States of America (USA), with three studies (25%), followed by England with two studies (16.6%). Regarding the language of publication, most articles were written in English (11 articles, 91.6%). Only one article came from Brazil and was published in Portuguese. Regarding the method, four (33.3%) were qualitative descriptive and exploratory studies and four (33.3%) were descriptive studies. The other methods included a case study, an exploratory study, and a descriptive study with a mixed methods approach, with one study each (8.3%).

Figure 3 - Characterization of journals, years, titles, study designs, and countries of origin of the publications. Curitiba, PR, Brazil, 2021

Source: Prepared by the authors, 2021.

Regarding the strategies for the development of nurses' leadership in health services recommended and used in the studies, the leadership development programs (LDP) stood out (A317, A519, A620, A811, A922, A1023, A1124), with some programs focusing on succession planning (A317, A922, A1124), coaching and mentoring (A216, A317, A418, A922, A1023, A1124, A1225), permanent and continuing education (A721, A811), and workshops (A115, A1225). It is important to mention that not all studies applied the recommended strategies. A summary of the strategies recommended and used in the studies is shown in Figure 4.

Figure 4 – Strategies used/recommended for developing nursing leadership in health services. Curitiba, PR, Brazil, 2021

Source: Prepared by the authors, 2021.

The leadership development strategies applied in the reviewed studies are detailed below.

Study A10(23) describes the implementation and evaluation of a 12-month blended learning program in which most learning occurs in the workplace. The course encompassed peer-to-peer learning components, workshops, ongoing communication activities, a mobile app that contained access to handouts and whiteboards, video, audio, and text tools, and offline review exercises that do not require an active Internet network connection. The program underwent a testing experiment in 2017, in which an increase in the ability to lead front-line teams was observed, strengthening universal health coverage and contributing to the skills of using technology (23).

Study A9(22) describes implementing a program focused on succession planning. The program was holistic, with education, exposure, and learning. Leadership was developed through didactic learning, written materials, and experience with mentors. The program proved to be effective for the development of leaders(22).

Article A5(19) also reports implementing a 12-month leadership development program that used an action learning approach and the contribution of 360° feedback. In the evaluation of this program, an improvement in communication skills, vision, performance, and self-awareness were identified. However, it was found that simple participation in the program was insufficient to develop clinical leadership, since the process of leadership development must occur in a continuous and interactive way(19). Still in this matter, article A6(20) reports the application of an integrated teaching leadership development program and action learning. In this study, it was identified that the development of managers is enhanced by a program that integrates theory, action learning, and a project based on the context of action(20).

Leadership is also promoted through the opportunity to mentor leaders in nursing and other professions. Studies A3(17), A9(22), A10(23), and A11(24) used mentoring as an integral part of the leadership development strategy, and some adopted this tool within the leadership development programs.

DISCUSSION

The act of leading takes many forms and changes greatly according to the task and the context. Thus, the debate about leadership development and greater variety and availability of programs and promotion activities is essential. The development of leaders is not an isolated, single act, it is not an easy process, but it comprises a continuous, participatory, and reciprocal action between the leader and the team, requiring continuous preparation and commitment, crucial factors for the development of nursing(19,26).

The leadership development process must also be initiated in the academic training process so that nurses can perform nursing leadership upon undergraduation(27). However, the process of developing leaders is strengthened with the practical experience of nurses, which may be associated with the time to adapt and understand the work process and the evolution of technical and relationship skills. In this sense, continuing health education should be considered a strategy for developing leaders in health services(11).

Permanent Education in Health (PEH) is seen as a political-pedagogical strategy characterized by an educational aspect that favors reflection on the work process, the transformation of practices, changes in institutional culture, and self-management. Its objective is to work with the needs arising from the health work process and includes teaching(28).

For this, professional nurses need to understand that they are part of the human resource of continuing education and that their engagement with PEH projects guides the construction, transmission, and use of knowledge to achieve the institution's mission(29). Thus, reflection, discussion meetings, and supervision are relevant practices that require the nurse's leadership, considering that the team's participation in the discussions presents good results concerning the acceptability of changes(30).

Therefore, it is important to highlight the role of institutions in leadership development, as this development process is better established when the organization is committed to a clear leadership system and development opportunities(20).

Furthermore, leadership development programs are among the strategies for developing nursing leaders. Implementing an effective leadership development program is essential to help the institution evolve. There are several formats of leader development programs. A program that combines the institution's internal knowledge with external knowledge and experience should be an efficient methodology to improve leadership(20,31).

Succession planning should also be considered a leadership development approach and aims to ensure organizational continuity, as it proposes to offer development and training possibilities to ensure that future leadership positions are properly filled. Consequently, succession planning ensures the continuation of the intellectual heritage formed by several generations of professional nurses(17,32,33).

Mentoring is integral to developing leaders and is, therefore, a priority. Being guided and having the possibility to put professional skills and competencies into practice can collaborate with developing leadership capacity. Nurse practitioners can learn from interacting with others and receiving constructive feedback from a mentor who serves as a role model for less experienced nurses. Tutoring can occur in different ways, such as in the coaching process, and does not require proximity, as it can occur at distance(19,31,34).

Coaching is a tool constantly related to the development of leaders. Nowadays, several programs and courses aim to enable coaches to become "developers" of leaders and creators of programs that aim to develop leaders(35).

Coaching emerges as a new attitude approach that can generate awareness and define roles within institutions, contributing to achieving results through experimental processes  that focus on relational skills(35-37).

In this sense, the coach's role is to encourage the individual so that his potential is developed, that is, to help the person learn and not just be trained, and to provoke the person to discover new paths naturally. In this way, the coach's role's uniqueness is related to directing, guiding, leading, and walking together, helping the one who is guided to achieve previously defined goals(38).

Another term that emerged from this review was mentoring. In the mentoring process, the knowledge and experiences of an experienced professional are shared, focusing on professional preparation, whose objective is to achieve the mentor's autonomy. It is important to mention that personal development can also be included in this process, as it aims at the integral development of the mentee. Although there are advances in terms of concepts and distinctions between coaching and mentoring, both have some singularities and similarities that relate and sometimes confuse(38). However, the need to distinguish these terms is questioned since they are relevant, and it is urgent to understand them as complementary methods that can be applied in the same process(39).

Furthermore, it is important to mention the importance of innovation in leadership development and training, as it expands the range of problem-solving strategies in complex scenarios. For this reason, clinical and academic spaces must demand cultures that encourage innovation and strong leadership potential. Practices such as in-service training, continuing education, thinking and reflection strategies, and practical stories, among other actions, can promote nursing leadership(16,40).

CONCLUSION

By carrying out this study, it was observed that although studies recognize nursing leadership as an essential competence for the professional practice of nurses, few have approached development strategies, especially in health services.

In the interim, leadership development programs constituted the most evident leadership development strategy in the literature, involving different methods and tools, in addition to tutoring processes, such as coaching and mentoring. It was also identified that part of the research worked with the development of leaders in a broad approach or with the development of managerial competencies, especially in administrative scenarios, with no focus on nursing leadership.

As a gap identified through this study, it was noticed that the studies have focused on development strategies recommended in health services, not including the strategies used in academic training. Thus, future investigations of strategies for developing nursing leaders beyond health services are recommended, and they must include other contexts, such as universities and other institutions in which nurses work.

CONFLICT OF INTERESTS

The authors have declared that there is no conflict of interests.

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Submission: 09/17/2021

Approved:  10/31/2022