review of literature on leadership qualities

The mindful leader: a review of leadership qualities derived from mindfulness meditation

Affiliations.

• 1 Business School, Nord University, Bodø, Norway.
• 2 Medical Yoga Sweden of California, Bodfish, CA, United States.
• PMID: 38505367
• PMCID: PMC10948432
• DOI: 10.3389/fpsyg.2024.1322507

Mindfulness has been practiced by global leaders and companies as an efficient way to build effective leadership. Because of its popularity, plus the lack of a comprehensive theoretical framework that explains it in a leadership context, the research literature has called for a coherent account of the qualities that is derived by those leaders that practice mindfulness. Here, we aim to answer that call, by clarifying what leadership qualities can develop from practicing mindfulness . We report on a semi-systematic literature review of extant research, covering 19 research articles published between 2000 and 2021, plus other relevant supporting literature from the disciplines of leadership and neuropsychology. Our proposed framework consists of three main qualities of the mindful leader: attention, awareness, and authenticity. We call them the "three pillars of mindful leaders." We also propose that mindfulness meditation must be integrated into our proposed framework, as we are convinced that leaders who hope to benefit from these qualities must integrate a regular mindfulness meditation practice into their daily leadership life.

Keywords: leadership; meditation; mindful leader; mindfulness; neuropsychology.

Copyright © 2024 Doornich and Lynch.

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• Systematic Review

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Traits of Effective Leaders: A Literature Review

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• NLC Public Service Leadership Literature Reviews
• Cabinet Office
• Leadership College for Government
• National Leadership Centre

A Literature Review on Effective Leadership Qualities for the NLC by Dr Martin King and Professor Rob Wilson

Published 15 December 2020

© Crown copyright 2020

This publication is licensed under the terms of the Open Government Licence v3.0 except where otherwise stated. To view this licence, visit nationalarchives.gov.uk/doc/open-government-licence/version/3 or write to the Information Policy Team, The National Archives, Kew, London TW9 4DU, or email: [email protected] .

Where we have identified any third party copyright information you will need to obtain permission from the copyright holders concerned.

This publication is available at https://www.gov.uk/government/publications/nlc-public-service-leadership-literature-reviews/a-literature-review-on-effective-leadership-qualities-for-the-nlc-by-dr-martin-king-and-professor-rob-wilson

Executive summary

The review conducted did not produce evidence for a distinct ‘qualities approach’ drawing on the five identified qualities applied consistently across the literature. This is because the review presented a field of research into leadership that is characterised by fragmentation and conflicting nomenclature. These inconsistencies in the findings prevent us from drawing strong conclusions across the literature. Nevertheless, organising the various strands of debate into clusters that capture shared ways of talking about leadership across different theories in the literature can be helpful. The evidence that the five qualities as defined by the National Leadership Centre (NLC) are the most relevant ones is mixed. We summarise the evidence on this and suggestions on how to potentially adapt the descriptions on the five qualities in Section 2. In Section 3, we turn to a discussion about the challenges of a ‘qualities approach’ to the study of leadership. We describe three main clusters of theories in the literature (explained in more detail in the glossary in Appendix II) that challenge the notion that leadership derives exclusively from properties of the individual. These clusters can provide inspiration for an expansion of the NLC understanding of leadership. We then turn to the issue of the outcomes and goals that leadership is measured against in the literature in Section 4. Finally, in Section 5 we report the questions that emerged from this literature review and suggest ways in which the NLC could explore these, including co-productive and qualitative research methods.

Table of contents

• Our approach to this literature review
• The evidence of the five qualities in the literature
• Critiques of a ‘qualities approach’ to leadership
• Measuring leadership impact
• Conclusions and recommendations for future research Appendix I: Search terms and key results Appendix II: Glossary Appendix III: Bibliography

1. Our approach to this literature review

The NLC identified five qualities of leadership based on a preliminary review of the leadership literature: ‘adaptive’, ‘connected’, ‘purposeful’, ‘questioning’, and ‘ethical’. The purpose of the brief was to undertake a wider review of the literature exploring the evidence base on public leadership and examining the support for the NLC five key qualities approach. The brief sought to address the following key questions:

• To what extent does the evidence base support the NLC’s assertion that there are five qualities exhibited by effective public service leaders?
• How could the NLC’s articulation and definition of the key attributes of effective public service leaders be iterated or improved to better reflect the evidence base?

Based on the questions in the brief, we approached the ‘rapid’ literature review through a general search and then separate ones for each of the five qualities. This review involved six searches of abstracts repeated across five academic databases capturing discussions of leadership across academic fields and disciplines. The results of these searches were analysed through an abstract review. The searches included keywords such as synonyms to capture wider discussion of the qualities, and additional phrases to capture discussion of leadership in the context of public services and under conditions of complexity or uncertainty. The searches returned 9318 results. These results were then filtered further to 575 papers based on the preferences expressed by the NLC, including a broad scope review capturing wider research into leadership qualities; a preferred focus on studies based in the UK and similar regional contexts; discussion of public administration at a senior level in the context of collaboration across sectors and organisations; and a focus on complex or ‘wicked problems’ in the public sector. A full breakdown of the search terms, databases, and results can be found in Appendix I, while the findings of each of the searches can be found in the separate Abstract Search documents.

The search produced results across disciplines (e.g. public administration studies, leadership studies), across theories and methodological approaches (e.g. transformational leadership, distributed leadership), and at different levels of focus (from abstract discussions of the nature of leadership to discussions specific to particular professions). In our review of the abstracts we summarised key themes and findings emerging from the literature, including findings relevant to specific qualities, additional ways of talking about leadership present in the literature, ideals and outcomes, methodological approaches, and theoretical models of leadership. The results of each search presented in the Abstract Search documents include an overall summary, collected themes, referenced papers, and a full list of abstracts. The process revealed a number of trends in the literature, notably a diversity of theoretical perspectives on leadership and a wealth of studies exploring leadership in relation to specific outcomes and goals. The full implications presented by these developments were not apparent through review of the abstracts alone. Therefore, in addition to the abstract review, we conducted deep dives into key papers. We draw out the conclusions from these studies in this paper. In addition, we provide a glossary in Appendix II that defines prominent leadership theories and related concepts featured in the literature.

2. The evidence of the five qualities in the literature

The literature review did not produce evidence for a distinct ‘qualities approach’ drawing on the five identified qualities applied consistently across the literature. The review presented a field of research into leadership that is characterised by fragmentation and conflicting nomenclature. While there was evidence of studies using the same terms outlined in the NLCs discussion of qualities, they were not necessarily writing from a self-consciously ‘qualities approach to leadership’, and there was a lack of unified understanding underpinning the debate. Many studies would talk about the attributes of leadership in terms of style, traits, skills, and competencies. Furthermore, while studies might be interpreted as interested in the quality of connectedness, they might talk about it and understand it in different ways, for example, talking instead of empathy or emotional intelligence. Additionally, studies may import broader theoretical frameworks in describing leadership attributes. Influential frameworks include ‘transformational leadership’, ‘charismatic leadership’, ‘collaborative leadership’, ‘authentic leadership’, ‘servant leadership’, ‘network leadership’, ‘place-based leadership’, and ‘complex leadership theory’, all of which are described in detail in Appendix II. These approaches frame discussion of qualities, meaning that people may use different words for the same concept, or the same word for different concepts, making it hard to assess the evidence available on specific qualities.

It does not necessarily follow from these findings that the five NLC qualities are not a helpful way of understanding leadership. Indeed, the review demonstrates that there is a lack of clarity and coherence in the debate on leadership that might be helpfully navigated by organising the various strands of debate into clusters that capture shared ways of talking about what is valued in leadership that cut across different theories and frameworks in the literature. There is mixed evidence that the five qualities might provide such a useful framework. In the case of ethical and adaptive leadership, there is direct evidence for discussion of these qualities, although there is variation in how they are understood. In the case of connected and purposeful, there is more indirect evidence for discussion of these qualities, and perhaps a need to adapt the articulation of these qualities to better reflect the direction of the literature. Discussion of the quality of questioning is arguably the weakest, or at least a case where there is a lot of overlap with other qualities. We discuss the findings of each individual quality in the tables below.

NLC definition

Adaptive leaders are able to change proactively and constantly learn in a complex, uncertain and volatile world. Number of abstracts reviewed: 141

Summary of findings

Adaptive leadership and the need to learn in the face of complex challenges featured prominently in the literature. The review revealed a more formalised understanding of ‘adaptive leadership’ presented in Appendix II. It should be noted that the discussions of this quality often encouraged a less individualistic understanding of adaptation, in some cases talking of adaptive organisations, relationships and cultures, and organisational agility.

In order to build on this the NLCs definition, it may be helpful to further explore the more specific understandings of adaptive leadership, as well as the relationship between individual adaptiveness and organizational-level adaptiveness.

Trends in the literature

• Discussion of adaptive leaders was common, including a formalised understanding of ‘adaptive leadership’, adaptive behaviours, and an adaptive leadership framework. Further ways of talking about this quality in the context of leadership included ‘learning’, ‘leaders as learners’, and related concepts included ‘self monitoring’.
• In addition to talking about adaptiveness as a quality of individual leaders, the literature also included discussion of adaptive organisations, relationships, and organisational agility.
• There was also some overlap with other qualities discussed in the brief, suggesting for example that in order to be an adaptive leader one also has to exhibit other qualities, such as attributes related to ethical leadership (e.g. trustworthy, authentic, purposeful, forward looking, visionary).

Ethical leaders consistently behave in ways that create trust, and they take a long-term, sustainable approach to fulfilling the organisation’s public service mission. Number of abstracts reviewed: 123

Ethical leadership featured prominently in the literature revealed the complex and multifaceted nature of the relationship between ethics and leadership. It was frequently discussed in the context of more formalised concepts such as ‘servant leadership’ and ‘authentic leadership’. The literature illustrated how the ethical implications of leadership can vary greatly depending on the professional context in which it is applied, and how leadership presents ethical dilemmas and potential tensions between the professional and ethical norms of leadership and what might be commonly perceived to be good.

Given the multi-faceted nature of ethical leadership, there may be a case for crafting a more specific definition, with thought given to how abstract-level definitions of ethical leadership interact with context-specific understandings of ethics.

• Ethical leadership was by far the most discussed quality of leadership, often in relation to frameworks of ‘servant leadership’ and ‘spiritual leadership’. It should be noted that ethics represents a much broader set of concerns than we might reasonably expect from the other qualities.
• Abstract-level discussions of the good leader can be contrasted with more context-specific discussions of leadership, including ethical frameworks, norms, and dilemmas encountered by specific professions such as nursing.
• Within the literature, there is a lot of focus on ‘building trust’ as outlined in the NLC definition with a focus on supporting others. There was some discussion around ‘sustainable’, ‘long-term’, and ‘public service ethos’, which is similar to public service mission.
• Some concepts that were mentioned in the literature that are not in the NLC definition include ‘integrity’, ‘credible leadership’, ‘authentic leadership’, ‘values’, and ‘self-efficacy’.
• Ethical leadership is also contrasted with administrative evil, mistrust, and narcissism.

Connected leaders are empathic, collaborative thinkers who consistently work across organisational boundaries to build strategic relationships across the public service. Number of abstracts reviewed: 127

Connected was not frequently discussed in the literature, however the elements of this quality described in the NLC definition were heavily discussed in relation to leadership. It was more common to talk of this quality in terms of empathy, while emotional intelligence can be interpreted as a related concept that features prominently in the research.

The results of the review present two general questions. The first is whether the NLC definition of connectedness is too rich as it encompasses both notions of empathy and collaboration. The second question is whether the notion of ‘collaborative thinkers’ captures the way in which the literature is talking about collaborative approaches as it potentially challenges the qualities approach (discussed in more depth in Section 3 of this paper). This is an area that would be helpful to explore further.

• Although connected leaders might be a helpful, more holistic way of talking about this quality of leadership, it was more common for this quality to be discussed in other terms including those listed such as ‘empathetic leadership’, but also through concepts like ‘emotional intelligence’ (although this terms obviously relates to a much more specific and contested concept).
• The description of ‘collaborative leaders’ who build strategic relationships is potentially relevant to a significant portion of the literature that deals with collaborative approaches and relational understandings of leadership (see for example the description of ‘network leadership’ and ‘collaborative leadership’ in Appendix II).

Purposeful leaders display absolute clarity about their mission and purpose, and they are able to see beyond the problems and pressures of the present. Number of abstracts reviewed: 36

Compared to other searches, such as ‘adaptive’ and ‘ethical’, ‘purposeful’ leadership did not return many results. This could be due to the fact that ‘adaptive’ and particularly ‘ethical’ are terms with much wider applications that are likely to be used in research. It may also be that the notion of purposeful leadership is not widely recognised or applied in the literature, even if related concepts feature more frequently.

The NLC could consider linking the idea of purposefulness with the ideas discussed in the literature of ‘boldness’ and ‘motivation’ on top of those of ‘mission’ and ‘clarity’ that are already present in the definition.

• Purposeful leadership is often discussed in terms of boldness, clarity, clear communication, clear goals, and planning. Related terms include ‘being bold’, ‘having vision’, and ‘thinking outside the box’. Studies also consider the relationship between these qualities and narcissism as a personality trait and charismatic leadership as a leadership type.
• One might argue though, that the notion of ‘purposeful leadership’ is implicit in the way people frame talk of ‘transformational leadership’ and ‘public service motivation’ (see Appendix II for more details)

Questioning

Questioning leaders are open minded and seek to understand the views and experiences of others. Number of abstracts reviewed: 42

There was little evidence to support ‘questioning’ as a distinct quality of leadership within the literature. It may be helpful to consider the purpose of distinguishing this quality from the ideas of ‘adaptive’ and ‘connected’ and what might be lost by merging it to these other attributes.

• Compared to other searches, such as ‘adaptive’ and ‘ethical’, ‘questioning’ leadership did not return many results. Those that it produced, emphasised the importance of ‘curiosity’ and the use of questions (rather than the quality per se) as a means of building trust, respect, constructing authority, and developing and building relationships. ‘Vigilance’ also appeared as a related concept.
• The concept description shares similarities to the description of ‘connected’ and ‘adapted’. For example, a person who is open minded and seeks to understand the views and experiences of others might be described as ‘empathetic’ in some contexts or perhaps receptive to change and capable of learning and adapting in other contexts. In this sense it may be that the literature tends to discuss these features in ways more aligned with that language.

3. Critiques of a ‘qualities approach’ to leadership

Stepping beyond the discussion of the evidence of individual qualities, the literature reviewed presented a number of challenges to taking a ‘qualities approach’ to the study of leadership altogether. Recent trends in the literature tend to depart from an understanding of leadership as deriving exclusively from properties of the individual. Based on deeper exploration of the key papers in this area, we explain the evolution of leadership studies towards less individualistic theories and the implications of these developments for a ‘qualities approach’ in the section below.

3.1 The evolution of leadership studies

Over the past fifty years, the understanding of public administration and governance in the literature has become increasingly nuanced and complex (Bussu and Galanti 2018, Horwath and Morrison 2007, Heifetz et al 2009). Many recent studies observe a shift from hierarchical, command and control mechanisms to coproduction and/or collaborative action across sectors, organisations and disciplines (Silvia 2011, Avolio et al 2009). In parallel to this, the study of leadership also evolved and branched out in this direction. Heroic, great-man theories that focused on traits and qualities unique to the leader used to be predominant, while now the literature presents more expansive understandings of leadership and its challenges that attend to the relational, situational, and context-specific elements (Bass and Bass 2008).

The shift to this more nuanced understanding of leadership is also a response to criticism of exclusively leader-centred approaches. Accounts of ‘charismatic’, and later ‘transformational leadership’, which emphasise the capacity of leaders to inspire and motivate followers to excel in their work and enhance performance (see Appendix II for more details), have been criticised for being too individualistic in their understanding of leadership. Stogdill (1948 in Bass and Bass 2008) argues that the qualities, characteristics, and skills required of a leader are determined to a large extent by the demands of the situation. Therefore, analysis of leadership cannot be abstracted from the context in which it occurs.

3.2 Three challenges to the qualities approach

As a result of these criticisms, there have been efforts to move beyond an individualistic account of leadership, resulting in a rich diversity of theories and models. These can broadly be grouped into three clusters of literature.

The first cluster (Bussu and Galanti 2018, Horwath and Morrison 2007, Tong et al 2018) responds to the increasingly horizontal and collaborative nature of public administration by rejecting heroic leadership approaches and encouraging us to reframe the leader’s role in terms of those around them. The unit of analysis remains individuals but rather than talking of leaders inspiring followers, these discussions will talk of leaders empowering others, fostering communication, building trust, and enhancing accountability. ‘Authentic’ and ‘servant’ theories of leadership belong to this strand of the literature (see Appendix II for more details).

A second cluster of the literature (Cullen-Lester and Yammarino 2016, Uhl-Bien and Marion 2009, Fairhurst 2007) rejects the individual as a focus of leadership, departing from talk of properties of individuals to properties of relationships, organisations, networks, and systems. Therefore we might talk of adaptive organisations rather than adaptive leaders, or we might think of qualities emerging through an intersubjective process of collaboration or relationship building. For example, the ‘leader member exchange’ theory (Dionne et al 2010) focuses on the relationship between leaders and followers where the quality of the relationship, not the qualities of leaders, determines effectiveness. Other examples of this strand are ‘distributed’ models of leadership (see Appendix II for more details), which consider the potential for leadership to emerge amongst different members of an organisation or network, regardless of their managerial role or seniority. The more extreme examples of this body of literature seek to transcend person-centred approach by focusing on sources of leadership outside of individual people (Ospina 2017). These approaches see leadership as an emergent process and practice intended to cultivate group members’ capacity to navigate to complexity, where leadership can emerge through relationships, system properties, networks as well as individual action. Theories that follow this approach include ‘network leadership theory’, ‘complexity leadership theory’, and ‘collective leadership’ (Ospina 2017, Bryson, Crosby and Stone 2015, Mandell and Keast 2009, Morse 2010) (see Appendix II for more details). These theories offer valuable insights and highlight the limitations of individualistic approaches, however they raise challenges of their own. Some of these more radical approaches are criticised in the literature for stretching the concept of leadership beyond any natural sense of the word, undermining the explanatory value of the term, and inviting one to consider whether such theories are meaningfully talking about leadership at all (Morrison 2010).

Finally, the third cluster of the literature departs entirely from grand theory of leadership altogether, focusing instead on specific types of challenges and barriers leaders face, as well as more specific goals and outcomes (Heifetz et al 2009, Ekstrom and Idvall 2015, Corazzini et al 2014). A prominent approach that belongs to this strand is ‘adaptive leadership theory’ (see Appendix II for more details). This is described not as a theory of leadership per se, but as a practice that mobilises people to tackle tough challenges and thrive (Heifetz et al 2009). The theory is oriented around specific types of challenges that have no ready answers and cannot be addressed with existing procedures and expertise. The activities recommended in the adaptive leadership theory literature may not be necessary or even desirable in other contexts. This approach draws our attention to the possibility that general theories of leadership may be too abstract to be helpful in understanding what is required in response to challenges that leaders face. A general leadership theory narrows our focus to a particular set of challenges anticipated by the theory, and this may neglect other barriers that might be experienced in practice.

An example of where this literature identifies challenges that might not be captured by general leadership theories is highlighted by Ekstrom and Idvall (2015). They discuss leadership challenges experienced by nursing staff, and the implications this has for retention of staff. A challenge the study highlights is the issue of nurses disassociating from their leadership role, concerned that they may appear lazy or bossy, and feeling uncomfortable in their role and therefore job. The discussion presents a specific challenge (the experience of disassociation) and its consequences for a specific outcome (staff retention). While this could be reinterpreted using the language of ‘transformational leadership’ or ‘leader member exchange’, it is not clear this would give us a better understanding of the problem or its potential solutions, rather it might obscure and over-complicate the issue. Intuitively this level of analysis is more helpful to understanding leadership in the context of nursing than the broader understanding introduced by general leadership theories. Further literature highlights the particular ethical dilemmas and frameworks for understanding ethics of leadership within particular professions, as these might present context-specific features (Storch et al 2013, Broussine and Miller 2005, Curtis and Hodge 1995). These discussions suggest a need to pay further attention to what is usefully gained, and also what is lost, by moving from the specific context to much more general understandings of leadership and leadership qualities.

3.3 Implications for the NLC’s qualities approach

To conclude, there is certainly a push from the literature to look beyond individual qualities of leaders and acknowledge the importance of the context and systems within which they operate. This doesn’t reject the validity of a ‘qualities approach’ but it calls for an expansive understanding of the qualities, which acknowledges that these may manifest in various ways and emerge from different sources other than the traditional leader. In this sense, in addition to thinking of adaptive qualities of individuals, the NLC could also consider how cultures or organisations demonstrate these qualities. Additionally, the literature would also suggest that attention needs to be paid to the situation in which leaders operate, including the specific challenges and barriers experienced by members of a system, and the specific goals or outcomes that would be desirable in a given professional context.

4. Measuring leadership impact

The discussion in the previous section considered sources of variety in how leadership is conceptualised and different approaches to understanding the challenges that leaders encounter. It is important to also reflect on variety in how good leadership is measured, and more specifically, the intended purpose of leadership — the goals and outcomes that leadership is judged against. The literature talks about leadership in the context of various outcomes, from the abstract to the context-specific, from outcomes relating to work output to satisfaction amongst employees or the wider public. The findings suggest a need to consider the compatibility and potential tensions between different goals and outcomes and therefore the need to understand the priorities of leadership in a given context, and the nature of the relationship between leadership style and particular outcomes.

4.1 Approaches to leadership outcomes

The impact of leadership is approached from a wide variety of theoretical perspectives and in many cases different theories are accompanied by specific methods of empirical measurement. For example, ‘authentic leadership’ has been approached through a leader authenticity scale and authentic leadership questionnaires (Avolio et al 2009). Nevertheless, it is helpful to note the presence of goals or outcomes that are applied across these different theoretical approaches as a measure of the impact of good leadership. We have captured numerous examples of these at the top of the Abstract Search documents, however the main ones identified in the literature reviewed are summarised in the table below.

This overview shows that the literature has explored leadership in relation to various outcomes. The measures of outcomes can vary; for example, Kotze and Venter (2011) measure an individual’s effectiveness by asking the individual and four colleagues to rate them, while Uster et al (2018) link effectiveness to external measures of performance. Some of the measures are easily verifiable (such as staff retention rates) to other outcomes such as trust or creativity that are more intangible and thus rely on more contested measures and indicators. Outcomes such as trust can be treated as a dependent variable by some studies (Agote et al 2016) and an independent variable by others (Lee et al 2010).

Finally outcomes are measured within different theoretical perspectives. For example, retention of staff has been explored from different theoretical frameworks, notably ‘leader member exchange’ and ‘transformational leadership’ (See Appendix II for more details). Joo (2010) and Joo (2012) both find a correlation between high-quality relationships between leaders and followers and staff retention in studies that utilise leader member exchange theory. Additionally, Wang et al (2018) explore the impact of transformational leadership and emotional intelligence on the retention of nursing staff, finding that transformational leadership and emotional intelligence were significant predictors of nurse intent to stay, with emotional intelligence found to partially mediate the relationship between transformational leadership and intent to stay.

In order to judge the significance of these findings, we would need to be able to establish the validity of the individual studies and the comparability of measures applied across studies to allow for meaningful comparisons, which is beyond the scope of this paper. An important consideration for the purpose of strengthening our understanding of leadership qualities is the extent to which the findings support a causal relationship between a given attribute of leadership and a given outcome, or whether they only establish correlation.

4.2 Implications for the NLC’s qualities approach

These examples from the literature illustrate multiple layers of variety in the research, from how leadership is understood and measured, to the variety of outcomes that are understood to be the desired goals of good leadership. It is beyond the scope of this paper to analyse the strength and validity of individual methodological approaches, the extent to which these studies establish a causal link between a given quality of leadership and a given outcome, or the most effective route to developing these qualities in leaders. Nevertheless, these questions are of importance to our understanding of a ‘qualities approach’ to leadership. For example, is the key to understanding how connected leaders are able to retain staff or enhance creativity emotional intelligence? If so, discussion on leadership development that focus specifically on enhancing emotional intelligence would be an important direction for further exploration. The developments in the literature suggest a need to think about the desired outcomes for leadership and the extent to which these are shared by different leaders, for example, whether particular outcomes are more relevant for particular fields, or specific challenges. Once there is a clearer sense of the desired outcomes and goals of leadership, it is possible to explore leadership attributes relevant to those outcomes and the strength of that research and potential for leader development.

5. Conclusions and recommendations for future research

The review undertaken here provides a wide ranging overview of leadership (with elements similar to a scoping review approach to the literature) through the lens of the NLC five qualities using the academic literature as its basis. Its strength is the breadth of the review and the broad grounding of the five qualities in relation to academic knowledge. The obvious weakness is the depth to which this review has been able to go into the details of the theoretical linkage of the literature with each quality. Another weakness is the limit of the academic literature generally — the context and contemporaneity — which are comparative strengths of the ‘grey’ literature. Literature reviews by their nature are prone to degrees of imprecision, particularly in an area as ambiguous as leadership and a context as complex as the public sector. Different approaches to reviews will always be prone to exaggerating aspects of a phenomenon and occluding others. Given these inevitable constraints, the key question is what to do with the knowledge base that this literature review provides.

Based on the findings and conversations with the NLC team, the following questions emerged as potential areas for future exploration that can advance both the NLC understanding of leadership and its goals as an organisation:

• What is the most useful balance of considerations between the individual qualities of leaders and the wider relational and contextual elements of leadership in public service contexts?
• How can the NLC make use of the plethora of theories of leadership that exist within the literature and judge the ways in which these may be helpfully applied in practice?
• How should the NLC understand the desired outcomes of leadership, how these might change depending on the context and how to navigate tensions between them?
• To what extent do findings and recommendations on leadership support leaders in interpreting challenges and providing effective leadership in practice?
• How can leadership qualities be usefully identified, learned, and practised through training?
• How can the NLC evolve their understanding of leadership overtime to ensure it accounts for the challenges and experiences of today’s leaders and supports their practice?

These are difficult questions and the first step in addressing them is identifying where the relevant knowledge can be found. The review provides a helpful resource to direct further exploration of the existing evidence base relevant to the issues raised by these questions. Further in-depth academic research could yield useful results, potentially in conjunction with ‘grey’ literature. However, the people best placed to provide the answers to these questions are the leaders themselves. Academic research helps to frame the debate but understanding the value of these theoretical insights, where and how they can be improved, requires closer collaboration and co-production with leaders and those who will translate these lessons into practice.

The NLC is uniquely positioned to tap into the knowledge of its network of public service leaders and gain primary insights into the challenges and attributes of leadership. It has the opportunity to genuinely co-produce with leaders the generation of insights into the way they operate in public service contexts and bring about better outcomes. This could be achieved through introducing co-production into the delivery of its programme or through using qualitative/participatory research methods. Using these methods would build the findings of this and other reviews and connect what is a rich but fragmented literature with the practice of leadership in a complex and ambiguous reality.

Appendix I: Search terms and key results

Appendix ii: glossary.

The literature review revealed how the study of leadership has been approached from a wide variety of theoretical perspectives appealing to specialised concepts and understandings of leadership and governance. The glossary below provides an introductory summary of the most prominent theoretical perspectives and concepts that were identified in the review. In each case, the definition is accompanied by a table providing references to papers discussing the theory, where the columns indicate where the theory has been applied in general leadership literature and in discussion of the five NLC qualities. The specific papers referenced in the columns can be found in the six Abstract search documents.

As for notation, papers are referenced by a number (e.g. [17]), where this refers to where the abstract appears in the search documents. An ‘! indicates a particularly important or relevant paper (e.g. [17!]), an ‘n’ indicates where no abstract was present (e.g. [17n]), a ‘-’ indicates limited information available (e.g. [17-]).

Charismatic leadership

Until the 1940s study of leadership primarily focused on individual traits. ‘Great-man’ theories and the ‘warrior model of leadership’ (see Machiavelli, Suntzu) understood leadership, as well as much historical and social progress, as attributable to the qualities of extraordinary individuals. Max Weber introduced the religious concept of ‘charisma’ into social sciences to describe leaders with extraordinary abilities and this notion of charismatic leadership has proven an influential modern continuation of the individual traits approach to leadership. Charismatic leaders are expressive, articulate and emotionally appealing. They are self-confident, determined, active and energetic. They have a positive effect on their followers who identify with them and have complete faith in them. House (1997) presented a theory of charismatic leadership resulting in renewed interest and empirical study of the concept.

Although theories that focus purely on traits have fallen out of favour and have been modified and adapted in recent literature. Charismatic leadership can be understood as a significant modern example of this approach to leadership. It has been influential on further developments such as ‘transformational’ and ‘authentic leadership’ (see p.23 and p.25 respectively), and remains part of the language of the study of leadership.

Transformational leadership

Transformational leadership is a theory of leadership that highlights a leader’s capacity to inspire their followers and thus enhance motivation, morale and performance. This is commonly understood to involve acting as a role model for followers, encouraging followers to act beyond their own self-interest and work for the good of the group, organisation or cause, take greater ownership for their work, to excel and self-actualise. It is commonly contrasted with ‘transactional leadership (see p.24) in which leaders rely on extrinsic rewards and punishments to produce more short term change in behaviour.

Transformational leadership was first mentioned by Downton (1973 in Bass and Bass 2008) and formalised in Burns (1978 in Bass and Bass 2008). Most articulations of transformational leadership treat charismatic leadership as an important dimension of transformational leadership, while including other elements such as inspirational leadership, intellectual stimulation and individualised consideration. Transformational leadership has also been understood to co-exist and indeed augment the results of transactional leadership. Scholars have noted limitations to transformational leadership, principally that the focus on leaders and followers is individualistic and represents only one way to understand and perform leadership (Ospina 2017). Furthermore the framework may be limited in its application to more collaborative and horizontal forms of leadership. Further theoretical developments in the study of leadership have moved away from the individual highlighting the importance of relationships and networks (for example see ‘network leadership’ and ‘collaborative leadership’).

Transactional leadership

Transactional leadership understands leadership in terms of an exchange or transaction between leader and follower, for example the exchange of reward for work. Transactional is often contrasted with transformational (see p.23). The main criticism of transactional approaches is that the rewards provide only basic motivation, may increase work rather than quality and may produce poorer results relative to transformational leadership.

Servant leadership

Servant leadership was formulated by Greenleaf (1977) who argues that leaders are required to curb their egos, convert their followers into leaders, and become the first among equals. The needs of others are the leaders’ highest priority, they are expected to build relationships that help their followers grow, while power has to be shared by empowering followers. According to Bass and Bass (2008) servant leadership shares much in common with transformational leadership such as vision, influence, credibility and trust. It is also linked with other models of leadership including self-sacrificial leaders.

Authentic leadership

Authentic leadership is a nascent but popular concept in the leadership literature that emphasises self-awareness, openness, fair-mindedness and the ethical foundations of leadership. The concept is related to ‘charismatic’ and ‘transformational leadership (see p.22 and p.23 respectively); the suggestion that there are pseudo (i.e inspirational but self serving) versus authentic transformational leaders led to research into authentic leadership (Avolio et al 2009:423). The moral or ethical component of authentic leadership has been questioned. Some have speculated on whether people can remain true or authentic to a value system or organisation that is itself damaging, harmful or corrupt. Similarly one might be able to inspire or build trust in people through superficial means without being trustworthy or honest in your interaction with them. These considerations highlight a distinction and potential tension between the norms or ideals of good leadership and broader considerations of the good. The philosophical foundations and methods of empirical study have also been challenged in the literature.

Adaptive leadership

Heifetz et al (2009) argue that adaptive leadership is a practice not a position. They define it as the practice of mobilising people to tackle tough challenges and thrive. It is an example of a ‘distributed leadership’ model (see p. 31), meaning leadership can be displayed by people across an organisation regardless of managerial role or seniority of position. Adaptive challenges have no ready answers and cannot be met by existing procedures or expertise. Adaptive change is uncomfortable, challenging our assumptions, beliefs and habits. Adaptive leadership requires non-traditional leadership behaviour, whereby leaders do not provide answers and accept a degree of conflict and discomfort to sustain adaptive change.

Three activities said to be core to adaptive leadership are

• Observing events and patterns without forming judgements about the data’s meaning.
• Tentatively interpreting observations by developing multiple hypotheses about what is going on.
• Designing interventions based on observations and interpretations in the service of making progress on the adaptive challenge.

Adaptive leadership has been criticised for failing to conform to traditional views of the leader, stretching the concept of leader to the point where it might be better described as a theory of facilitation. McCrimmon (n.d) develops an argument against the concept that suggests not all leadership occurs in the context of a problem, and not all change entails a response to an adaptive challenge. It is not clear that adaptive leadership makes such assumptions, though it may be better understood as a recommended response to a specific type of challenge rather than a general theory of leadership.

Complexity Leadership Theory

According to Uhl-Bien et al (2007), complexity leadership theory is a leadership paradigm that focuses on enabling learning, creative and adaptive capacity of complex adaptive systems within the context of knowledge-producing organisations. The conceptual framework includes three entangled leadership roles (adaptive leadership, administrative leadership, and enabling leadership) that reflect a dynamic relationship between the bureaucratic, administrative functions of the organisation and the emergent, informal dynamics of complex adaptive systems.

Morrison (2010) provides a critique of complexity theory. While acknowledging its rise in popularity and the valuable insights it offers, Morrison presents a range of concerns with the approach. These include the claim that it can be regarded as disguised ideology conflating description and prescription and that it risks exonerating leaders from expectations of accountability and responsibility.

Related theories: Complex Adaptive Systems: General [75]

Collaborative leadership

Collaborative leadership entails working across boundaries and in multisector and multi actor relationships (O’Leary et al 2010). In discussion of collaborative governance, Getha-Taylor and Morse (2013), observe that the traditional model of leadership development focused on leading within bounded hierarchy and via command and control mechanisms. This approach, they argue, fails to accurately reflect the nature and challenges of leadership encountered in contemporary joint public service delivery, which involves multiple government and for profit and nonprofit agencies. Such an approach must therefore be moderated with a focus on collaborative problem solving, working in flattened structures and incentivising behaviour in new ways. Collaborative governance, collaborative leadership and collaborative management are prominently discussed in leadership literature to highlight these considerations.

Related theories: Collaborative management: General [1][17] Collaborative governance: General:[24][27][29][51] [67][71][87] [107] Adaptive: [34]

Network leadership

According to Ospina (2017), network leadership theory views leader or follower attributions as properties of the system, in which influence relationships define relational structures, whether they be within a single organisation or across inter-organisational and cross sector networks. Silvia (2011) describes understandings of governance moving from hierarchical or command and control mechanisms to public services jointly produced by networks including government and private and third sector organisations. Network leadership can be understood as the study of leadership and management within these collaborations. For example, Silvia and McGuire (2010 in Silvia 2011) find differences in leadership between these two contexts, with an increased emphasis on people oriented behaviours such as motivating personnel, creating trust, maintaining a close-knit group and treating others as equals. The concept is also discussed in terms of collaborative leadership (see p.27). While the discussion of collaborative leadership is often framed as a response to a change in the nature of public administration, requiring consideration of factors including networks, discussion of network leadership appears to centre discussion on those networks and understand further features of the system through this lens.

Leader Member Exchange

Leader member exchange (LMX) refers to the exchange relationship between a leader and member (follower). LMX theory claims that the quality of the relationship between leader and member determines the effectiveness of leadership. High quality LMX relationships yield high levels of mutual trust, support and obligation, while low quality relationships are more instrumental and less effective (Ospina 2017). Associated with Graen (1976 in Bass and Bass 2008), LMX theory assumes that the leader behaves differently toward each follower and that these differences must be analysed separately. This theory is contrasted with most earlier theories that assume leaders behave in much the same way to all group members. Graen (1976) categorises followers as belonging to an in-group and an out-group with different behaviour expected of leaders in relation to these groups. Although it is less leader-centred it remains person-centred, and therefore has received some criticism from those seeking to broaden the object of study to factors external to the individual (such as ‘collective leadership’ on p.31 for example).

Related theories: See also Relational leadership [13]

Distributive leadership

Distributive models of leadership decouple leadership roles from formal positions of authority and propose that leadership may emerge in different locations, drawing on the collective intelligence of an organisational system in which interdependence and connectedness are critical. According to Ospina (2017), shared/distributed theories focus more directly on the relational nature of leadership and its collective dimensions by attending to new demands associated with horizontal relationships of accountability in contemporary organisations. The terms ‘distributive’, ‘distributed’ and occasionally ‘distributary’ leadership appear to be used interchangeably in the literature to capture the same issue.

Collective leadership

Collective leadership theories locate the source of leadership one level up from the individual or the relationship at the system of relationships — the collective (Ospina 2017). The primary source of leadership is not exclusively the leader (see transformational), the dyadic relationship (see leader member exchange), or the shifting roles (see shared/distributed), leadership can also emerge from other system properties such as the networks of interdependent relationships influencing what its members can and ought to do or other processes associated with the new demands of organising to achieve joint results (Ospina 2017:281).

Discussion of collaborative leadership focuses on shifts in the nature of public administration and the changing requirements of leaders, there is more flexibility in how leadership is discussed relative to these changes. In contrast, discussion of collective leadership reflects a more deliberate effort to reimagine the nature of leadership. Relative to some of the more traditional approaches to leadership, collective leadership can be understood as seeking to incorporate these approaches yet also broaden the scope of the object of study. It shares similar theoretical strands with network leadership and complexity leadership theory (p. 28 and p.27 respectively). Ospina et al (2017) argues that collective leadership lenses are particularly helpful in the study of leadership in networked governing arrangements.

The risks presented by expansive projects such as collective leadership is that they are vulnerable to concept stretching, distorting talk of leadership to the point that it loses explanatory value. When the focus moves beyond individual catalysts and persons, it is reasonable to question whether we are meaningfully talking about leadership at all.

Public Service Motivation

Public Service Motivation (PSM) is not a theory of leadership in itself but it is a widely referenced concept in discussions of public leadership. It is defined as an attribute of government and NGO employment that explains why individuals have a desire to serve the public and link their personal actions with the overall public interest. This concept features prominently in literature on leadership, notably in relation to transformational leadership (p.23) and discussions of roles, identity and motivation relating to both leaders and followers.

Leadership of place

Leadership of place is described as an inclusive model of leadership based on systems thinking in a spatial context. It is discussed within the context of New Civic Leadership (NCL), an approach which is understood as an alternative to New Public Management, and a response to the challenges of the complex multi-level, multi-disciplinary environment of a knowledge based economy (Gibney et al 2009). NCL, and by extension leadership of place, draws attention to the power of place in policy making. It is argued that the strong feelings of commitment people have to their locality have been neglected by other approaches to public management theory and practice. NCL highlights the role of place based leadership in spurring the co-creation of enhancing life in a locality. It has been associated with a number of aims, including drawing on the commitment of leaders to their locality in delivering long term benefits for the local community, using and building on local knowledge and building relationships and capacity within a community and local context. It has been observed that the concept of leadership of place is in its infancy and is used by different organisations to mean subtly different things.

Appendix III: Bibliography

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Bass, B. M. & Bass, R., 2008. The Bass Handbook of Leadership; Theory, Research, and Managerial Applications. New York: Free Press

Broussine, M., & Miller, C. (2005). Leadership, ethical dilemmas and ‘good’ authority in public service partnership working. Business Ethics: A European Review, 14(4), 379–391. https://doi.org/10.1111/j.1467-8608.2005.00419.x

Bryson, John M., Barbara C. Crosby, and Melissa Middleton Stone (2015). Designing and Implementing Cross-Sector Collaborations: Needed and Challenging. Public Administration Review 75(5): 647–63

Bussu, S., & Galanti, M. T. (2018). Facilitating coproduction: the role of leadership in coproduction initiatives in the UK. Policy and Society, 37(3), 347–367. https://doi.org/10.1080/14494035.2018.1414355

Corazzini, K., White H. Buhr G T,, McConnell E, & Colón-Emeric C (2015). Implementing Culture Change in Nursing Homes: An Adaptive Leadership Framework. The Gerontologist, 55(4), 616. https://doi.org/http://dx.doi.org/10.1093/geront/gnt170

Cullen-Lester, K L., and Yammarino, F. (2016). Collective and Network Approaches to Leadership. Leadership Quarterly 27(2): 173–80.

Curtis, L. C., & Hodge, M. (1995). Ethics and boundaries in community support services: New challenges.New Directions for Mental Health Services, 1995(66), 43–60. https://doi.org/10.1002/yd.23319950206

Dionne, S. D., Sayama, H., Hao, C., & Bush, B. J. (2010). The role of leadership in shared mental model convergence and team performance improvement An agent-based computational model. Leadership Quarterly, 21(6), 1035–1049. https://doi.org/10.1016/j.leaqua.2010.10.007

Silvia, C. (2011). Collaborative Governance Concepts for Successful Network Leadership. State and Local Government Review, 43(1), 66–71. Retrieved from https://search.proquest.com/docview/870998417?accountid=14987

Fairhurst, Gail (2007). Discursive Leadership. Thousand Oaks, CA: Sage Publications.

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Heifetz, R., Grashow, A. & Linsky, M., 2009. The Practice of Adaptive Leadership; Tools and Tactics for Changing Your Organization and the World. Boston: Harvard Business Press.

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An integrative review of leadership competencies and attributes in advanced nursing practice

Maud heinen.

1 Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Institute for Quality of Healthcare, Nijmegen The Netherlands

Catharina van Oostveen

2 Spaarne Gasthuis Hospital, Spaarne Gasthuis Academy, Haarlem The Netherlands

3 Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam The Netherlands

Jeroen Peters

4 Hogeschool van Arnhem en Nijmegen, HAN University of Applied Sciences, Nijmegen The Netherlands

Hester Vermeulen

5 HAN University of Applied Sciences, Nijmegen The Netherlands

Associated Data

To establish what leadership competencies are expected of master level‐educated nurses like the Advanced Practice Nurses and the Clinical Nurse Leaders as described in the international literature.

Developments in health care ask for well‐trained nurse leaders. Advanced Practice Nurses and Clinical Nurse Leaders are ideally positioned to lead healthcare reform in nursing. Nurses should be adequately equipped for this role based on internationally defined leadership competencies. Therefore, identifying leadership competencies and related attributes internationally is needed.

Integrative review.

Embase, Medline and CINAHL databases were searched (January 2005–December 2018). Also, websites of international professional nursing organizations were searched for frameworks on leadership competencies. Study and framework selection, identification of competencies, quality appraisal of included studies and analysis of data were independently conducted by two researchers.

Fifteen studies and seven competency frameworks were included. Synthesis of 150 identified competencies led to a set of 30 core competencies in the clinical, professional, health systems. and health policy leadership domains. Most competencies fitted in one single domain the health policy domain contained the least competencies.

Conclusions

This synthesis of 30 core competencies within four leadership domains can be used for further development of evidence‐based curricula on leadership. Next steps include further refining of competencies, addressing gaps, and the linking of knowledge, skills, and attributes.

These findings contribute to leadership development for Advanced Practice Nurses and Clinical Nurse Leaders while aiming at improved health service delivery and guiding of health policies and reforms.

1. INTRODUCTION

Developments in health care, like a growing number of patients with chronic diseases, an increased complexity of patients, a stronger focus on person‐centred care and a demand for less institutionalized care ask for well‐trained master level‐educated nurses operating as partners in integrated care teams, with leadership qualities at all levels of the healthcare system. Changes in health care are also underlined by a definition of health as proposed by Huber et al. (Huber et al., 2011 ) where health is defined as ‘the ability to adapt and self manage in the face of social, physical and emotional challenges’ as a refinement of the World Health Organization (WHO) definition where health is ‘a state of complete physical, mental and social well being’ (WHO, 1948 ). This stipulates the de‐medicalization of health care and society and emphasizes the need for change in the way health care is organized. Also the Institute of Medicine with their report on ‘The Future of Nursing’ supports the urge for nurses to take their roles to address changes in health care (IOM, 2011 ). However leading change is a complex and not yet well understood process (Nelson‐Brantley & Ford, 2017 ). Therefore, especially master level‐educated nurses have to be trained in leadership based on internationally established leadership competencies. This review investigates what leadership competencies are expected from and can be identified for master educated nurses from an international perspective.

1.1. Background

Clinical nurses who are trained at master's level, for example, Advanced Practice Nurses (APNs) and Clinical Nurse Leaders (CNLs), are in a unique position to take a leadership role, in collaboration with other healthcare professionals, to shape healthcare reform, as they use extended and expanded skills and are trained to focus on improved patient outcomes, the application of evidence‐based practice and assessing cost‐effectiveness of care (Stanley et al., 2008 ). The focus of this review is on APNs and CNLs, where APN is regarded as a general designation for all nurses with an advanced degree in a nursing program, that is, Certified Nurse Practitioner (NP), Certified Registered Nurse Anaesthetist, Certified Nurse Midwife and Clinical Nurse Specialist (CNS) (APRN Joint Dialogue Group, 2008 ) . APNs are prepared with specialized education in a defined clinical area of practice. With APN in this review, we refer to the NP and the CNS. The CNL is educated to improve the quality of care and coordinate care in general through collaboration at the microsystems level in the entire healthcare team (APRN Joint Dialogue Group, 2007 ). Both groups of professionals are trained to integrate science in practice and education, have increased degrees of autonomy in judgments and clinical interventions and are expected to be engaged in collaborative and inter professional practices to achieve the best outcomes for patients, personnel and organization (American Association of Colleges of Nursing, 2011 ). They are also expected to substantially contribute to clinical outcomes through, that is, continuous quality improvement in patient care and creating a supportive environment for their colleagues, and to contribute to the development of their profession, healthcare systems and healthcare policy. (American Association of Colleges of Nursing, 2004 ; Bender, Williams, & Su, 2016 ; Hamric, Hanson, Tracy, & O'Grady, 2014 ). Therefore developing leadership competencies is an essential prerequisite for these master educated nurses, APNs however appear to experience a lot of difficulties in enacting their leadership role (Begley, Murphy, Higgins, & Cooney, 2014 ; Elliott, Begley, Sheaf, & Higgins, 2016a ).

Leadership is subject of many discussions can be regarded from different perspectives and is mostly related to specific contexts. Hence, there is no single definition applicable to all settings and professions. Leadership is mostly regarded in relation to managing a team or organization (Gosling & Mintzberg, 2003 ) but can also be defined as a set of personal skills or traits, or focussing on the relation between leaders and followers (Alimo‐Metcalfe & Alban‐Metcalfe, 2004 ; Bolden, 2004 ). Transformational and situational leadership are also commonly used concepts where transformational leadership is regarded as the process of leading and inspiring a group to achieve a common goal (Northouse, 2014 ) and situational leadership is focusing on the interaction between individual leadership styles and the features of the environment or situation where the leader is operating. (Fiedler, 1967 ; Hamric et al., 2014 ; Lynch, McCormack, & McCance, 2011 ). In this review, leadership is regarded as a process where nurses can develop observable leadership competencies and attributes needed to improve patient outcomes, and personnel and organizational outcomes (Kouzes & Posner, 2012 ). This implies that leadership competencies can be viewed as intended and defined outcomes of learning and that leadership and leadership competencies are not restricted to one single theory. A competency can be defined as ‘an expected level of performance that results from an integration of knowledge, skills, abilities and judgment’ (American Nurses Association, 2013 ).

The lack of an unambiguous definition of leadership in clinical practice, including clearly defined leadership competencies in nursing, is reflected in education. For most training programs and curricula, it is unclear whether the profiles used in education are up‐to‐date and aiming` at internationally accepted leadership competencies with evidence‐based methods to achieve these competencies. To enhance leadership qualities in master educated nurses, it is necessary to explicitly define what leadership competencies are expected from APNs and CNLs (Delamaire & Lafortune, 2010 ). Identifying and establishing internationally agreed on leadership competencies in master educated nurses is a first step to developing evidence‐based curricula on leadership (Falk‐Rafael, 2005 ; Vance & Larson, 2002 ). Such a curriculum facilitates APN and CNL students to not only become competent clinical and professional leaders but also well‐prepared for organizational systems and political leadership (Hamric et al., 2014 ). As such, it enables them to have a positive and significant impact on patient, personnel and organizational level outcomes. Accordingly, this review aims to identify and integrate leadership competencies of the master level‐educated nurse (APN and CNL) from an international perspective.

2. THE REVIEW

Based on the decision flowchart developed by Flemming et al. (Flemming, Booth, Hannes, Cargo, & Noyes, 2018 ), this review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses statement (Moher, Liberati, Tetzlaff, & Altman, 2009 ) and the Enhancing transparency in reporting the synthesis of qualitative research statement (Tong, Flemming, McInnes, Oliver, & Craig, 2012 ).

To identify and integrate leadership competencies of the master level‐educated nurse (APN and CNL) from an international perspective.

2.2. Design

An integrative review design was used, which allows for the combination of various study designs and data sources to be included. In using this methodology, a rigorous and systematic approach is ensured (Whittemore & Knafl, 2005 ). We followed the five stage methodology by Whittemore and Knafl (Whittemore & Knafl, 2005 ), however for the data synthesis phase, we used the four leadership domains of Hamric et al (Hamric et al., 2014 ; Hamric, Spross, & Hanson, 2009 ) as an a priori framework to integrate the extracted data.

The APN Leadership competency is conceptualized by Hamric et al. (Hamric et al., 2014 ) as occurring in four primary domains; in clinical practice with patients and staff, in professional organizations, in healthcare systems and in health policy‐making arenas. As stated above, this review focuses on the leadership competencies of APNs and CNLs. Additionally, knowledge, skills and attributes (KSA) needed to develop leadership competencies were topic of interest, where knowledge is regarded as being acquired through cognitive learning, skills through practice and attributes as behaviours that are learned over time (Koolen, 2016 ). We would like to add a reference to support this one, the full reference is added to the remark concerning Koolen in the reference list. The reference that needs to be added here is; ​Guillén and Saris ( 2013 )

2.3. Search methods

First, MEDLINE, EMBASE and CINAHL databases were searched from January 2005 ‐ December 2018 to identify articles concerning leadership in APNs and CNLs. To find all literature fitting our scope, we used the words attitude* role* attribute* next to leadership and competenc*. The search strategy was designed and conducted with the help of a clinical librarian (Data S1 ).

Articles were eligible if they explicitly described leadership competencies or related knowledge, skills or attributes in: (a) studies reporting on theory or theoretical leadership models; (b) developmental studies on leadership programmes (c) studies reporting on the effects of leadership programmes. No restrictions on study designs were applied. Studies were excluded when they concerned managerial leadership, if they did not concern APNs or CNLs (i.e., bachelor nurses and/or undergraduate nurses); or described leadership styles in general. Box gives an overview of in and exclusion criteria.

Inclusion and exclusion criteria.

Secondly, the websites of international professional nursing organizations were searched for documents on leadership competencies in NPs, CNSs, and CNLs. Worldwide, there are more than 100 nursing organizations, usually part of one umbrella association or council. Therefore, this review focused on frameworks of umbrella organizations in Australia, Europe, and North America and international nursing councils. Frameworks had to describe nursing leadership and related competencies in NPs, CNSs, or CNLs.

Eligible articles and frameworks were independently selected by three reviewers (MH, AH, CvO) based on the relevance of their titles and abstracts, as retrieved by the search. If articles met the inclusion criteria, full‐text versions of the articles were obtained and further scrutinized for eligibility by (MH, AH, CvO). HV was involved in any cases of disagreement, where consensus was reached through discussion. The reference lists of included articles were checked to detect any potential additional studies.

2.4. Search outcome

The search strategy in PUBMED, CINAHL, and EMBASE resulted initially in 4,220 records. After removing duplicates, the remaining 2,839 articles were screened on title and abstract. As a result, 168 articles and nine additional articles, added through reference checking, were included for full‐text assessment. Twenty‐four articles were not available in full text. Fifteen articles were eventually included in this review. The flow diagram (Figure ​ (Figure1) 1 ) gives an overview of the inclusion process.

Flow diagram (PRISMA 2009) [Colour figure can be viewed at http://www.wileyonlinelibrary.com/ ]

2.5. Quality appraisal

A quality appraisal (Data S2 ) was conducted by two researchers (MH, AH) on all 15 studies. Quality appraisal of the included studies was conducted using the Mixed methods Appraisal Tool MMAT (Hong, Gonzalez‐Reyes, & Pluye, 2018 ). The MMAT is a critical appraisal tool that is designed for the appraisal stage of systematic mixed studies reviews. It permits to appraise the methodological quality of five categories studies. The MMAT starts with two screening questions to determine whether the study is an empirical study and the tool can be used. For each category, five criteria are defined to rate the quality of the studies. It is advised not to calculate an overall score from the ratings of each criterion and excluding studies with low methodological quality is discouraged. Quality was therefore not used to include or exclude studies from the review, also because of the difficulties in comparing quality of studies using different designs (Whittemore & Knafl, 2005 ). The goal of the quality appraisal was to evaluate the quality of studies and the degree of evidence in an unbiased and transparent way. A quality appraisal of included frameworks was not conducted.

2.6. Data extraction

Data extraction was performed using a pre‐defined, structured data extraction sheet and was double‐checked by three researchers (MH, AH, CvO). The following data were extracted: author, year of publication, title, methodology, country and setting, master's APNs or CNLs. Competencies and KSA were derived from the frameworks and studies, by the same three researchers (MH, AH, CvO). Involvement of three independent researchers was used to ensure rigour of data extraction (Whittemore & Knafl, 2005 ).

2.7. Synthesis

Competencies described in the original studies subsequently were designated to the leadership domains described by Hamric et al. (Hamric et al., 2014 ) by three researchers (MH, AH, CvO). In cases of discrepancy, the selected domains were discussed until consensus was reached. The next step consisted of clustering of overlapping competencies by two researchers (MH, AH), which were checked by a third researcher (CvO). The competency from the overlapping items that best described the content was chosen for the final overview of competencies, sometimes with a minor adaptation to fully grasp the essence of this competency. The same process was followed for the KSA‐items.

3.1. Individual studies

One out of 15 articles concerned both the NP and the CNS, seven were about the NP, three were about the CNS and four articles focused on the CNL. Most articles (9/15) originated from the United States of America (USA), three from Australia and three articles originated from Canada, the UK, and Finland respectively. Two articles published different aspects of the same research (Carryer, Gardner, Dunn, & Gardner, 2007 ; Gardner, Carryer, Gardner, & Dunn, 2006 ) (Table ​ (Table1 1 ).

Overview of included studies (15) and frameworks (7)

Abbreviation: NA, Not Applicable.

Sample sizes were relatively small, ranging from 6‐50 respondents and consisted of nurse leaders (Bahouth et al., 2013 ; Goldberg et al., 2016 ; O'Rourke & Higuchi, 2016 ), experienced nurses (Bender, Williams, Su, & Hites, 2017 ; Carryer et al., 2007 ; Gardner et al., 2006 ; Kalb et al., 2006 ; Leggat, Balding, & Schiftan, 2015 ; Nieminen, Mannevaara, & Fagerström, 2011 ) and APN or CNL students (Ailey, Lamb, Friese, & Christopher, 2015 ; Gerard, Grossman, & Godfrey, 2012 ; Leggat et al., 2015 ; Nieminen et al., 2011 ; Sievers & Wolf, 2006 ).

Multiple research designs were used. These included surveys, interviews, and focus groups to describe experiences on integrating NPs and CNSs into hospitals (Bahouth et al., 2013 ; O'Rourke & Higuchi, 2016 ; Sievers & Wolf, 2006 ) and expressed clinical competences (Nieminen et al., 2011 ), a case study on an education program for CNLs (Ailey et al., 2015 ), exploring the effect of a mentor program of NP students on developing leadership competencies (Leggat et al., 2015 ), piloting an assessment for performance review of NPs and CNSs (Kalb et al., 2006 ) and multi‐method research to develop shared competencies and educational standards for APNs (Bender et al., 2017 ; Carryer et al., 2007 ; Gardner et al., 2006 ; Goldberg et al., 2016 ). Eight were descriptive studies on (experiences with) educational programs for CNLs or CNSs (Ailey et al., 2015 ; Baernholdt & Cottingham, 2011 ; Gerard et al., 2012 ; Goldberg et al., 2016 ; Leggat et al., 2015 ; Maag, Buccheri, Capella, & Jennings, 2006 ; Sievers & Wolf, 2006 ; Thompson & Nelson‐Marten, 2011 ) Baernholdt and Cottingham (Baernholdt & Cottingham, 2011 ) also reported on the development of the CNL role in practice. Six studies explicitly described leadership competencies (Bender et al., 2017 ; Gardner et al., 2006 ; Gerard et al., 2012 ; Goldberg et al., 2016 ; Kalb et al., 2006 ; Nieminen et al., 2011 ). Furthermore, studies focused on knowledge (Ailey et al., 2015 ; Carryer et al., 2007 ), leadership skills (Baernholdt & Cottingham, 2011 ; Maag et al., 2006 ; Thompson & Nelson‐Marten, 2011 ) and leadership attributes (Bahouth et al., 2013 ; Sievers & Wolf, 2006 ).

For eight out of 15 studies, quality could not be determined on the basis of quality appraisal tools for research (Data S2 ), five studies scored positive on all five MMET domains (Bender et al., 2017 ; Carryer et al., 2007 ; Goldberg et al., 2016 ; Nieminen et al., 2011 ; O'Rourke & Higuchi, 2016 ), one study scored positive on four out of five domains (Leggat et al., 2015 ) and one study scored positive on one domain (Bahouth et al., 2013 ).

3.2. Frameworks

Seven competency frameworks, including leadership competencies, were identified. The frameworks were developed between 2006 and 2014 and originated internationally in Europe (1/7) (ICN, 2015 ), the USA (4/7) (American Association of Colleges of Nursing, 2006 , 2013 ; The National Organization of Nurse Practotioner Faculties, 2014 ), Canada (1/7) (The Canadian Nurses Association, 2010 ) and Australia (1/7) (Nursing and Midwifery Board of Australia, 2014 ). All frameworks describe leadership competencies for the NP, CNS, or CNL but the extent to which the four leadership domains (i.e., clinical‐, professional‐, system‐, and health policy leadership) are covered differed (Table ​ (Table1). 1 ). In Australia, leadership is linked to four defined practice standards in the nursing process. Additionally, leadership is defined as the ability to lead care teams where the NP supports other professionals through clinical supervision and mentoring (Nursing and Midwifery Board of Australia, 2014 ). The Canadian Nurse Practitioner Core Competencies Framework identifies leadership as a core competence for the NP that should be reflected in excellent clinical practice and by mentoring colleagues and students. Leadership activities should not be limited to the NPs' own practice or institution but should focus on the entire care continuum, also including the political field of health care (The Canadian Nurses Association, 2010 ). The NONPF‐USA defines nursing leadership as the ability to change care systems, create partnerships, establish adequate communication and to participate in professional organizations (The National Organization of Nurse Practotioner Faculties, 2014 ). The Clinical Nurse Specialist Core Competencies Framework has assigned leadership competencies mainly to the heading ‘System leadership’ and describes specific leadership behaviour and associated sphere of influence and nurse characteristics needed (The National Organization of Clinical Nurse Specialists, 2010 ). The Essentials of Doctoral Education for Advanced Nursing Practice (American Association of Colleges of Nursing, 2006 ) is designed to prepare nurses for the highest level of leadership in practice and scientific inquiry.

Leadership competencies mainly refer to the category ‘Organizational and system leadership for quality improvement and systems thinking’. Leadership competencies are applied in clinical practice, as well in the entire field of health care. The ‘Master's Essentials and Clinical Nurse Leader Competencies’ outlined in the ‘Competencies and Curricular Expectations for Clinical Nurse Leader Education and Practice’ (American Association of Colleges of Nursing, 2013 ) describes the CNL as ‘a leader in the healthcare delivery system in all settings where healthcare is delivered’ (American Association of Colleges of Nursing, 2013 , p. 4). The leader competencies are embedded in nine categories, with the core leadership competencies mainly described in ‘Essential 2: Organisational and Systems Leadership’. Finally, the International Council of Nurses Leadership for Change™ (LFC) program is developed to prepare nurses to take a leadership role during health sector change and reform and enhance their contribution to health services (ICN, 2015 ). Leadership competencies are mainly focused on a system‐ and health policy leadership. Four frameworks provide suggestions for curriculum development concerning required KSA or performance indicators (ICN, 2015 ).

3.3. Data synthesis

The 150 competencies derived from the literature are displayed in Data S3 . Table ​ Table2 2 shows the final synthesis of the extracted competencies which resulted in the identification of 30 core leadership competencies, assigned to the four leadership domains of Hamric et al. (Hamric et al., 2014 ). The highest number of competencies ( n  = 8) was designated to the clinical and to the systems leadership domains, six to the professional and two to the health policy leadership domains. Six competencies fitted more than one domain, of which one competency related to three domains, the clinical, the health systems, and the health policy domains and four competencies were linked to the clinical, and to the health systems leadership domains. One competency was designated to the professional and the health systems leadership domains. The model in Figure ​ Figure2 2 presents this synthesis of competencies.

Final 30 leadership Core competencies within (four) leadership domains

Model competencies [Colour figure can be viewed at http://www.wileyonlinelibrary.com/ ]

Seven studies and two frameworks reported on knowledge (Ailey et al., 2015 ; Bahouth et al., 2013 ; Carryer et al., 2007 ; The National Organization of Nurse Practotioner Faculties, 2014 ), skills (Ailey et al., 2015 ; Baernholdt & Cottingham, 2011 ; Maag et al., 2006 ; The National Organization of Clinical Nurse Specialists, 2010 ; The National Organization of Nurse Practotioner Faculties, 2014 ; Thompson & Nelson‐Marten, 2011 ) and attributes (Ailey et al., 2015 ; Bahouth et al., 2013 ). Both Ailey et al. (Ailey et al., 2015 ; Sievers & Wolf, 2006 ) and the NONPF (The National Organization of Nurse Practotioner Faculties, 2014 ) described skills and knowledge in terms of explicit curricula content for APNs. Other studies reported broadly formulated KSA. Eleven knowledge items, 21 skills and 21 attributes were identified (Table ​ (Table3) 3 ) and assigned to a leadership domain.

Overview of identified needs for knowledge, skills, and attributes

Abbreviations: CL, clinical; PR, professional; HS, health systems; HP, health policy.

4. DISCUSSION

The results of this integrative review lead to the synthesis of 30 leadership competencies for APNs and CNLs derived from international literature and official documents of international nursing organizations. Competencies were furthermore designated to the clinical, professional, health systems or the health policy leadership domains, according to Hamric et al. (Hamric et al., 2014 ). Six competencies were linked to more than one domain. The clinical, professional and the health systems domains dominated regarding the number of competencies.

In the clinical leadership domain, core competencies are focused on delivering excellent patient care and concern items like collaboration with professionals and other health agencies, implementation of innovations, and enhancing EBP. Although EBP is often viewed as a stand‐alone competency (Hamric et al., 2014 ), leadership and EBP are strongly connected (Sastre‐Fullana et al., 2017 ). Stetler et al. (Stetler, Ritchie, Rycroft‐Malone, & Charns, 2014 ) assume supportive leadership as a key driver for the successful institutionalization of EBP in an organization (Stetler et al., 2014 ).

Competencies on the professional leadership domain appear to be clearly formulated and provide for sufficient direction to further develop the nursing profession. This is important because hospital decision makers need to learn from professionals about their roles and a collaborative evidence‐based vision on APN (Carter et al., 2013 ) (Kilpatrick et al., 2014 ; Kleinpell, 2013 ).

The leadership competencies in the Health Systems domain are shifting from direct patient care to the strategic level. Influencing at the strategic level requires an in‐depth understanding of healthcare systems to create and share an organizational vision on quality improvement, leading to the implementation of changes and to evaluate their results. (Thompson & Nelson‐Marten, 2011 ; Walker, Cooke, Henderson, & Creedy, 2011 ). Health system leadership also means that APNs and CNLs articulate the nursing perspective by joining or chairing interdisciplinary committees and raise their voice in the boardroom. However, formal positions for APNs and CNLs at strategic level are not self‐evident. System leadership can therefore only be reinforced when supported by managers and administrators of the organization (Hanson, 2015 ; Higgins et al., 2014 ).

Competencies related to the health policy domain were minimally present. Identified core competencies in the health policy domain were the guiding and initiating of leadership in policy‐related activities, to practice influence in health care and the articulation of the value of nursing to key stakeholders and policymakers on the (inter)national level. These rather abstract competencies do not allow for a clear understanding of the content and nature of health policy leadership. Further specification and operationalization are needed to guide nurses to the political arena. For example, health policy competences should be focussing on in‐depth understanding of global trends in relevant health issues and the profession's involvement in healthcare policy decisions (Rains & Barton‐Kriese, 2001 ). Additionally, information technology including e‐health applications and ‘Big Data’ analytics are important issues on the health policy agenda and the nursing perspective should be part of decision‐making processes in this area.

Half of the studies and two frameworks reported on KSA (table ​ (table3) 3 ) needed for the development of leadership competencies. The distinction between KSA however, appeared somewhat unclear. Being knowledgeable about legal rules was described as an attribute in one study (Bahouth et al., 2013 ) and as knowledge in others (Ailey et al., 2015 ; Carryer et al., 2007 ). Although KSA are closely related to each other, a distinction is helpful to specify what is needed to achieve defined leadership competencies.

Acquiring leadership competencies and related KSA occurs over time and is comparable with Benner's continuum ‘from novice to expert’ (Benner, 1982 ). Both APNs and CNLs curricula and clinical learning programs should train and empower their students to become leaders. Evidenced‐based training programs for clinical, professional, and systems leadership are scarce (Elliott, Farnum, & Beauchesne, 2016b ). Training programs for political leadership are even scarcer, which is in line with the identified competency gap in the health policy domain. The model laid out in this paper could provide a useful base for evidence‐based curriculum development, although identified competencies need to be further refined and discussed and completed with KSA related to each competency. Educational programs which integrate course work and clinical learning seem promising in developing and improving leadership competencies in especially the clinical and systems domains (Ailey et al., 2015 ; Sievers & Wolf, 2006 ; Thompson & Nelson‐Marten, 2011 ). Ainslie (Ainslie, 2017 ) advocates that organizations should map leadership competences to observable milestones so that progress can be clearly determined. This competence‐based learning has similarities with the concept of Entrustable Professional Activity (EPA). EPAs are elements of professional practice, that is, tasks or responsibilities that are observable and measurable in their process and outcome (Ten Cate, 2013 ) and may also be useful in developing leadership in APNs and CNLs. An assessment determines the entry competency levels and point out a personalized leadership development path. An APN, for example, may test at the expert level for ‘promoting and performing EBP’ but test at the novice level for ‘leading inter professional healthcare teams’. Additionally, situated coaching and mentoring is considered an essential element in educational and clinical learning programs (Ailey et al., 2015 ; Elliott, 2017 ).

Positive results are found for the effects of hierarchical leadership in nursing on quality of care and, more specifically, on nursing‐sensitive patient outcomes (Vaismoradi, Griffiths, Turunen, & Jordan, 2016 ; Wong, Cummings, & Ducharme, 2013 ). However, further research is needed to establish the relationship between leadership practices of APNs and CNLs and nursing‐sensitive patient outcomes (Dubois et al., 2017 ; Kapu & Kleinpell, 2013 ).

A limitation of this review is the fact that 24 of the 177 literature articles included based on title and abstract were not available in full text and the final selection of only 15 studies consisted of varying study designs and quality. Furthermore, most studies originated from the United States and Australia which might be challenging the representativeness of this review from an international perspective. Nonetheless, this review represents an integrative overview including a gap analysis of leadership competencies for APNs and CNLs in the current literature and as established by international nursing organizations.

5. CONCLUSION

This review identified 30 core leadership competencies for APNs and CNLs in the clinical, professional, health systems, and health policy leadership domains. The next steps include: (a) discussing gaps in this overview of competencies with master level‐educated nurses and educational institutes and linking KSA to each of the established leadership core competencies; (b) translating these competencies and aligned KSA to curricula and clinical learning programs; and (c) evaluating the effect of leadership competencies on nurse sensitive outcomes. These steps should be part of a continuous process needed for continuous quality improvement, healthcare reform, and high‐reliability health care.

AUTHOR CONTRIBUTIONS

MH, CvO, JP, HV, AH: made substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; MH, CvO, JP, HV, AH: Involved in drafting the manuscript or revising it critically for important intellectual content; MH, CvO, JP, HV, AH: Given final approval of the version to be published. Each author should have participated sufficiently in the work to take public responsibility for appropriate portions of the content; MH, CvO, JP, HV, AH: Agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Supporting information

Heinen M, van Oostveen C, Peters J, Vermeulen H, Huis A. An integrative review of leadership competencies and attributes in advanced nursing practice . J Adv Nurs . 2019; 75 :2378–2392. 10.1111/jan.14092 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Contributor Information

Maud Heinen, Email: [email protected] , https://twitter.com/MaudHeinen .

Catharina van Oostveen, https://twitter.com/CatharinavanOOstveen .

Jeroen Peters, https://twitter.com/jeroenpeters6 .

Hester Vermeulen, https://twitter.com/hvermeulen67 .

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INNOVATIONS in pharmacy

Vol. 15 No. 2 (2024)

Copyright (c) 2024 Patrick Gallegos, Salaar, Michael

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License .

Copyright of content published in INNOVATIONS in pharmacy  belongs to the author(s).

Leadership and Followership in Health Professions: A Systematic Review

Patrick Gallegos

Cleveland Clinic Akron General

Muhammad Salaar Riaz

Nassau University Medical Center

Michael Peeters

University of Toledo

DOI: https://doi.org/10.24926/iip.v15i2.5987

Keywords: Leadership, Followership, Health Professions

Objective: Leadership discussion, including leadership development programs, is common. However, discussion of followership as a component of leadership seems less frequently discussed. With a focus on leadership and followership, this investigation reviewed the health-professions education literature and characterized leadership-followership within health-professions education.

Methods : Using PubMed, ERIC, and Google Scholar, two investigators independently and systematically searched health-professions education literature for articles related to leadership and followership. Reports were categorized based on the articles by type, application, profession, leadership, and followership qualities.

Results: Eighty-one articles were included. More than half (48/81, 59%) were theoretical, 27% (22/81) empirical, 7% (6/81) commentaries, and 6% (5/81) letters-to-the-editor). Empirical studies did not share outcomes that could be meaningfully combined quantitatively by meta-analysis; however, the vast majority (96%) of theoretical articles discussed a healthcare-related application of leadership and followership (e.g., improving patient care, improving communication, improving organizational efficiency). Thus, a qualitative review was completed. Of the 81 articles, 57% (n=46) involved multiple professions, while 43% (n=35) focused on a specific profession [Nursing (n=16), Medicine (n=7), Others (n=5) Surgery (n=3), Pharmacy (n=2), Veterinary Medicine (n=2)]. While most articles (75%) discussed leadership qualities (with top qualities of effective communication, visionary, and delegating tasks), fewer (57%) discussed followership qualities (with top qualities of being responsible, committed, and supportive). Of note, some qualities overlapped in both leadership and followership (with top qualities of effective communication, being supportive, and providing/receiving feedback).

Conclusions: Leadership-Followership was described in many health-professions’ education literature. However, Pharmacy and Veterinary Medicine had substantially fewer articles published on this topic. Notably, followership did not receive nearly as much attention as leadership. Leadership has a dynamic and complex interaction with followership highlighting that an effective leader must know how to be an effective follower and vice versa. To improve leadership within healthcare teamwork, education should focus on both leadership-followership.  

Author Biographies

Muhammad salaar riaz, nassau university medical center.

Internal Medicine Resident

Michael Peeters, University of Toledo

Director of Interprofessional Education

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Review of Literature on Leadership- An Excerpt from the New Book, “The Ohtli Encuentro – Women of Color Share Pathways to Leadership”

• by Pam McCollum, Ph.D.  • IDRA Newsletter • June – July 2005

These analytic reflections are offered as a complement to the narrative journal, The Ohtli Encuentro – Women of Color Share Pathways to Leadership , which tells the story of the Ohtli Encuentro and of the leadership pathways of the Ohtli women through the voices of the women, themselves. The reflections provide a brief review of the general literature on leadership, with an emphasis on women’s leadership and studies of leadership of women of color, as a context within which to situate the Ohtli women’s stories and insights.

Definitions of leadership can be placed on a continuum from hierarchical to transformational . At the hierarchical end, leadership is viewed as one of “power over,” the ability to exercise authoritative dominance over others through hierarchical position, physical might or control of resources. This form of leadership is agentic and is more commonly ascribed to men than women. Leaders who exhibit agentic qualities have been commonly and traditionally described as aggressive, ambitious, dominant, forceful, independent, daring, self-confident and competitive (Eagly and Johannesen-Schmidt, 2001).

At the other end of the continuum is transformational or communal leadership, which is characterized by “power with” or “power through” due to the relationship between the leader and followers. Transformational leaders recognize a need for change, have a vision and focus, pursue worthy goals, and inspire others to work cooperatively to achieve a desired change (Gillis, 2005).

Transformational leaders are skilled communicators who can communicate their vision to others and inspire them to pursue a common goal, empowering them in the process. These types of leaders are adept at developing others’ personal ownership of the vision, stimulating commitment, supporting people to work together and inspiring collective loyalty. The influence that leaders have over followers is constantly being negotiated and is a function of several variables, including the self-identity of the followers (Douglas, Brown and Freiberg, 1999).

Another type of leadership that has been described in the business literature is transactional leadership, which is managerial. Instead of being communal, the emphasis is on individuals or small groups of employees within organizations or businesses who vie for favored status with a manager. Cooperation occurs through negotiations and loyalty is bought with reward to individuals. In these cases, some employees demonstrate little or no commitment to the organization’s mission or vision, and cooperation is the result of negotiations. This model emphasizes marginal improvements in performance based on exchange relationships with subordinates (Bass and Avolio, 1993).

Yet another type of leadership seeks service for the greater good, as in servant leadership described by Greenleaf (1991). Others write, “Leadership is an art” (DePree, 1989).

Gender and Leadership Styles

A good portion of the studies on leadership styles has examined gender differences in leadership style when style is understood as relatively stable patterns of behavior that are manifested by leaders (Yoder, 2001). Many of these studies have focused on whether women and men have different leadership styles or on the adequacy of women’s leadership styles for a given profession. This line of research focused on women who worked in traditionally male-dominated professions and examined whether their leadership style was adequate (Miller, Taylor, and Buck, 1991). The difference/similarity research in leadership styles between men and women also has enjoyed popularity in the popular press. Authors of these studies, who formerly worked in the business world, published results of interviews and surveys that examined the issue of gender and leadership style and found that the leadership style of women is less hierarchical, more cooperative and collaborative, and more oriented to enhancing others’ self-worth (Book, 2000; Helgesen, 1990; Rosener, 1995).

Acknowledging that leadership was much more complex than the simple difference/similarity dichotomy, social scientists such as Powell (1990) began to minimize the importance of these reported differences in leadership styles. There was a realization that leadership is gendered (Boldry, Wood and Kashy, 2001; Eagly and Johannesen-Schmidt, 2001; Heilman, 2001).

Researchers also began to examine leadership as a process that occurs within a social context that is itself gendered (Biernat and Fuegen, Winter 2001). The context of the leadership setting can vary according to several factors such as the gender composition of the group, task characteristics, and shifting standards. Gender is important in defining both leadership and the specific context in which leadership operates. Yoder (2001) states, “Leadership does not operate in a genderless vacuum.”

Gender and Leader Effectiveness

Analyzing the contextual settings of leadership has broadened the polemic over the effectiveness of female vs. male leaders. These studies have examined the gender congeniality of contexts where leadership occurs. Gender congeniality can be thought of as a kind of “comfort index” that differs by gender. The research was done largely through meta-analyses that operationalized the gender congeniality of social contexts in which leadership occurs (Eagly and Johnson, 1990; Eagly and Karau, 1991; Eagly, Karau and Makhhijani, 1995). Variables that influenced the social context were group composition, gender typing of the task, valuing task performance over all other outcomes, and power emphases. When assessing leader effectiveness in this model, one must take into account the gender of the leader and the gender congeniality of the context where the leader operates. Leader effectiveness is defined as positive leader and follower satisfaction, enhanced group and individual performances, and unit cohesiveness. The types of power typically used in women-uncongenial contexts draws on “power over,” or dominance, and “power from,” or the ability to resist demands of others. “Power to” or empowerment of self and others is more common in women-congenial contexts (Yoder, 2001).

Studies have shown that effective leadership traits for men in masculinized contexts in many cases are ineffective when adopted by women operating in masculinized contexts (Porter, Geis and Jennings, 1983). Assertiveness, an agentic trait of male leaders, was found to be threatening when exhibited by women (Carli, 1995) and contributed to them being disliked (Butler and Geis, 1990).

Studies focusing on other agentic qualities of male leadership all found that women leaders who exhibited the agentic qualities in masculinized contexts were not viewed as effective. The qualities studied were: dominance (Ellyson, Davidio and Brown, 1992); autocratic or directive behavior (Eagley, Makhijani and Klonsky, 1992; Jago and Vroom, 1982); and self-promotion (Rudman, 1998).

Yoder (2001) states that what makes leaders effective in masculinized settings is power. She states, “Because social status and power are confounded by gender, the playing field is tilted for women leaders even before they begin.”

Ethnicity and Leadership

The scope of leadership research has expanded from males as the sole focus of study to include gender and, most recently, to a focus on leadership in members of various ethnic groups. These studies are generally qualitative in nature, the most common employing in-depth interview techniques and surveys. Ramírez (2001) surveyed 3,032 Latinos in the United States (Mexican American, Puerto Rican and Cuban) ages 18 and older and asked them to name traits they considered important in a leader. He found 20 desirable traits that clustered around four leadership traits that Latinos expect to see in a leader: character, competence, compassion and community servanthood. Latinos, like most Americans, highly value the importance of character (honesty and integrity) and competence.

However, the Ramírez study showed that Latinos place a much higher priority on leadership traits associated with compassion and community servanthood than their non-Latino counterparts. Latinos want their leaders to be competent but not at the expense of compassion and community servanthood.

There are many similarities between Latinos’ expectations for leaders and African Americans’. The centrality of the community for African Americans has much in common with Latino communal values. Most of the early work on leadership in African American communities was done within the race dominance and power approach, seeking to explain Black leadership theoretically in terms of the subordinate power position of Blacks in relation to Whites (Walters and Smith, 1999): “Because of the subordinate position of Blacks relative to Whites in the U.S., African American leaders have been faced with the dual task of organizing internally within the Black community while simultaneously ‘mobilizing’ the community to develop the pressure on the majority” (Ibid., p.112).

Both Kilson (2000) and Walters and Smith (1999) feel that Black leadership tends to be transformational in nature and cite Dr. Martin Luther King as an example of a Black transformational leader.

While there is a great deal of diversity in the lifestyles of the 550 recognized Indian nations in the United States, their cultures can generally be characterized by similar social and religious systems where women occupy a matriarchal position (Gutiérez, 1991). American Indian women have a rich history of political involvement in their communities and have struggled to attain tribal sovereignty, control over Native lands and resources, and cultural preservation. Since the 1970s, women have held a variety of elected or appointed positions in their tribal governments (Prindeville, 2000).

Leadership studies with professionals of various ethnicities began to appear in the 1980s. These studies tended to be written by members of ethnic groups who studied how members of their ethnic group fared in comparison to majority group employees within the organization. Initially, these were analyses that examined why there were so few minorities in leadership positions relative to majority group members within various careers. Studies in this vein examined leadership in higher education (Madrid, 1982; Valverde and García, 1982; Waring, 2003), community organizing (Straus and Valentino, 2003) and school administration (Bloom and Erlandson, 2003). Presently, studies are examining leaders from ethnic groups in positions of power within organizations.

To read more about leadership in women of color, read the newly-released, The Ohtli Encuentro – Women of Color Share Pathways to Leadership . This beautiful book presents the voices of 30 African American, Latina and Native American women who share their leadership journeys. IDRA brought together these women leaders to capture, honor and share their inspiring stories of leadership. This book highlights their moving stories. The book also discusses common themes that arose from the women’s interactions in a multicultural, multi-generational gathering designed to explore leadership in women of color.

For more information visit www.idra.org or contact IDRA (210-444-1710, [email protected]). References are located in the Ohtli Encuentro book and are also available online.

Pam McCollum, Ph.D., is a senior associate in the IDRA Division of Professional Development. Comments and questions may be directed to her via e-mail at [email protected] .

[©2005, IDRA. This article originally appeared in the June- July 2005  IDRA Newsletter by the Intercultural Development Research Association. Permission to reproduce this article is granted provided the article is reprinted in its entirety and proper credit is given to IDRA and the author.]

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Effective leadership is a cornerstone of success in any organization, driving growth, innovation, and employee engagement. Developing leadership skills implies more than acquiring knowledge; it requires nurturing qualities that inspire and motivate others. Whether you're a seasoned leader or aspiring to become one, comprehending the key attributes of effective leadership is essential. We will delve into the critical qualities of effective leaders, explore strategies for nurturing these attributes, and offer practical insights for personal and professional development. Additionally, leaders in digital marketing can significantly benefit from leveraging white label SEO services to enhance their team's capabilities and deliver comprehensive solutions to clients.

Understanding Leadership

Leadership involves guiding, influencing, and inspiring others to achieve common goals. It involves setting a vision, motivating team members, and fostering collaboration and trust. Effective leaders possess a blend of personal qualities and professional skills that enable them to navigate challenges, make knowledgeable decisions, and drive organizational success. Comprehending the multifaceted nature of leadership is the first step toward developing the skills paramount to lead effectively.

Cultivating Emotional Intelligence

Emotional intelligence (EI) is a foundational quality of effective leadership. It involves the ability to recognize, understand, and manage one's own emotions, as well as the emotions of others. Leaders with high emotional intelligence can build strong relationships, manage stress, and resolve conflicts effectively. Cultivating EI implicates self-awareness, self-regulation, empathy, and social skills. By developing emotional intelligence, leaders can create a positive work environment, foster collaboration, and enhance team performance.

Building Communication Skills

Clear and effective communication is paramount for successful leadership. Leaders must convey their vision, expectations, and feedback in a manner that is comprehended and accepted by their team. Building communication skills implicates active listening, clarity in messaging, and adapting communication styles to different audiences. Effective leaders use communication to build trust, align team members with organizational goals, and foster an open and inclusive culture.

Developing Decision-Making Abilities

Decision-making is a critical aspect of leadership. Leaders must often make tough choices under pressure, balancing short-term needs with long-term goals. Developing decision-making abilities involves gathering and analyzing information, considering various perspectives, and assessing potential outcomes. Effective leaders are decisive yet flexible, willing to adjust their approach based on new information or changing circumstances. Leaders can navigate complexities and guide their teams toward success by honing their decision-making skills.

Fostering a Growth Mindset

A growth mindset is the belief that abilities and intelligence can be developed through dedication and hard work. Leaders with a growth mindset embrace challenges, comprehend failures, and persist in facing setbacks. Fostering a growth mindset implicates encouraging continuous learning, seeking feedback, and viewing obstacles as opportunities for growth. By cultivating this mindset, leaders can inspire their teams to strive for excellence, innovate, and achieve their full potential.

Encouraging Collaboration and Teamwork

Effective leaders understand the power of collaboration and teamwork. They create an environment where team members feel valued, respected, and empowered to contribute their ideas and skills. Encouraging collaboration implicates building a culture of trust, facilitating open communication, and recognizing the strengths of each team member. Leaders who foster teamwork can harness their team's collective intelligence, drive creativity, and achieve better results.

Enhancing Problem-Solving Skills

Problem-solving is essential for leaders, enabling them to address challenges and find effective solutions. Enhancing problem-solving skills implicates critical thinking, creativity, and analyzing situations from multiple perspectives. Leaders must be able to identify root causes, develop actionable plans, and implement solutions efficiently. By improving their problem-solving abilities, leaders can navigate obstacles, drive progress, and support their team's success.

Nurturing Creativity and Innovation

Creativity and innovation are vital for organizational growth and competitiveness. Leaders play a key role in nurturing a culture that encourages creative thinking and innovation. This implies providing experimentation opportunities, supporting risk-taking, and recognizing and rewarding innovative ideas. By fostering an environment where creativity thrives, leaders can drive continuous improvement, inspire their teams, and usher their organizations toward new opportunities and successes.

Developing Conflict Resolution Skills

Conflict is a natural part of any team dynamic, and effective leaders must be adept at resolving conflicts constructively. Developing conflict resolution skills involves comprehending the underlying issues, facilitating open communication, and finding mutually beneficial solutions. Leaders who handle conflicts with empathy and fairness can maintain a positive team atmosphere, stem disruptions, and strengthen relationships. Leaders can ensure a harmonious and productive work environment by mastering conflict resolution.

Encouraging Accountability

Accountability is a key component of effective leadership. Leaders must hold themselves and their team members accountable for their actions and performance. Encouraging accountability implicates setting clear expectations, providing regular feedback, and fostering a culture of responsibility. Leaders who emphasize accountability can drive high performance, ensure alignment with organizational goals, and build a sense of ownership and commitment within their team.

Inspiring Vision and Purpose

A compelling vision and a sense of purpose are paramount for motivating and guiding a team. Effective leaders articulate a clear, inspiring vision aligning with the organization's values and goals. They communicate this vision with passion and conviction, helping team members comprehend their role in achieving it. By inspiring vision and purpose, leaders can unite their team around common goals, foster a sense of meaning, and drive collective effort toward success.

Fostering Adaptability and Flexibility

In a rapidly changing world, adaptability and flexibility are paramount leadership qualities. Leaders must respond to new challenges, opportunities, and environmental shifts. Fostering adaptability implies being open to change, embracing new ideas, and continuously learning. Flexible leaders can effectively adjust their strategies, innovate, and usher their teams through transitions. By cultivating adaptability, leaders can ensure their organization remains resilient and competitive in the face of change.

Building Trust and Credibility

Trust and credibility are fundamental to effective leadership. Leaders must earn the trust of their team through consistent actions, honesty, and integrity. Building trust implicates being transparent, keeping commitments, and demonstrating genuine concern for the well-being of team members. Credible leaders are respected and followed willingly, making motivating and guiding their team easier. Leaders can build strong, cohesive teams and drive organizational success by fostering trust and credibility.

Leveraging Technology and Innovation

In today's digital age, leveraging technology and innovation is paramount for effective leadership. Leaders must stay informed about technological advancements and comprehend how to integrate them into their organization's operations. Leveraging technology involves using tools and systems to enhance productivity, communication, and decision-making. Innovative leaders seek out new technologies that can drive efficiency and competitiveness. By embracing technology, leaders can usher their organization into the future and maintain a competitive edge.

Encouraging Diversity and Inclusion

Diversity and inclusion are paramount for fostering innovation, creativity, and a positive work environment. Effective leaders recognize the value of diverse perspectives and create an inclusive culture where everyone feels valued and respected. Encouraging diversity implicates actively seeking out diverse talent, promoting inclusive practices, and addressing biases. Leaders championing diversity and inclusion can build stronger teams, enhance problem-solving, and drive better decision-making. By fostering an inclusive environment, leaders can ensure that their organization thrives and benefits from various ideas and experiences.

Leading Through Change

Change is inevitable in any organization, and effective leaders must be able to usher their teams through transitions successfully. Leading through change involves clear communication, empathy, and a strategic approach. Leaders must help their team understand the reasons for change, address concerns, and provide support throughout the process. By fostering a positive attitude toward change and demonstrating resilience, leaders can smoothly guide their teams through transitions and maintain morale. Effective change leadership ensures the organization remains agile and ready to adapt to new challenges and opportunities.

Building a Positive Organizational Culture

A positive organizational culture is paramount for employee satisfaction, engagement, and productivity. Leaders play a paramount role in shaping and maintaining this culture. Building a positive culture involves promoting core values, recognizing achievements, and fostering a sense of community. Leaders must direct by example, demonstrating the behaviors and attitudes they wish to see in their team. By creating a supportive and positive work environment, leaders can enhance employee well-being, drive high performance, and ensure long-term success.

Developing leadership skills is a continuous journey that involves nurturing key qualities such as emotional intelligence, communication, decision-making, and resilience. Effective leaders inspire and motivate their teams, foster collaboration, and drive organizational success. By understanding and cultivating these paramount attributes, leaders can enhance their personal and professional growth and lead their organizations toward triumph. Whether you're an aspiring leader or looking to improve your leadership abilities, focusing on these qualities will help you build a strong foundation for effective leadership.

Copyright © 2024 SCORE Association, SCORE.org

Funded, in part, through a Cooperative Agreement with the U.S. Small Business Administration. All opinions, and/or recommendations expressed herein are those of the author(s) and do not necessarily reflect the views of the SBA.

• Open access
• Published: 28 May 2024

Leadership in intellectual disability practice: design, development, and evaluation of a programme to support practice

• Owen Doody 1 ,
• Maeve O’Halloran 2 ,
• Eileen Carey 1 ,
• Marie Kilduff 3 ,
• Ann Gilmartin 4 &
• Ruth Ryan 1  

BMC Health Services Research volume  24 , Article number:  674 ( 2024 ) Cite this article

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Intellectual disability services have and continue to experience changes in service provision. This has an implication for leadership in practice as the quality of leadership has a direct influence on staff practice and care provided.

To design, deliver, and evaluate a leadership programme for nurse and social care managers in Ireland.

An accredited programme was designed based on evidence from literature, practice, and national expertise. A cross-sectional survey was used to collect information on the attitudes and behaviour of participants before commencing and after completing the programme. Data from the questionnaires were analysed using SPSS and open-ended questions were analysed using content analysis.

Intellectual disability services.

Participants

102 participants completed the programme and survey.

Pre-post survey and reported using the CROSS guidelines.

Participants’ expectations were rated highly, and all items scored higher in the post-survey. Qualitative data was overall positive regarding opportunities for more time to work through each aspect of the programme. The key learning was through the forum day where participants shared their group projects.

Conclusions

Overall, the programme was positively evaluated and through engaging with the programme participants’ perceptions moved from seeing leadership as mostly task-oriented to realising that qualities such as good communication, person-centredness, advocacy, supporting, role modelling, and empowering are key to leadership.

Peer Review reports

Introduction

Irish intellectual disability services have experienced a changing landscape of service provision over the past three decades [ 1 ]. This evolving landscape has seen a movement towards community settings, a changing culture, the provision of personalised supports, and a changing demographic profile [ 2 ]. Irish intellectual disability services are primarily funded through a combination of government allocations, health service budgets, and contributions from non-profit organisations. In Ireland, the context of practice leadership in intellectual disability services is shaped by various factors, including historical, societal, and political influences. The provision of support for people with intellectual disability has undergone significant changes over the years, often in response to various pressures and challenges within the healthcare system and broader society. One significant pressure for changing support provision has been the occurrence of hospital scandals, which have highlighted shortcomings in the care and treatment of individuals with intellectual disability. These scandals, exposed instances of neglect, abuse, and substandard living conditions within residential care settings and highlighted the urgent need for reform and improvement in the delivery of services for individuals with intellectual disability. Key policy documents and strategies guiding change in Ireland include; Time to Move on from Congregated Settings [ 3 ], Progressing Disability Services for Children and Young People [ 4 ], New Directions [ 5 ], A National Framework for Person-Centred Planning in Services for Persons with a Disability 6 , UNCRPD [ 7 ], Assisted Decision Making (Capacity) Act [ 8 ] and Sláintecare [ 9 ]. These policy documents and strategies have implications for intellectual disability services in terms of leadership, professional care, and support skills required to address the needs of people with intellectual disability (and their families). Key principles within these policies/strategies are person-centred care, rights, quality, safety, and risk management and in line with Irish policies, all designated centres for people with disabilities (children and adults) must be registered with the Health Information and Quality Authority (HIQA) since November 2013.

All registered designated centres are subject to inspections by HIQA inspectors who examine and evaluate services to safeguard that they comply with the National Standards for Residential Services for Children and Adults with Disabilities [ 10 ]. The legislation underpinning the standards also necessitates that a Person-in-Charge (PIC) for each designated centre be appointed and that the PIC should have relevant clinical and leadership skills and experience to safeguard the effective administration of their service and deliver safe, effective care to support clients/service users and their families. Under the most recent HIQA guidance [ 11 ], a PIC should have the appropriate qualifications to fulfil the post and have the relevant skills and experience to effectively manage the size of the centre, the number of residents, and the assessed needs of the residents. A PIC may be over more than one designated centre and variations exist in the number of designated centres and the number of residents. However, the specific requirement for leadership knowledge is vague with a requirement of 3 years in a management or supervisory role.

In the context of practice leadership for frontline managers, such as PICs in intellectual disability services in Ireland frontline managers often lead interdisciplinary teams comprising various professionals, including nurses, social care workers, psychologists, therapists, and support staff. Nurses in intellectual disability services may indeed work in both social care settings, such as community residences or day centres, and residential care settings, depending on the needs of the individuals they support. Ireland’s intellectual disability services encompass a mixed economy of care, involving voluntary, private, and state-managed organisations, and comprise a diverse range of supports tailored to meet the needs of individuals across the lifespan. Services vary in size, with some supporting a small number of residents in shared living arrangements, while others may accommodate larger groups. The exact number and size of services fluctuate across regions based on population demographics, local demand, and available resources.

The significance of leadership has been emphasised in the literature [ 12 , 13 ] and National reports [ 14 , 15 ]. Evidence within the international literature indicates that the quality of front-line management and leadership is a multi-faceted and complex role and has a direct influence on staff practice [ 16 , 17 ]. In recognition of the impact of leadership and the rapidly changing health and social care environments, there is a need to support managers/leaders working in intellectual disability services to provide support in the form of education and training to meet the PIC requirements/role. The National Clinical Leadership Centre for Nursing and Midwifery (NCLC) commissioned the authors to design, deliver, and evaluate a leadership programme for Clinical Nurse Manager (CNM) and Social Care Leader (SCL) grades with PIC responsibilities. The programme was developed based on preliminary work with CNMs and SCLs from intellectual disability services to identify core elements and priority areas of leadership competencies in intellectual disability health and social care leadership roles. This co-design element informed the development of the NCLC’s seven competencies (self-awareness, empowerment, advocacy, communication, decision-making, quality and safety, and teamwork) that underpinned the programme. To support the co-design of the programme an experienced intellectual disability nurse with experience in inspections, leadership, management, and consultancy work supported the design, delivery, and evaluation process (MO’H).

The need for leadership within all staff in the health and social care system has been expressed [ 18 ] and within intellectual disability, staff are from either a nursing or social care context who respond to situations that require intervention. Such responses require initiative, resourcefulness, motivation, an ability to solve problems, active awareness, persistence to achieve goals, and communication with team members i.e., leadership [ 19 ]. Effective leadership improves client/service user satisfaction and care outcomes [ 20 , 21 ] and while leadership is customarily considered in the context of upper management roles [ 22 ], leadership and teamwork within practice has gained interest [ 23 ]. The move away from a transactional model of leadership which emphasised a hierarchical top-down management structure 24 , has seen a shift to an approach that seeks to develop; the ethos, values, and motivation of team members, and effective relationships, communication, empowerment, and engagement of all staff [ 25 ]. Also, it is recognised that health and social care organisations, should support leadership that focuses on team building, work relationships, promoting participation, and the co-creation and facilitation of care processes [ 19 ].

Addressing leadership and supporting leaders is fundamental to intellectual disability organisations/service providers as they face numerous challenges that impact the effectiveness, efficiency, and sustainability of service design and delivery. Such impacts are seen in licensing requirements, accreditation standards, performance monitoring, and consumer expectations and this calls for a new kind of leadership away from heroic individual leaders to a model of distributed leadership across organisations and systems [ 26 ]. As we face the future, we must continually question if standard practices are working well, and how we will enhance personal outcomes and generate organisation outputs that reflect a good return on investment. Given that effective leadership is vital to prevent poor standards and ensure people with intellectual disability experience significant improvements in their lives there is a need for new leadership approaches and thinking within health and social services [ 27 ]. This paper describes the design, delivery, and evaluation of a leadership programme for CNMs and SCLs with PIC responsibilities in Ireland.

Methodology

Programme design and delivery.

Within the programme design stage, the academic leads, members of the NCLC, and the CNMs and SCLs involved in the preliminary work assisted in co-designed the programme based on the evidence from the literature and the NCLC seven leadership competencies. Within the co-design process, it was agreed academic and professional accreditation was important to value participant engagement and work. To acknowledge this firstly, the programme was submitted to the Nursing and Midwifery Board of Ireland (NMBI) to gain professional accreditation (5.5 days) and the maximum 35 Continuing Education Units (CEUs). The second accreditation process involved presenting the programme in a module format (9 Credit (ECTS) Level 9) for academic accreditation which would enable access to postgraduate level 9 courses for those who do not hold a degree level qualification (programme learning outline/outcomes Table  1 ).

The programme philosophy aimed to enhance participants’ confidence and skills to enable them to effectively apply these skills in developing plans for improvement or change. Moreover, to empower them to initiate initiatives in practice that prioritise the delivery of person-centred care and support. Participants were encouraged to draw on their experiences of practice and explore theories and models of leadership and management within the context of health and social care practice. Participants explored aspects of PIC leadership and management, focusing on learning, quality, and improvement e.g., communication, empowerment, decision-making, operational management, effective governance, and administration of the designated centres, health promotion, and protection activities, and supporting a safe quality service.

Participants were recruited through national intellectual disability services, where a poster advert for the programme was sent for distribution within the organisation. To avail of a place participants had to have service support and release to attend the 5.5-day programme and other than travel the programme was free to the service and participant. The programme delivery was coordinated by the lead author (OD) and facilitated in person by the academic leads, guests with leadership roles in health and social care services or leadership centres, and the intellectual disability nurse as part of the co-design team. Participants would reflect on their learning and document their professional knowledge through reflective inquiry. The accumulation of learning would be presented as group projects in a half-day event (forum day) open to service providers and staff. The forum day consisted of an opening presentation to mark the focus of the programme, a speaker from the NCLC, the group presentations, an invited inspirational guest speaker on leadership, and a closing event. Projects for the forum day (Table  2 ) were decided upon based on identifying areas of practice and leadership that participants wished to address and develop within their practice and translated across services so the group could benefit and participate. This process ensured initiatives spanned across services and was supported and mentored by the intellectual disability nurse on the co-design team.

Evaluation process

The forum day was the evaluation process for the project undertaken and this was assessed by academic colleagues, members of the NCLC, and service managers based on the value of the project to practice, its transferability across service, and its impact on client/service users lives. Permission to conduct the study was granted by the lead author’s University Research Ethics Committee (Education and Health Sciences, Research Ethics Committee), and participant’s rights to confidentiality and anonymity were upheld throughout the conduct of this study. Participants were Clinical Nurse Managers (1 or 2) or Social Care Managers with PIC responsibilities working in residential services for people with intellectual disability in Ireland. Four programmes were delivered over two years February to June and September to January with 25 to 30 participants per cohort. In total across the four programmes 110 participants registered of which 102 completed the programme. Attrition of the eight participants was due to personal reasons ( n  = 1), issues regarding release from work due to staff shortages ( n  = 6) and moving to a new job ( n  = 1). A cross-sectional survey tool developed by the researchers for this study (Supplementary file S1 ) was used to collect information on the attitudes and behaviour of the participants before commencing and after completing the programme. The survey tool was developed for this study as this was a new programme and creating the survey tool allowed for the tailoring of questions to address the specific evaluation and unique elements of the programme. A hard copy format was distributed before the programme commenced and after the forum day and returned by participants on the day or by post. Data collection and analysis were managed by the intellectual disability nurse who was part of the co-design team. The questionnaire consisted of 53 questions divided into five sections. Section one covered demographic details (Q1-Q13), section two addressed aspects before commencing the programme (Q14-Q22), section three addressed expectations during the programme (Q23-Q33), section four addressed expectations upon completion of the programme (Q34-Q52) and section five (Q53) were an open text for additional comments to add depth and give meaning to participants experience. Data from the questionnaire pre/post were analysed using SPSS where descriptive statistics and a Cronbach value (α) were calculated to check the reliability of each subsection. Elo and Kyngäs [ 28 ] systematic approach to content analysis was used for categorising and analysing the textual data to identify patterns, themes, or relationships.

As part of the programme evaluation, a pre-post self-report survey was used to capture demographic details, perceptions regarding commencing the programme, expectations during the programme, and expectations upon completion of the programme. Of the participants on the programme, 15 (14.7%) were male and 87 (85.3%) were female with 93 (91.2%) working full-time and the remaining 9 (8.8%) working part-time. From a working pattern perspective, 52 (51%) worked day duty with no weekends, 31 (30.4%) worked day duty with weekends, and 19 (18.6%) worked shift work including nights. General demographic details of age, role, qualification, and years of experience are presented in Table  3 . Cronbach’s alpha was calculated to measure the internal consistency of scale reliability with the three scales performing well for the pre and post survey; scale 1 perceptions regarding commencing the programme, α (0.689 pre, 0.860 post), scale 2 expectation during the programme α (0.712 pre, 0.787 post) and scale 3 expectation upon completion of the programme α (0.960 pre, 0.943 post).

Scale one measured participants’ perception regarding the programme, and pre- and post-program delivery. Participants’ expectations were rated highly and regardless of the high expectation evident in the pre-survey all items did perform and scored higher in the post-survey. Of note was that participants rated the question on the programme assisting in the prospect of promotion lowest (58.8%) in the pre-survey and while it remained lowest in the post-survey it had increased to 91.2% indicating the potential and perceived value of the programme for the participant’s career advancement. The overall scoring of each item on the scale is presented in Table  4 .

The second scale measured participants expectations regarding the programme, pre- and post-programme delivery. Again, participants’ expectations were rated highly and regardless of the high expectation evident in the pre-survey all items did perform and scored higher in the post-survey. Of note was that participants rated the question on their perceived difficulty in adjusting to academic life lowest (39.2%) in the pre-survey and while it remained lowest in the post-survey it had increased to 78.4% indicating the difficulty participants have in balancing academic work, their daily work and family life. This is surprising given that 87.3% of the participants held a degree level or above. However, 87.3% were 11 years or more post qualification and participants’ difficulty may relate to their time out of education. The overall scoring of each item on the scale is presented in Table  4 .

The third scale measured participants’ expectations regarding the programme upon completion and pre- and post-programme delivery. Again, participants’ expectations were rated highly and regardless of the high expectation evident in the pre-survey all items did perform and scored higher in the post-survey. Of note was that participants rated the question on the possibility of the programme increasing their responsibility lowest (53.9%) in the pre-survey and while it remained lowest in the post-survey it had increased to 87.3% indicating that because of the programme participants perceived their level of responsibility had increased. The overall scoring of each item on the scale is presented in Table  4 .

Data from the qualitative open questions addressed; learning, anything participants would change, topics that participants would like included in the programme, the forum day, and general comments.

Qualitative comments regarding learning (n = 40) from the programme were positive and revolved around learning, the opportunity to meet other leaders, reflection, and linking theory and practice:

Thought provoking. good to have time to think about my role, very enjoyable, great to meet with people from different services. learning to self-evaluate and link it to everyday practice, it was very good and interesting with a good balance given between information and reflection.

Qualitative comments regarding anything they would change (n = 28) revolved around the assignment and group work and the one thing suggested for change was the aspect of including parents/family in decision-making and care provision:

‘More clarification on what overall assessment is, I thought I would do my own assignment, and group work was difficult at first, however, a practical example was very helpful’. ‘Would like more discussion on parent/family involvement, how to support it, how to lead it and how to role model it for staff’.

Qualitative comments regarding topics that participants would like to be included ( n  = 15) revolved around the priority of topics rather than topics to be addressed. Participants were generally happy with the content and comment suggested participants knew the topics would be covered but emphasised the ongoing need for support around leadership issues and that having time as a group to interact and discuss topics as a peer support system would be beneficial:

We can’t get enough support on issues like ‘Supervision’ ‘Time management’ ‘Management conflict’ ‘Motivating the team’, ‘Team building’, ‘Engagement of frontline staff’, ‘Change Management’, ‘Promoting good leadership’, ‘Mentorship’ and ‘Reflective thinking’. ‘Allocate extra time to the groups as it’s difficult to get it all done and meet as a group as there are things you need to discuss as a group of peers that you need to bounce off others before you bring to the facilitators’.

Qualitative comments regarding the forum day (n = 34) acknowledged it as a key source of learning and sharing where participants presented their group project. A broad range of projects were addressed, and key areas addressed by participants across groups were regulation aspects (inspection, preparedness), supervision (process, engagement, recording) person-centredness (choice, goal setting, transition, quality of life, decision making, quality improvements (communication, paperwork, handover, team meetings) and staff support (debriefing, stress). Participants highly valued the forum day as it presented an opportunity to share their work gain peer validation and gain from other participants’ projects and take ideas back to practice and highlight:

‘This was a great day; I gained so much from it and all the presentations, I got so much from working with the group as we were all from different services and while it was difficult at the start to choose something, we could all do in our own service, in the end we did something of value to each of our services for the clients/service users and staff’. ‘I got some much from doing the group project but the real benefit was seeing and hearing the other groups as there was so much of their work that I can bring back to my area and want to introduce now also’.

Qualitative comments addressing general comments related to having clear information before the programme (n = 5), factors influencing their decision to undertake the programme (n = 8), and the programme meeting their expectations (n = 22). Regarding having clear information participants expressed their desire and motivation for programmes to meet their needs and that the programme was undersold in their organisation. In terms of the decision to undertake the programme participants expressed their desire to ‘ learn from others’, ‘update knowledge’, ‘improve their leadership’ , and ‘to be effective and confident’ . Regarding expectations participants expressed their appreciation for the programme and were happy to have undertaken it and that it had sparked their interest and passion:

‘Very beneficial to my current role, fantastic meeting others and networking a fantastic course and support I will miss it but have made valuable contacts which I will use in the future I have gained great insight and knowledge into areas as I have found the topics in the course thought-provoking’. ‘An excellent programme which has greatly increased my confidence and knowledge, great learning and shared opportunities, it has highlighted the importance of leadership and it has developed my way of thinking, the language I use and has brought me back to the beginning of being person-centred’. ‘I would be interested in doing another module like this as it has positively impacted on my career and learning as it increased my self-awareness and knowledge of how to communicate more effectively with colleagues’.

Overall, the programme was positively evaluated with all aspects increasing from pre to post programme. However, while this increase is small it is nonetheless important, and given that 70% of the sample had 11 + years in service the pre-scores may have been more positively reported and indicate leadership programmes may have greater value for those in the early career stage (0–8 years). The co-design aspect of the programme ensured a focus on person-centredness, participants’ experience/s, and viewing participants as shared decision-makers [ 29 ]. Fundamental to the co-design of the programme delivery was drawing on the experience of participants and recognising the importance of reflective practice [ 30 ]. This was embedded throughout the programme where facilitators utilised methods that sought to draw on the participants’ aesthetic experience of what and how it feels like to use or be part of the service. Within the programme participants initially perceived leadership as mostly task-oriented but came to realise that in the reality of current practice and service provision qualities such as communication, person-centredness, advocacy, supporting, role modelling and empowering are key to modern leadership and that leadership is regarded as a distinct field and separate from management [ 31 ]. It’s important to consider certain limitations when interpreting the results. Firstly, the absence of a validated survey tool may have impacted the reliability and validity of the data collected. Secondly, the use of a cross-sectional design, rather than a longitudinal one, limits our ability to assess changes over time and draw causal conclusions. Thirdly, to truly ensure the programme philosophy is achieved a follow-up study would be recommended. Fourthly, the self-selection process may have attracted participants interested, eager, and motivated to engage in the programme and leadership. Additionally, the involvement of authors in delivering the programme and participants being aware that their responses, while anonymous, would be known to the research team, may have influenced participants’ responses, and resulted in a positively biased response.

Nonetheless, this programme emphasises the crucial need for support in transitioning service provision to a community-based model, which necessitates a cultural shift and the identification of leaders at an organisation level capable of leading change. Change within intellectual disability services has long been anticipated, yet progress remains slow, and much remains to be done [ 32 ]. The evolution of leadership presents a challenge, particularly in congregated settings where a top-down model of organisational management exists. In addition, a challenge for community-based settings staff will be working in small teams where managerial support is more remote [ 33 ]. Without organisational support and adequate education, there may be an apprehension and reluctance to assume leadership roles, this is seen anecdotally in the difficulty to recruit to leadership/PIC positions. However, the findings of this study suggest that with adequate support, time for reflection, and networking opportunities, participants can develop confidence and interpersonal leadership skills necessary for navigating change. Supportive measures such as mentoring, role modelling, and empowerment contribute significantly to this process.

Changes in policy, legislation, and service delivery pose both challenges and opportunities necessitating a re-evaluation of leadership and the need to enhance leadership capacity, adapt to contextual demands, and fulfil responsibilities [ 34 ]. This programme has made strides in addressing these challenges by fostering capacity, framing leadership within current issues, recognising leadership at various levels, and nurturing leadership qualities among staff. Moreover, participants grew to realise their role within the system and how they could influence developments through their encounters, both formal and informal, with staff and within their organisation [ 35 ]. Consequently, leadership is viewed as relational [ 34 ] aligning with the holism, person-centredness, advocacy-focused, and empowering models of care and support within intellectual disability services. However, for many participants in the programme, this realisation only occurred after providing them with the time and space away from work to reflect and develop.

In the dynamic landscape of service provision landscape characterised by advances in technology, economic fluctuations, and shifting policy direction, swift change can be unsettling for both staff and clients/service users. Therefore, investment in education and training to augment employees’ personal and professional development is crucial in managing change effectively and fostering a sense of belonging and engagement. Personal development and growth are important and participants in this programme articulated evidence of personal growth regarding increased confidence and motivation through engagement with the programme. Recognising that change can be stressful leading to skill reduction or feelings of confusion, being overwhelmed, and being undervalued [ 36 , 37 , 38 ]. Leaders play a vital role in influencing individuals and groups through their behaviours, perceptions, thoughts, and beliefs [ 39 , 40 ]. Thereby, it is vital to cultivate leaders who can adapt their leadership style and principles to suit the goals, context, and characteristics of their team/s. Effective leaders are those who can learn, evolve, and navigate challenges with experience, thereby achieving results even in difficult situations [ 41 ].

Personal growth facilitated by self-awareness fosters a more accepting and compassionate self-view of oneself, enhances leadership capacities, and reshapes leaders’ values in navigating the change process [ 42 ]. Good leadership involves credibility through regular consistent feedback, role modelling, active presence in observing staff [ 43 ], and providing support [ 44 ]. Thus, leadership involves skilled professional guidance, instruction support, and an educational role that extends beyond mere direction [ 44 ]. Essential within this process is fostering dialogue between leaders, staff, and clients/service users, promoting mutual exploration of relationships [ 45 ]. This requires leaders, to articulate and communicate a clear vision, enhance knowledge and understanding through productive engagement, empowering others, providing feedback and reinforcement, and grounding new approaches [ 46 ]. Such an approach supports the distribution of responsibility, ensuring that rewards are collectively owned rather than individualistic. Effective change management hinges on strong communication strategies, early consultation with all stakeholders, and generating enthusiasm for change [ 47 ]. These strategies help mitigate against resistance and enhance implementation success [ 48 ] and encourage active participation and engagement of staff in the change process [ 49 ].

Within the programme, a key element in fostering effective communication was participants understanding of individual personality types and communication styles. The relationship between leaders and their teams’ hinges on trust, mutual respect, understanding, and the sharing of information. Strong leaders can empower individuals and teams to identify their learning needs, thus enhancing self-motivation and empowerment, crucial for sustaining a lifelong commitment to learning and instigating a cultural shift [ 50 ]. Strong organisational leadership plays a vital role in supporting educational opportunities for leaders tailored to the priorities of intellectual disability services. This enables leaders to motivate and maximise the benefit for individuals, staff, client/service users, and the overall service [ 51 , 52 ]. Evidence suggests that strong leadership and role modelling involve promoting continuous professional development for individual staff [ 53 ], facilitating mentorship programmes [ 50 ], and empowering team members to contribute to service improvement initiatives [ 53 , 54 ].

A three-pronged approach focusing on education, leadership, and practice cultivates an environment conducive to inquiry, facilitating and promoting evidence-based practice [ 52 ]. Investment in equipping leaders with the skills to provide high-quality, transformational, mentorship and leadership. Continuous professional development holds significant relevance as evidenced by the impact on participants. Such impact can influence one’s self-motivation, enhance practical relevance and application, affect workplace learning, foster enabling leadership, and contribute to a positive workplace culture [ 55 ]. However, while participants acknowledged the value of continuous professional development, their primary exposure to it, beyond this programme, often revolved around mandatary training provided through in-service programmes. The lack of outward continuous professional development initiatives may contribute to a sense of isolation, as articulated by participants who valued the opportunity to connect with peers from other services and the networking opportunities this fostered.

Effective leadership is fundamental to providing integrated health and social care [ 56 ], improving performance [ 57 , 58 ], ensuring quality care [ 59 ], and fostering organisational commitment [ 60 ]. Research across health and social care has established a connection between leadership and client/service user care outcomes, including patient mortality rates [ 61 , 62 ], medication errors [ 62 ], hospital-acquired infections [ 62 ], patient outcomes [ 19 ], and higher patient satisfaction [ 62 ]. Such correlations may be linked to supportive leadership fostering better work environments, improved resources, appropriate staffing levels, and effective care practices [ 19 , 60 , 63 ]. Given that change is unavoidable leaders must harness the knowledge, abilities, and skills of all team members, acknowledging that expertise can emerge from various sources within the team [ 64 ]. Such an approach necessitates a shift away from hierarchical managerial structures towards fostering and developing individuals as reflexive leaders [ 51 , 65 ]. Leadership education should strike a balance between individual development and wider service priorities to ensure the efficient delivery of person-centred, safe, and effective care [ 55 ]. Crucial to effective leadership is cultivating a positive workplace culture [ 66 ], knowing what needs to change, and implementing practical strategies for enacting change [ 67 , 68 ]. All members of staff hold some level of responsibility and it is advocated that leadership training be extended to all staff members [ 69 ]. This emphasis on leadership training is further reinforced by the focus on vulnerability and risk management embedded in policies and standards overseen by HIQA in Ireland.

Within the programme, participants were primarily focused on crisis-avoiding/managing and fulfilling the criteria set out by the funding and monitoring bodies. This position inhibits the potential for leadership to emerge and flourish, often resulting in ineffective adherence to policies and standards and a heightened risk of care erosion. Instances of such shortcomings have been observed in scandals in Ireland ( 70 , 71 ) and the UK [ 72 ] where the absence or failure of leadership has had profound consequences for all. Thereby, leadership is imperative at various levels within intellectual disability services and should be considered a role and responsibility of all staff. The diverse skills and strengths present within an organisation represent a vast reservoir of untapped leadership talent [ 34 ]. Recognising the contribution and value of all staff in a team necessitates a departure from the notion of concentrated leadership in the hands of a few, in favour of a more devolved leadership model and a collective decision-making approach. This entails expanding the pool of potential leaders and ensuring leadership emerges from collective efforts rather than relying solely on individual capabilities [ 73 ]. To accomplish this, there is a need to empower others to take initiative [ 74 , 75 ] and prioritise the support and empowerment of leaders, so they can in turn support and empower others. This reframes leadership as a collaborative endeavour focused on partnership, engagement, and shared responsibility, transcending hierarchical power dynamics and seniority-based perspectives within the health and social care hierarchy [ 76 ].

Practice leadership in intellectual disability services has been studied and documented in both Australia and the UK [ 12 , 13 , 43 , 77 , 78 , 79 ], with a focus on improving the quality of life for individuals with intellectual disability. A key concept that has emerged in this literature is the implementation of “active support,” which involves empowering individuals with disabilities to engage in meaningful activities and make choices in their daily lives, with appropriate support from staff members [ 77 , 78 , 79 ]. Practice leaders, including frontline managers and supervisors, play a pivotal role in creating a positive organisational culture that values person-centred care, fosters staff empowerment, and promotes continuous learning and improvement. Studies have shown that practice leaders who effectively implement active support report better staff experiences of working in challenging environments.

While service models have evolved towards a more person-centred approach, intellectual disability services, and their leaders still face challenges in the transition to modern leadership paradigms. These new approaches emphasise individualised support, self-determination, effective teamwork, and evidence-based practice, which are integral to developing inclusive and participatory human service models focused on supporting individuals in achieving their goals. Effective leadership serves as a catalyst for organisational change and is closely associated with delivering safe, effective quality care and promoting positive outcomes. ( 80 , 81 ) Despite widespread research into management and leadership in health and social care services, the field of intellectual disability remains relatively under-researched, often described as both an important and neglected area [ 82 ].

Effective leadership improves outcomes for clients/service users and what is evident within this evaluation is that intellectual disability leaders are eager for change and improvement but may lack clarity on how to enact such changes. Moreover, providing high-quality personalised care presents challenges, thereby there is a need to invest in leader development and illustrate how their skills can drive service improvement, engage clients/service users in care planning, and embed person-centred care across the health and social care system. There is a pressing need to create and nurture practice leaders within intellectual disability services and relay the message that leadership is a shared responsibility among all individuals striving to enhance people’s care experiences, particularly for those who are most vulnerable. This involves transforming services into human-centred care models focused on fulfilling person-centred outcomes. 83 . 84 Leaders play a pivotal role in promoting well-being, supporting independence, and ensuring people experience high-quality care and the best possible health outcomes. Overall, this evaluation reveals that participants’ knowledge and understanding of leadership improved through this programme and participants’ experiences were largely positive. However, consideration needs to be given to how leadership interventions related to support for individuals with intellectual disability, and future programme evaluation need to consider staff practice and service users’ experience has been measured.

Strengths and limitations of this study

This study captures the development and evaluation of a leadership programme for staff working in intellectual disability services with person in charge responsibilities in Ireland.

A large sample was achieved across four cohorts of the programme delivery and both survey and interview data were collected.

The survey instrument was developed for this study but was not a valid tool.

Social desirability bias from participants in their responses may have influenced their responses.

Data availability

Dataset is available on figshare open platform https://doi.org/10.6084/m9.figshare.22013186 and any additional information can be made to the corresponding author dependent upon privacy or ethical restrictions.

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Acknowledgements

The research team would like to thank all participants for their collaboration and the National Clinical Leadership Centre.

The programme design, delivery, and evaluation were funded by the National Clinical Leadership Centre for Nursing and Midwifery (Office of Nursing and Midwifery Service Directorate) of the Irish Health Service Executive.

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National Clinical Leadership Centre for Nursing and Midwifery, Health Service Executive, Dublin, Ireland

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Funding acquisition OD, EC, RR; Conceptualization MK, OD, EC, RR; Methodology OD, EC, RR, MOH; Investigation OD, MOH; Formal analysis OD, MOH; Writing - Original Draft AG, MK, OD, EC, RR; Writing - Review & Editing AG, MK, OD, EC, RR; Project administration OD, MOH.

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All procedures were in accordance with the University of Limerick, Education, and Health Sciences, Research Ethics Committee ethical standards (approval 2018_10_07_EHS) and the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Voluntary participation and informed consent were utilised in the survey and written informed consent was obtained from all participants who engaged in the interview study. All participants were made aware that the data collected may be disseminated and used for publication, conferences, or posters.

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The programme design and delivery were co-production by the independent researchers and the National Clinical Leadership Centre for Nursing and Midwifery, and the evaluation was conducted by the independent researchers. The independent researchers have no competing interests to declare.

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Doody, O., O’Halloran, M., Carey, E. et al. Leadership in intellectual disability practice: design, development, and evaluation of a programme to support practice. BMC Health Serv Res 24 , 674 (2024). https://doi.org/10.1186/s12913-024-11124-7

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Heterotopic ossification following COVID-19 infections: systematic literature review of case reports and case series

• Hachem Chaitani 1 ,
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BMC Musculoskeletal Disorders volume  25 , Article number:  421 ( 2024 ) Cite this article

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This review aims to study the clinical characteristics, diagnostic results, treatments, and outcomes in patients with heterotopic ossification following COVID-19 infection.

A literature search for eligible articles was conducted using MEDLINE/Pubmed, Global Health, and Scopus databases (January 12th, 2023), including all case reports and case series from any country and language. The criteria for inclusion in this review were cases of COVID-19 infection subsequently developing heterotopic ossification.

This systematic review analysed 15 reports ( n  = 20 patients) documenting cases of heterotopic ossification following COVID-19 infection. 80% of the patients were male, with a median age of 59 years. All patients required intensive care unit stay with an average duration of 48.5 days. Mechanical ventilation was necessary for all patients and 30% of them underwent tracheostomy. Common symptoms included stiffness and pain, most frequently affecting multiple locations (70%), with the hips and shoulders being predominantly involved. X-rays were the most commonly used imaging modality, followed by computed tomography. Although treatment was given, some of the patients continued to experience symptoms, particularly stiffness.

20 patients who developed heterotopic ossification after COVID-19 have been reported, the majority of which had at least two independent risk factors for this condition. The link between those two clinical entities is therefore uncertain, requiring further investigation. It is nonetheless important to suspect heterotopic ossification in patients with severe COVID-19 infection, prolonged immobilisation, mechanical ventilation, who develop joint pain and stiffness, as this condition can significantly impact patients’ quality of life.

Protocol registration

CRD42023393516.

Peer Review reports

Introduction

The coronavirus disease 2019 (COVID-19) global pandemic erupted in December 2019, resulting in numerous infections caused by severe acute respiratory syndrome coronavirus two (SARS-CoV-2). Although the viral infection affected mostly the lower respiratory tract causing acute respiratory distress syndrome (ARDS), many extrapulmonary complications have been described after COVID-19 infections. They may be the result of the viral infection itself, systemic inflammation, or other factors including intensive care unit (ICU) stay and prolonged bed rest [ 1 , 2 ]. The aetiology of heterotopic ossification (HO) is still not clearly understood. It can be defined as the emergence of bone tissue in ectopic tissue such as muscles. It occurs most commonly following traumatic brain or spinal cord injuries, intense trauma, severe thermal injuries, surgeries (e.g. hip arthroplasty), and immobilisation [ 3 , 4 ].

No link has been described yet between COVID-19 infection and HO, as the two phenomena remain unclear generally. We conducted a systematic review of case reports to summarise the evidence in the literature of the association between severe COVID-19 infections and HO development. Although a systematic review cannot demonstrate a causal relationship between these two processes, it can help make a few hypotheses requiring further research investigations. One potential hypothesis is that the systemic inflammatory response triggered by COVID-19 infection may contribute to dysregulation in bone formation pathways, thus predisposing individuals to HO. This study aims to give a better understanding of the clinical features in patients who get HO after contracting COVID-19. It serves as a starting point for delving deeper into the potential reasons behind this connection.

Materials and methods

This systematic review was conducted (protocol registration: ​​ CRD42023393516 ) following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [ 5 ], as shown in Fig.  1 .

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart

Search strategy

We conducted a literature search for eligible articles published until January 12th, 2023, using three databases (MEDLINE/Pubmed, Global Health, and Scopus). The search strategy used the following keywords: “heterotopic ossification” or “ectopic ossification” or “myositis ossificans” and “COVID-19” or “SARS-CoV-2” or “coronavirus”. The title and abstract determined the eligibility of the case report.

Eligibility criteria

We searched case reports and case series of HO and COVID-19. No language restriction was applied. Cases reporting COVID-19 infection and a diagnosis of HO were included. Review articles, commentaries, articles concerning fibrodysplasia ossificans progressiva, and articles with a lack of relevant clinical data were excluded.

Study selection

Two authors reviewed independently the titles, abstracts, and full articles. These authors confirmed articles with predetermined eligibility criteria.

Data collation and quality assessment

One author extracted data and another cross checked it. Physician collaborators helped in extracting data from articles written in other languages than English (French, Spanish, Portuguese, German, and Dutch). Subsequent details were drawn out for each case report: author, origin country, patient’s age, gender, past medical history (including other complications that the patient has developed during hospitalisation), presenting symptoms, ICU stay duration (if not specified, mechanical ventilation duration was taken into consideration), mechanical ventilation or tracheostomy use, time to HO diagnosis after COVID-19 onset (if the duration was not explicitly stated, we calculated an approximative duration in months by considering the hospitalisation duration and the time of HO symptom onset or imaging), HO diagnosis technique, HO location(s), serum alkaline phosphatase value, treatment of HO, and follow-up.

Data analysis and synthesis

We summarised the extracted information qualitatively. Methods for synthesising qualitative data such as meta-analysis were not used, as we are providing a summary of case reports. Thus, no effect measures were calculated.

This review included 20 patients diagnosed with HO following COVID-19 infection, as reported in 15 published studies [ 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 ]. Table  1 provides a compilation of the extracted data from each article.

The first case was reported in September 2020 [ 6 ], and the last one in October 2022 [ 20 ]. The majority of the cases were reported from Europe (13 patients, 65%), followed by the Americas (6 patients, 30%), and finally from Asia (1 patient, 5%).

The age of the patients ranged from 23 to 76 years with a median age of 59 years and a standard deviation of 14.5 years. 80% of the patients were male.

63.2% of the patients with known past medical history ( n  = 19) had hypertension, 15.8% of them had chronic obstructive pulmonary disease (COPD), and 21.1% of them had polyneuropathy of which one patient developed tetraparesis. One patient had a recent left humerus head fracture and multilocular cerebral infarction with left hemiparesis, and one patient had recent shoulder surgery. Other patients had deep vein thrombosis, pulmonary embolism, sepsis, and septic shock.

All patients required ICU care, with an average length of stay of 48.5 days (standard deviation: 26.7 days). Additionally, all patients required mechanical ventilation, and 30% underwent tracheostomy.

Of the patients for whom the presenting symptoms are known ( n  = 19), stiffness of the affected joint and pain were the predominant symptoms of HO. One patient presented soft tissue swelling [ 12 ] and one patient had a palpable mass in the knee [ 19 ]. Symptoms prompted imaging to diagnose HO in 90% of the patients, while in two cases (10%), HO was incidentally detected during imaging requested for other purposes. On average, HO was diagnosed 2.8 months after the onset of COVID-19, with a standard deviation of 1.6 months.

X-rays were the most used diagnosis technique (80%), followed by computed tomography scans (CT-scans) (60%). Bone scintigraphy was carried out in 30% of cases. 15% of the patients underwent magnetic resonance imaging (MRI) and one patient underwent a single-photon emission computed tomography (SPECT). Of the 12 cases for which serum alkaline phosphatase fluctuations were reported, 11 of them showed elevated levels.

Across all patients, HO was found to be unilocular in 30% of cases and multilocular in 70% of cases. The most common location of HO was the hip joint, accounting for 65%. Additionally, the bilateral presentation of HO in the hip was more common (69.2%) than the unilateral presentation (30.8%). Following the hip, the shoulder joint was the second most common location for HO (55%) and was also more commonly found bilaterally (72.7%) than unilaterally (27.2%).

Table  2 summarises treatments received by the patients and their follow-up. For patients with known treatment ( n  = 15), 86.7% of them received physical therapy. Three patients underwent surgery or had a surgical excision planned, and four patients were treated with nonsteroidal anti-inflammatory drugs (NSAIDs). Other therapeutic measures included corticosteroids and radiotherapy (refer to Table  3 for an overview of patient characteristics and trends). Out of 20 cases, follow-up data was available for seven patients. Among these, three experienced persistent mobility restriction, while three showed improvement in joint mobility.

HO is frequently divided into two groups: acquired HO, which is the most common, and rare genetic cases of fibrodysplasia ossificans progressiva and progressive osseous heteroplasia [ 3 , 4 ]. Three conditions are required for HO to develop: a local environment compatible with osteogenesis, an osteogenic precursor, and a triggering event [ 4 , 21 ]. Factors influencing the environment are pH, oxygen tension, micronutrients availability, and mechanical stimuli [ 22 ]. An insult triggers local inflammation with the recruitment of inflammatory cells including macrophages, lymphocytes, and mast cells, damaging skeletal muscle cells, which launches HO formation by inducing undifferentiated cell proliferation [ 21 ].

The prevalence of HO in patients with severe COVID-19 infection remains undetermined. Nevertheless, in a study by Stoira et al. [ 23 ]. which focused on a cohort of 52 COVID-19 infected patients admitted to the ICU and subjected to CT-scans, a notably high prevalence of 19.2% was observed. According to published case reports and case series, males were more commonly affected by HO, potentially due to sex-related differences that may influence predisposition [ 22 ]. 70% of the patients developed HO in multiple locations, with the hips and shoulders being the most frequently affected joints. Interestingly, these joints are also frequently affected in conditions such as traumatic brain injuries, spinal cord injuries, and burns [ 22 ].

Traumatic brain injury and spinal injury are known causes of HO formation [ 3 , 4 , 22 ]. Non-traumatic brain injuries were described as possible aetiologies for HO, such as vascular or anoxic brain injuries. This risk of developing HO is correlated to the severity of the brain lesions, and a higher occurrence in diffuse brain lesions was pointed out rather than focal brain lesions. It might be the result of mesenchymal cell differentiation into osteoblasts in ectopic tissues such as muscles, due to an anoxic insult [ 24 ]. Dahmen A. et al. [ 9 ] indicated that the patient had a prior history of multilocular cerebral infarction resulting in left hemiparesis, which could have contributed to the triggering of HO in addition to a humeral head fracture, with COVID-19 potentially confounding the situation.

Prolonged immobilisation and hypoxia have been identified in the literature as potential risk factors for HO [ 3 , 22 ]. Since the majority of reported cases involve prolonged stays in the ICU with mechanical ventilation or tracheostomy, this is a potential confounding factor for HO development. This finding is consistent with the study conducted by Stoira et al. where HO was linked to extended periods of mechanical ventilation and prolonged hospital stays [ 23 ]. Additionally, mechanical ventilation can induce a proinflammatory state [ 25 ], which may further contribute to the development of HO.

Mesenchymal cell function is influenced by type two diabetes, which can contribute to bone emergence [ 21 ]. Two patients were reported with diabetes mellitus in their past medical history, which could exacerbate the development of HO.

SARS-CoV-2 affects mostly the higher respiratory tract but can also affect the lower respiratory tract causing pneumonia, and an ARDS in severe infections. Disease severity is not only correlated to the viral infection, but to the inflammatory response as well [ 2 ]. In severe COVID-19 infections, uncontrolled inflammation can spread and result in multi-organ damage. It implicates macrophages, monocytes, and lymphocytes generating a cytokine storm. The angiotensin-converting enzyme two (ACE2) receptor, in conjunction with the transmembrane protease, serine two (TMPRSS2) allows the entry of SARS-CoV-2 into specific cell types, in particular type two pneumocytes. While other cells, such as smooth muscle cells, synovial cells, and articular cartilage, have been found to express these proteins, the musculoskeletal system is also a potential target for the viral infection. In addition to cytokines and a proinflammatory condition, it could possibly lead to muscle and joint diseases [ 25 ]. A clinical trial is necessary in order to demonstrate the relevance of this hypothesis. Furthermore, Davis et al. reported a case in 2012 of HO after prolonged intubation due to H1N1 influenza, highlighting the potential link between HO and ARDS caused by H1N1 infection. This underscores the need for further investigation into the association between HO and infection-related ARDS, offering potential avenues for future research in understanding the underlying mechanisms and developing targeted interventions for prevention and treatment [ 26 ].

HO’s diagnosis is based on the clinical history and on radiographic imaging, which has been performed in the majority of the reported cases. The most commonly reported patient complaints were joint stiffness, restriction of mobility, and pain. Radiography and CT-scans are the gold standards for diagnosis, although three-phase bone scintigraphy is the most sensitive medical imaging to detect HO, it is also recommended for follow-up and to determine the accurate stage for surgical excision. Moreover, ultrasonography (US) is an imaging technique that is safe, affordable and easy to use. It is sensitive for detecting soft tissue lesions and calcification. Its bedside application is particularly beneficial for bed-confined patients, while also enabling quantitative assessment of HO progression during rehabilitation through variations in grey-scale values across different stages of HO maturation [ 4 ]. Serum alkaline phosphatase levels, calcium, and phosphorus are not reliable markers for diagnosis, nor for prognostication of HO [ 22 ]. We note an elevation of serum alkaline phosphatase in 91.7% of the cases. This could serve as a potential indicator of HO development. However, further confirmation is required.

Treatment for HO is divided into two categories: prophylaxis for high-risk patients, and management of already developed ectopic bone. In prophylaxis, low-dose radiation and NSAIDs tend to deliver the same result, the latter being less costly. Physical therapy is controversial in the management of formed HO but is the most commonly used treatment in the patients included in the case reports of this review. Surgical excision is recommended when the ectopic bone growth has matured and a functional deficit persists [ 3 , 4 , 22 ]. Although there are no specific guidelines for treating patients who have developed HO after contracting severe COVID-19 infections, they present several risk factors that predispose them to HO. Therefore, prophylaxis could be employed in such cases. Some of the treated patients had residual effects, particularly reduced mobility, which could ultimately result in a decreased quality of life. New therapy lines targeting specific mediators are being tested and are giving promising effects like targeting the hypoxia-inducible factor 1-alpha that normally stimulates endothelial cell precursors subsequently to ischemia [ 22 ], or stimulating the retinoic acid receptor (RAR) that is a chondrogenesis’ inhibitor, or inhibiting the bone morphogenic protein (BMP) pathway implicated in the differentiation of the progenitor cells to endochondral differentiation or chondrogenesis lineage [ 21 ].

It is important to acknowledge several limitations of our study. Firstly, our study primarily relies on a review of case reports, which inherently presents limitations related to data consistency and comprehensiveness. Secondly, due to the nature of our study, we lack an accurate count of these cases, which impedes our ability to calculate the prevalence of HO within the population of COVID-19 patients. Additionally, the absence of quantitative analysis, including outcome and effect measures, limits our capacity to draw definitive conclusions about the clinical impact and outcomes associated with HO in this context. Furthermore, none of the included case reports provided data on bone density, which could have shed light on the relationship between bone resorption following immobilisation and HO development. In light of these limitations, our study serves as a preliminary exploration of HO in the context of COVID-19, emphasizing the need for more extensive and rigorous research in the future to address these shortcomings and provide a more comprehensive understanding of this phenomenon.

This systematic review provides a comprehensive overview of the clinical characteristics, diagnostic results, treatment options, and outcomes related to HO in COVID-19 patients. The study included 20 COVID-19 patients who developed HO. Most of them had at least two independent risk factors for developing HO, such as prolonged immobilisation and mechanical ventilation. The link between SARS-CoV-2 and HO remains uncertain, and multivariate analysis with adjustment for these risk factors are required. Although there is some evidence suggesting that SARS-CoV-2 might be targeting cells of the musculoskeletal system, it is unclear whether this is related to the development of HO. HO should nonetheless be suspected in patients with prolonged immobilisation, mechanical ventilation, and presenting joint pain and stiffness. This condition can have a significant impact on the patient’s quality of life, and its diagnosis is typically confirmed through radiographic imaging, which is considered the gold standard. The treatments of HO are controversial, and new studies are being conducted to explore new therapy lines. Therefore, it is important to continue investigating this pathology to identify effective treatment options and improve patient outcomes.

Data availability

All data generated or analysed during this study are included in this published article.

Abbreviations

coronavirus disease 2019

severe acute respiratory syndrome coronavirus two

intensive care unit

heterotopic ossification

chronic obstructive pulmonary disease

computed tomography

magnetic resonance imaging

single-photon emission computed tomography

nonsteroidal anti-inflammatory drugs

angiotensin-converting enzyme 2

hemagglutinin 1 neuraminidase 1

transmembrane protease, serine 2

retinoic acid receptor

bone morphogenic protein

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All authors contributed to the study conception and design. HC and SK conducted the material preparation and the literature review. Data collection and analysis were performed by HC and cross checked by LF. All authors contributed to the interpretation of data. All authors contributed to writing the manuscript, read and approved the final version.

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Chaitani, H., Fabeck, L. & Koulischer, S. Heterotopic ossification following COVID-19 infections: systematic literature review of case reports and case series. BMC Musculoskelet Disord 25 , 421 (2024). https://doi.org/10.1186/s12891-024-07537-4

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