Introduction

With globalization and scientific advances, health institutions and services are faced with increasingly demanding users and, to ensure quality of the care provided, they need more qualified workers with differentiated skills, who can meet the demands of the labor market. At the same time, in the national context there is a need to train health workers, especially nurses, so that they can assume new responsibilities linked to leadership behaviors, in addition to the essential competences to achieve the organizational goals in their work environment. (¹)

In this context, the term “competence” refers to a basic set of knowledge, skills and attitudes in which professionals can effectively develop their job in relation to the required challenges. (²) On the other hand, leadership is a skill that involves interpersonal relationships, and the essential elements for the exercise of leadership are effective communication, decision-making and responsible and effective team management. (³)

In the health area, the Nursing team stands out as the largest professional category, representing from 60 % to 89 % of the health workforce. (⁴) Thus, it is important for nurses, responsible for leading this team, to keep constantly improving regarding the development of competencies related to leadership.(⁵)

In Brazil, according to the National Nursing Curriculum Guidelines, during nurses' training, it is indispensable to develop attributes essential to the profession and which are entirely associated with the role of a leader, namely: managerial vision, real-time decision-making, communication skills, planning of care and managerial actions, permanent education, problem-solving ability, emotional stability and good interpersonal relationship skills for the implementation of dynamic and active assistance. Nurses' performance and skills as leaders depend on their actions promoting good interpersonal relationships in the organization where they work. (3, 6)

The role of leadership in Nursing has recently been highlighted at the global level. The State of the World's Nursing 2020 report, by the World Health Organization in partnership with the International Council of Nursing (ICN), highlighted the importance of investments in public policies that value the profession, which is the largest health workforce, considering that nurses act as protagonists of health actions and, historically, are always on the front line in the fight against epidemics and pandemics that threaten the health of the population. The data presented in this document show the need for actions aimed at strengthening Nursing leadership in the professional practice, providing society with more quality in the care provided. (⁷)

In view of the above, it is considered as extremely important to identify the instruments adopted by health institutions to identify nurses' essential leadership competencies, considering that the skills explained in the instruments reflect the organizational, managerial and care needs of Nursing services.

Thus, the objective of this study was to identify, in the literature, the instruments for assessing the skills required for leadership in Nursing.

Method

This is an integrative literature review, which synthesizes and evaluates published studies using different methodologies, in an orderly manner, contributing to deepening on the topic. (⁸-⁹)

This integrative review went through six standardized stages for this type of study, namely: I) identification of the topic and elaboration of the guiding question; II) definition of inclusion and exclusion criteria for the studies selected; III) data extraction from the studies selected; IV) critical evaluation of the studies selected; V) interpretation of the results; and VI) presentation of the knowledge synthesis. (⁸)

The PICo acronym was used to formulate the research question, where P stands for the study population, I for the intervention or exposure, and Co for the context. (¹⁰) Consequently, the guiding question for this review was as follows: “Which are the instruments available in the literature that identify the skills required for leadership in Nursing?”.

The inclusion criteria corresponded to primary studies, with no publication time limit, which addressed evaluative instruments to identify nurses' leadership competencies, available in full in Portuguese, English and Spanish.

Data collection was conducted in October 2021, resorting to the following databases: Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Scopus. Table 1 shows the search strategy and the descriptors used.

Table 1: Search string used in the databases to identify studies that address instruments for assessing the skills required for leadership in Nursing 

^Source: Own elaboration (2021)

Secondary studies, letters to the editor, duplicates, proceedings, opinion and reflection texts, theses and dissertations, course conclusion papers, manuals, reports, books, book chapters and incomplete texts were excluded. The critical evaluation of the articles selected was based on the inclusion and exclusion criteria.

The Data from the studies were extracted using an instrument developed by the authors, with diverse information regarding country of publication, authors, year, journal, objective, and main results.

Presentation of the studies included in this review was carried out in a descriptive manner, by means of tables and charts. The analysis and discussion were synthesized in a narrative way.

To classify the levels of evidence of the studies included, the seven-level pyramid was used, as follows: level 1 (strongest), evidence from a systematic review or meta-analysis of randomized clinical trials; level 2, evidence derived from well-designed randomized clinical trials; level 3, evidence obtained from well-designed clinical trials without randomization; level 4, evidence from well-designed cohort and case-control studies; level 5, evidence from a systematic review of descriptive and qualitative studies; level 6, evidence derived from a single descriptive or qualitative study; and level 7 (weakest), evidence from experts' opinions. (¹¹)

For being a study that evaluated secondary data, approval by the Research Ethics Committee was waived. Nevertheless, this study followed all the ethical precepts in terms of research, referencing the studies selected.

Results

Initially, the search strategy identified 1,135 studies in the databases. Of these, 749 were duplicates, leaving 386 for reading titles and abstracts. After the reading stage corresponding to the titles and abstracts, 370 studies were excluded for not meeting the inclusion criteria, such as: not being fully available, being written in languages other than English, Portuguese, or Spanish, or using other instruments that did not evaluate the competencies for leadership in Nursing. Six of the remaining 16 studies were excluded for not meeting the research objective. Consequently, 10 studies were selected to comprise the current review. The search and selection process are represented by means of the flowchart recommended by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), (¹²) as shown in Figure 1.

Figure 1:  Flowchart corresponding to the studies selected to comprise the integrative review 

Most of the studies referred to international publications. (¹³-²⁰) The publication period was from 2008 to 2020. The year with the highest number of publications on the theme was 2019, totaling three studies. (¹⁴-¹⁶)

In relation to language, all the studies were published in English. Regarding the countries of origin, there was one from Ireland, (¹⁴) two from the United States of America, (15, 21) one from the United Kingdom, (¹⁸) one from Iran, (¹⁹) one from Brazil, (²²) two from Sweden, (¹³,²⁰) one from Spain (¹⁷) and one from Finland. (¹⁶)

The managerial positions were held by professionals who lacked previous experience or specialization in the management area. The investigations in all studies were based on the professional experiences of nurses and of the Nursing team, based on elaboration or application of an instrument with the objective of identifying the competencies essential to leadership in Nursing.

The following instruments were identified in this review: Ambulance Nurse Competence (ANC);(¹³) Clinical Leadership Needs Analysis (CLeeNA) Instrument;(¹⁴) Kuopio University Hospital Transformational Leadership Scale (KUHTLS);(¹⁶) Cotter Preceptor Selection Instrument (CPSI);(²¹) Leadership Practices Inventory (LPI);(²²) Advanced Practice Nursing Competency Assessment Instrument (APNCAI); (¹⁷ Multisource Feedback (MSF);(¹⁸) Performance Evaluation Tool;(¹⁹) Leadership and Management Inventory(²⁰) and an instrument whose title was not informed by the authors, consisting of constructs to enable communication behaviors of Nursing leaders. (¹⁵)

Table 2 T2a T2b T2c presents the characterization of the studies, as well as the objectives and main results.

Table 2: Publications selected about the Instruments for assessing the skills required for leadership in Nursing 

^Source: Own elaboration (2021)

Discussion

The analysis of all ten studies showed that the use of different evaluative instruments is important to identify competencies necessary for nurses' leadership. These tools can be divided into three large groups that are directed at “assisting, leader's behavior, and care management”. ⁽⁶

In this review, four instruments classified in the “care management” category were obtained within this classification, namely: Ambulance Nurse Competence (ANC) scale; Clinical Leadership Needs Analysis (CLeeNA) Instrument; Advanced Practice Nursing Competency Assessment Instrument (APNCAI); and Leadership and Management Inventory; six tools comprised the “leader's behavior” category: Kuopio University Hospital Transformational Leadership Scale (KUHTLS); Cotter Preceptor Selection Instrument (CPSI); Multisource Feedback (MSF); Performance Evaluation Tool; and Leadership Practices Inventory (LPI); and one instrument did not have its title informed by the authors.

Care management is part of the leadership process, as well as one of the nurses' duties. Care planning, as well as its organization, should aim at achieving better care practices in the health services, with actions that favor comprehensive and quality care, through forecast and provision of essential resources for care. ⁽²³

Among the competencies necessary for care management, the following stand out: teaching, organizational skills, updated information, readiness for analysis and decision-making, organization and delegation of functions, care and time management, as well as prioritization of activities and financial management. ⁽²⁴

The most relevant skills in this group observed in the current review were as follows: decision-making, care management, having information, and being strategic. ⁽¹⁴

These competencies are evidenced in the study on the Clinical Leadership Needs Analysis (CLeeNA) Instrument. ⁽¹⁴ The results showed that the most important competencies for the nurse-leaders participating in this study were those related to technology, finance, and service management. With globalization, many technological tools and instruments are used by nurse-leaders and contribute to the management process, optimizing work organization.

In addition to that, knowledge and skills in financial management are increasingly necessary for nurses who have been gaining space in higher instances of the health services.⁽²⁵

Nurse-leaders must enable the best care conditions for the patients and ensure the professionals' best performance possible. These conditions can be observed in the Ambulance Nurse Competence (ANC) scale, ⁽¹³ which among the items evaluated contains patient-centered care, teamwork and collaboration, fundamental requirements for nurses working in pre-hospital services that need rapid and effective action.

In the Leadership and Management Inventory instrument ⁽²⁰ decision-making was the skill that was considered most important in nurse-leaders’ evaluation. Decision-making requires instrumentalization of managerial tools and administrative theories that can facilitate and support the nurse-leaders' decisions, achieving effectiveness in the results of their decisions. ⁽²⁶

The competencies from the “leader's behavior” category encompass the dimensions inherent to the attitudes that nurses must have, such as punctuality, preparation, motivation, social skills, collaboration, enthusiasm, and support to those led, among others. ⁽¹⁸

Among these competencies, social skills stand out, as they constitute an evaluative attribute of a successful behavior or set of behaviors, as they are important to exercise leadership because they contribute to professional development combining care management with care practices. ⁽²⁷

The social communication skill is essential for nurses, both in care development and in the leadership process. Communication consists in understandability, active listening, openness, feedback, empathy, non-verbal language, para-language and cooperation. ⁽¹⁵

Among the forms of communication, writing is the most used in the care management process, followed by oral communication, used strategically for fast transmission of a message to inform, guide, and carry out the planning of actions, which are indispensable for conflict resolution. ⁽²⁸

It is noted that the instrument called Leadership Practices Inventory (LPI) ⁽²² presented the “Enable others to act” dimension as the most relevant among the behavioral competencies of social skills that nurse-leaders must possess.

In this perspective, nurses should provide their team with opportunities that enable them to effectively perform care, through permanent education actions and practical examples during daily management of the patient/family, in addition to encouraging and allowing teamwork, winning the collaboration of all. ^{(22, 29)}

The Cotter Preceptor Selection Instrument (CPSI) ⁽²¹ and the Performance Evaluation Tool¹⁹ also addressed that the main competencies for nurse-leaders are those guided in the behavioral area, which are the collaboration and interpersonal skills, respectively.

Therefore, social and interpersonal skills, as well as collaboration, constitute a set of behaviors with high potential to produce reinforcing consequences for the individual and for the other members of the Nursing team. ⁽³⁰

Another competence considered relevant and highlighted in the articles evaluated was the ability to lead the team, observed in the study by Sapountzi-Krepia et al., ⁽¹³ who used the Kuopio University Hospital Transformational Leadership Scale (KUHTLS), and in the paper by Lakshminarayana et al., ⁽¹⁸ through the Multisource Feedback (MSF) instrument. The ability to lead is one of the main competencies for nurses to develop, as it is considered inherent to the professional practice.

Thus, it is up to the leader to stimulate creativity of the direct reports, allow them to participate in decision-making processes and adapt to each situation imposed on them, to achieve qualification of the Nursing services. ⁽³¹

It is noted that care management and leadership in Nursing are fundamental in nurses' professional practice, through planning and organization actions to guarantee their continuity and confer sustainability to the institution's policies and strategic guidelines. ⁽⁶

The relevance of this review consists in showing that, using an evaluation instrument, managers can identify the necessary competencies for leadership in Nursing that must be sought and developed in nurses' professional practice. This demonstrates the managers' responsibility to develop strategies for the personal and professional growth of the leaders who work in their staff, as well as for the Nursing team to meet the main demands of those they lead.

A limitation of this study was the lack of studies that use instruments to assess nurses' managerial competence not only at the hospital level, but also in Primary Health Care and at other health care levels, so that these skills can be equated and articulated according to the needs of the services.

Conclusion

This integrative literature review identified ten instruments to assess the essential competencies for leadership in Nursing.

Communication was identified as one of the main skills aligned to the manager's role. Decision-making, social skills, team management, up-to-date information and strategic and financial management are elements of paramount importance in nurses' managerial and care exercise, to establish a harmonious relationship between leaders and those led in the work process.