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Ten years ago, the American Organization of Nurse Executives (AONE) published its paper on the role and function of nurses in executive practice. This document outlined the transitions occurring in healthcare leadership and the dimensions and processes that were instrumental in executive success. Last year, the AONE Board of Directors determined that it was time to update this work with a more in-depth description of the competencies integral to the practice of nurse executives.
The turbulent, ever-changing world of healthcare continues to present new challenges. With its vision of “shaping the future of healthcare through innovative nursing leadership,” AONE recognizes that excellent leadership is essential to ensure excellent patient care.
The competencies listed on these pages describe skills common to nurses in executive practice regardless of their educational level or titles in different organizations. They are presented as information for both nurse leaders and those who employ or work with them. Executives can use these competencies as a self-assessment tool, useful in the identification of possible areas for growth. Aspiring nurse leaders can use them in planning personal preparation for their careers. Healthcare organizations may see them as a guideline for job descriptions, expectations and evaluations of nurse leaders. Nurse educators can utilize them as a curriculum guideline for the educational preparation of nurses seeking expertise and knowledge in executive practice.
The competencies are captured in a model developed by the Healthcare Leadership Alliance in 2004. Members of the Alliance include AONE, the American College of Healthcare Executives, American College of Physician Executives, Healthcare Financial Management Association, Healthcare Information and Management Systems Society and Medical Group Management Association. This graphic model is being used in ongoing work to identify a common core set of competencies for leadership executives in healthcare.
The vision of the American Organization of Nurse Executives (AONE) is to shape the future of healthcare through innovative nursing leadership. Innovative nursing leadership requires that nurses in leadership positions are competent.
AONE believes that managers at all levels must be competent in:
I
Communication and relationship-building
II
A knowledge of the healthcare environment
III
Leadership
IV
Professionalism
V
Business skills
While all nursing leaders share these competency domains, the emphasis on particular competencies will be different depending on the leader's specific position in the organization.
Communication and relationship-building competencies include:
•
Effective communication
•
Relationship management
•
Influence of behaviors
•
Ability to work with diversity
•
Shared decision-making
•
Community involvement
•
Medical staff relationships
•
Academic relationships
Knowledge of the healthcare environment includes:
•
Clinical practice knowledge
•
Patient care delivery models and work design knowledge
•
Healthcare economics knowledge
•
Healthcare policy knowledge
•
Understanding of governance
•
Understanding of evidence-based practice
•
Outcome measurement
•
Knowledge of and dedication to patient safety
•
Understanding of utilization/case management
•
Knowledge of quality improvement and metrics
•
Knowledge of risk management
Leadership skills include:
•
Foundational thinking skills
•
Personal journey disciplines
•
The ability to use systems thinking
•
Succession planning
•
Change management
Professionalism includes:
•
Personal and professional accountability
•
Career planning
•
Ethics
•
Evidence-based clinical and management practice
•
Advocacy for the clinical enterprise and for nursing practice
•
Active membership in professional organizations
Business skills include:
•
Understanding of healthcare financing
•
Human resource management and development
•
Strategic management
•
Marketing
•
Information management and technology
The following discussion provides an in-depth description of the skills needed for competency in the five AONE leadership domains.
Nurse Executive Competencies
I Communication and relationship-building
1.
Effective Communication
◦
Make oral presentations to diverse audiences on nursing, healthcare, and organizational issues
◦
Produce cogent and persuasive written materials to address nursing, healthcare, and organizational issues appropriate to the audience
◦
Resolve and manage conflict
2.
Relationship Management
◦
Build trusting, collaborative relationships with:
-
Staff
-
Peers
-
Other disciplines and ancillary services
-
Physicians
-
Vendors
-
Community leaders
-
Legislators
-
Nursing and other educational programs
◦
Deliver “bad news” in such a way as to maintain credibility
◦
Follow through on promises and concerns
◦
Provide service recovery to dissatisfied customers
◦
Care about people as individuals and demonstrate empathy and concern while ensuring that organizational goals and objectives are met
◦
Accomplish objectives through persuasion, celebrate successes and accomplishments, and communicate a shared vision
◦
Assert views in non-threatening, non-judgmental ways
3.
Influencing Behaviors
◦
Create and communicate a shared vision
◦
Reward appropriate behaviors and confront and manage inappropriate behaviors
◦
Develop, communicate and monitor behavior expectations
4.
Diversity
◦
Create an environment which recognizes and values differences in staff, physicians, patients, and communities
◦
Assess current environment and establish indicators of progress toward cultural competency
◦
Define diversity in terms of gender, race, religion, ethnicity, sexual orientation, age, etc.
◦
Analyze population data to identify cultural clusters
◦
Define cultural competency and permeate principles throughout the organization
◦
Confront inappropriate behaviors and attitudes toward diverse groups
◦
Develop processes to incorporate cultural beliefs into care
5.
Shared Decision-Making
◦
Engage staff and others in decision-making
◦
Promote decisions that are patient-centered
◦
Provide an environment conducive to opinion-sharing
6.
Community Involvement
◦
Represent the organization to non-healthcare constituents within the community
◦
Provide consultation to community and business leaders regarding nursing and health care
◦
Be an effective board member for community and/or professional organizations
7.
Medical Staff Relationships
◦
Build credibility with physicians as a champion for patient care, quality and nursing professionalism
◦
Confront and address inappropriate behavior towards patients and staff
◦
Represent nursing at medical executive committee and other medical staff committees
◦
Collaborate with medical staff leaders in determining needed patient care services
◦
Collaborate with physicians to develop patient care protocols, policies and procedures
◦
Collaborate with physicians to determine patient care equipment and facility needs
◦
Utilize medical staff mechanisms to address physician clinical performance issues
◦
Facilitate disputes involving physicians and nurses or other disciplines
8.
Academic Relationships
◦
Determine current and future supply and demand for nursing care
◦
Identify educational needs of existing and potential nursing staff
◦
Collaborate with nursing programs to provide required resources
◦
Collaborate with nursing programs in evaluating quality of graduating clinicians and develop mechanisms to enhance this quality
◦
Serve on academic advisory councils
◦
Collaborate with nursing faculty in nursing research and incorporate nursing research into practice
II Knowledge of the healthcare environment
1.
Clinical Practice Knowledge
◦
Maintain knowledge of current nursing practice and the roles and functions of patient care team members
◦
Articulate patient care standards as published by JCAHO, CMS, and professional nursing literature
◦
Understand, articulate, and ensure compliance with the State Nurse Practice Act, State Board of Nursing regulations, regulatory agency standards, and policies of the organization
◦
Ensure that written organization clinical policies and procedures are reviewed and updated in accordance with evidence-based practice
◦
Role model lifelong learning, including clinical subjects such as disease processes, pharmaceuticals, and clinical technology
2.
Delivery Models/Work Design
◦
Maintain current knowledge of patient care delivery systems and innovations
◦
Articulate various delivery systems and patient care models and the advantages/disadvantages of each
◦
Serve as change agent when patient care work/workflow is redesigned
◦
Determine when new delivery models are appropriate, and then envision and develop them
3.
Healthcare Economics
◦
Articulate federal and state payment systems and regulations, as well as private insurance issues, which affect organization's finances
◦
Understand and articulate individual organization's payer mix, CMI and benchmark database
4.
Healthcare Policy
◦
Articulate federal and state laws and regulations that affect the provision of patient care, e.g., tort reform, malpractice/negligence, reimbursement
◦
Participate in the legislative process concerning health care through membership in professional organization and personal contact with public officials
◦
Educate patient care team members on the legislative and regulatory processes and methods for influencing both
◦
Interpret impact of state and federal legislation on nursing and health care organizations
5.
Governance
◦
Articulate the role of the governing body of the organization in the following areas:
-
Fiduciary responsibilities
-
Credentialing
-
Performance management
◦
Represent patient care issues to the governing body
◦
Participate in strategic planning and quality initiatives with the governing body
◦
Interact with and educate the organization's board members regarding healthcare and the value of nursing care
◦
Represent nursing at the organization's board meetings
6.
Evidence-Based Practice/Outcome Measurement
◦
Interpret information from research
◦
Utilize research findings for the establishment of standards, practices, and patient care models in the organization
◦
Disseminate research findings to patient care team members
◦
Participate in studies that provide outcome measurements
◦
Allocate nursing resources based on measurement of patient acuity/care needed
7.
Patient Safety
◦
Support the development and implementation of an organization-wide patient safety program
◦
Design safe clinical systems, processes, policies and procedures
◦
Monitor clinical activities to identify both expected and unexpected risks
◦
Support a non-punitive reporting environment and a reward system for reporting unsafe practices
◦
Support safety surveys, responding and acting on safety recommendations
◦
Ensure staff is clinically competent and trained on their role in patient safety
◦
Articulate and take action to support the JCAHO National Patient Safety Goals
8.
Utilization/Case Management
◦
Articulate organization decision-making for the criteria model adopted by the organization
◦
Communicate key points of the model to a variety of audiences (nursing, financial, medical staff)
◦
Involve physicians in on-going utilization management practices
◦
Design continuum of care options for managing patient throughput (long term care units, urgent care centers, admission/discharge units, etc.)
9.
Quality Improvement/Metrics
◦
Articulate the organization's QI program and goals
◦
Determine patient care quality improvement goals and objectives
◦
Define metrics as related to process improvement
◦
Explain and utilize metrics as a unit of measure for any process
◦
Articulate the link between metrics and goals
◦
Articulate the link between organization metrics and national quality initiatives/metrics
◦
Target outcomes that are evidence-based (comparison data benchmarking)
◦
Define quality metrics by:
-
Identifying the problem/process
-
Measuring success at improving specific areas of patient care
-
Analyzing the root causes or variation from quality standards
-
Improving the process with the evidence
-
Controlling solutions and sustaining success
10.
Risk Management
◦
Identify areas of risk/liability
◦
Ensure staff is educated on risk management and compliance issues
◦
Develop systems which encourage/require prompt reporting of potential liability by staff at all levels
◦
Envision and take action to correct identified areas of potential liability
III Leadership
1.
Foundational Thinking Skills
◦
Address ideas, beliefs or viewpoints that should be given serious consideration
◦
Recognize one's own method of decision making and the role of beliefs, values and inferences
◦
Critically analyze organizational issues after a review of the evidence
◦
Maintain curiosity and an eagerness to explore new knowledge and ideas
◦
Promote nursing leadership as both a science and an art
◦
Demonstrate reflective leadership and an understanding that all leadership begins from within
◦
Provide visionary thinking on issues that impact the healthcare organization
2.
Personal Journey Disciplines
◦
Value and act on feedback that is provided about one's own strengths and weaknesses
◦
Demonstrate the value of lifelong learning through one's own example
◦
Learn from setbacks and failures as well as successes
◦
Assess one's personal, professional and career goals and undertake career planning
◦
Seek mentorship from respected colleagues
3.
Systems Thinking
◦
Promote systems thinking as a value in the nursing organization
◦
Consider the impact of nursing decisions on the health care organization as a whole
◦
Provide leadership in building loyalty and commitment throughout the organization
◦
Synthesize and integrate divergent viewpoints for the good of the organization
4.
Succession Planning
◦
Promote nursing management as a desirable specialty
◦
Conduct periodic organizational assessments to identify succession planning issues and establish action plans
◦
Serve as a professional role model and mentor to future nursing leaders
◦
Establish mechanisms that provide for early identification and mentoring of staff with leadership potential
◦
Develop a succession plan for one's own position
5.
Change Management
◦
Utilize change theory to plan for the implementation of organizational changes
◦
Serve as a change agent, assisting others in understanding the importance, necessity, impact and process of change
◦
Support staff during times of difficult transitions
◦
Recognize one's own reaction to change and strive to remain open to new ideas and approaches
◦
Adapt leadership style to situational needs
IV Professionalism
1.
Personal and Professional Accountability
◦
Create an environment that facilitates the team to initiate actions that produce results
◦
Hold self and others accountable for actions and outcomes
◦
Create an environment in which others are setting expectations and holding each other accountable
◦
Answer for the results of one's own behaviors and actions
2.
Career Planning
◦
Develop own career plan and measure progress according to that plan
◦
Coach others in developing their own career plans
◦
Create an environment in which professional and personal growth is an expectation
3.
Ethics
◦
Articulate the application of ethical principles to operations
◦
Integrate high ethical standards and core values into everyday work activities
◦
Create an environment that has a reputation for high ethical standards
4.
Evidence-Based Clinical and Management Practice
◦
Advocate use of documented best practices
◦
Teach and mentor others to routinely utilize evidence- based data and research
5.
Advocacy
◦
Role model the perspective that patient care is the core of the organization's work
◦
Assure that the clinical perspective is included in organizational decisions
◦
Ensure that nurses are actively involved in decisions that affect their practice
6.
Active Membership in Professional Organizations
◦
Participate in at least one professional organization
◦
Support and encourage others to participate in a professional organization
V Business skills
1.
Financial Management
◦
Articulate business models for healthcare organizations and fundamental concepts of economics
◦
Describe general accounting principles and define basic accounting terms
◦
Analyze financial statements
◦
Manage financial resources by developing business plans
◦
Establish procedures to assure accurate charging mechanisms
◦
Educate patient care team members on financial implications of patient care decisions
2.
Human Resource Management
◦
Participate in workforce planning and employment decisions
◦
Champion a diverse workforce
◦
Use corrective discipline to mitigate workplace behavior problems
◦
Interpret and evaluate employee satisfaction/quality of work surveys
◦
Create opportunities for employees to be involved in decision-making
◦
Reward and recognize exemplary performance
◦
Formulate programs to enhance work-life balance
◦
Interpret legal and regulatory guidelines
◦
Manage collective bargaining environments or implement programs to avoid the need
◦
Identify and eliminate sexual harassment, workplace violence, and verbal and physical abuse
◦
Implement ergonomically sound work environments to prevent worker injury and fatigue
◦
Develop and implement bioterrorism, biohazard and disaster readiness plans
◦
Identify clinical and leadership skills necessary for performing job-related tasks
◦
Select top talent, matching organizational needs with appropriate skill sets (assess job candidate skills sets)
◦
Manage performance through rewards, recognition, counseling and disciplinary action
◦
Provide mentorship and career counseling to aspiring clinicians and leaders so they may develop required skill sets (succession planning)
◦
Identify future skill sets needed to remain competitive
◦
Analyze market data in relation to supply and demand and manage resources to ensure appropriate compensation
◦
Develop and implement recruitment and retention strategies
3.
Strategic Management
◦
Analyze the situation and identify strategic direction
◦
Conduct SWOT and gap analyses
◦
Formulate objectives, goals, and specific strategies related to mission and vision
◦
Understand what organizations should measure in order to “balance” the financial perspective
◦
Measure and analyze performance from the learning and growth, business process, customer, and financial perspectives
4.
Marketing
◦
Analyze marketing opportunities
◦
Develop marketing strategies
◦
Integrate marketing and communications strategies
◦
Use public relations and media outlets to promote your organization
5.
Information Management and Technology
◦
Demonstrate basic competency in e-mail, common word processing, spreadsheet, and Internet programs
◦
Recognize the relevance of nursing data for improving practice
◦
Recognize limitations of computer applications
◦
Use telecommunication devices
◦
Utilize hospital database management, decision support, and expert system programs to access information and analyze data from disparate sources for use in planning for patient care processes and systems
◦
Participate in system change processes and utility analysis
◦
Participate in the evaluation of information systems in practice settings
◦
Evaluate and revise patient care processes and systems
◦
Use computerized management systems to record administrative data (billing data, quality assurance data, workload data, etc.)
◦
Use applications for structured data entry (classification systems, acuity level, etc.)
◦
Recognize the utility of nursing involvement in the planning, design, choice and implementation of information systems in the practice environment
◦
Demonstrate awareness of societal and technological trends, issues and new developments as they apply to nursing
◦
Demonstrate proficient awareness of legal and ethical issues related to client data, information, and confidentiality
◦
Read and interpret benchmarking, financial and occupancy data
Conclusion
This document is not intended to be an exhaustive list of all areas of expertise for individual nurses in executive practice. It does, however, illustrate how complex and important their roles have become. Nursing leadership/management is as much a specialty as any other clinical nursing specialty. As such, it requires proficiency and competent practice specific to the executive role. The AONE Nurse Executive Competencies sets the standard for that practice.
☆Special thanks to the AONE 2004 Education Committee for its extensive work on this project: Patricia Conway-Morana, Rosemary Roth, Rose Sherman, Kathy Harris, Janice Wharton, Beth Brooks, Pamela Thompson, and Veronika Oven (staff liaison).
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