Journal of Nursing Management, 2017, 25, 7781

Commentary
Building leadership capacity in advanced nurse
practitioners the role of organisational management

Correspondence ELLIOTT N. (2017) Journal of Nursing Management 25, 7781

Naomi Elliott
School of Nursing and Midwifery
Trinity College Dublin, the
University of Dublin
24 DOlier Street
Dublin 2, DO2 T283
Ireland
E-mail: naomi.elliott@tcd.ie
Building leadership capacity in advanced nurse practitioners the role of
organisational management
Aim To highlight the organisation-level managements role in building leadership
capacity in advanced nurse practitioners and the need for appropriate supports to
increase their becoming leaders.
Background Little is published about the role of organisation-level management
in building leadership capacity and in developing the next generation of nurse
leaders. In times of economic constraint, organisations need to focus their efforts
on targeted leadership initiatives. Advanced nurse practitioners are ideally
positioned to act as leaders both within and beyond the health care organisation.
Evaluation From the available research evidence, several support structures and
mechanisms are identified as enablers for advanced nurse practitioners to enact
their leadership role.
Conclusion Health care organisations need to include building leadership capacity
as a priority in their strategic plan and take action to build-up the level of
advanced nurse practitioner leadership.
Implications for nursing management Nurse executives have a vital role in
influencing the organisations strategic plan and making a business case for
prioritising leadership capacity building within advanced nurse practitioners. A
challenge for nurse executives faced with competing service and leadership
development demands, involves strategic decision-making regarding whether the
advanced nurse practitioners role is limited to service delivery or its potential in
leading health care reforms is realised.
Keywords: advanced nurse practitioner, clinical leadership, leadership capacity, nurse
consultant, organisational management

Accepted for publication: 20 September 2016

2010), however, missing in the leadership literature is

Introduction
Building leadership capacity is not a new concept to
nursing or health care management (Ferguson &
Donaho 1999, Alleyne & Jumaa 2007, Jooste &
Cairns 2014, West et al. 2015). As the demand for
health care reform is increasing rapidly, the need to
develop leaders who can respond by innovating and
improving health care practice is escalating, and build-
ing leadership capacity has become a priority. Within
nursing, advanced nurse practitioners are ideally posi-
tioned to act as leaders both within and beyond the
health care organisation (Delamaire & Lafortune
a focus on the role of organisation-level management
in building leadership capacity and enabling advanced
nurse practitioners to enact their leadership role.
Previous leadership development initiatives associ-
ated with established international and national insti-
tutes, such as the International Council of Nurses
[ICN]-Burdett Global Nursing Leadership Institute
(http://leadership.icn.ch/gnli/), American Academy of
Nursing [AAN] Institute for Nursing Leadership (http://
www.aannet.org/nurse-leaders), National Health Ser-
vice [NHS] Leadership Academy (http://www.leader
shipacademy.nhs.uk/), and Health Services Executive

DOI: 10.1111/jonm.12444
2016 John Wiley & Sons Ltd 77
Commentary
[HSE] National Leadership and Innovation Centre
(http://www.hse.ie), have supported leadership develop-
ment in nursing over the decades. Whilst progress has
been made most notably in the areas of leadership edu-
cation and training across all grades of nurses, the chal-
lenge for future leadership development is to build
leadership capacity and to recognise the role that organ-
isation-level management has in developing advanced
nurse practitioners as leaders.
For executive-level nurses, working in complex and
business orientated health care organisations creates
challenges arising from competing demands; such as
between the need for building leadership capacity in
advanced nurse practitioners and the service demand
for increased access to quality clinical services and
reduced waiting time for growing numbers of patients.
Numerous studies have identified heavy clinical work-
load as a major barrier to leadership insofar as the
time available for advanced nurse practitioners lead-
ership activities is constantly being eroded by clinical
service demands (Guest et al. 2004, Woodward et al.
2005, DiCenso & Bryant-Lukosius 2010, Simmons
2010, Chang et al. 2012, Higgins et al. 2014). What
is missing in the leadership literature is a discourse on
the role of organisational management in building
leadership capacity and importantly, what support
structures and mechanisms need to be included in the
leadership development programme for advanced
nurse practitioners.
Key differences between leadership capacity and
leadership capability
Although leadership capacity and leadership capability
are inter-related (Severinsson 2014), there are subtle
yet important differences that have implications for
organisational management. For Weiss and Molinaro
(2005), leadership capacity involves organisation-level
systems and practices to build up the number and
level of leaders, whereas leadership capability focuses
on the development of individual-level leadership
skills, abilities and competencies through education
programmes. In nursing, a trend in leadership develop-
ment has been to focus on the individuals skills and
behaviours as described by the various leadership the-
ories, for example, transformational leadership (Bass
& Avolio 1994) or situational leadership (Hersey
et al. 2012). More recently, research evidence is begin-
ning to emerge that shifts the focus from the individ-
ual to the workplace context and identifies
organisation-level factors as a major influence on the
nurses ability to enact leadership (Simmons 2010,
78
Higgins et al. 2014, Elliott et al. 2016). Findings from
a scoping review of the research evidence on barriers
and enablers to leadership enactment in advanced
practice contexts (Elliott et al. 2016), point to organi-
sation-level gaps in leadership development and the
need for leadership capacity building strategies in
order to build up both the number and level of nurse
leaders within organisations.
Building leadership capacity in advanced nurse
practitioners
An essential of any programme for leadership develop-
ment is that executive directors include building lead-
ership capacity as one of the priorities within the
organisations strategic plan (Weiss & Molinaro
2005). The goal of building up the number and level
of nurse leaders is not a short-term goal but requires a
long-term strategic approach and a sustained commit-
ment from the organisation in the form of providing
appropriate support structures and resources that will
continue to support nurse leaders beyond the initial
start-up either of new leadership posts or new practice
development projects. In countries such as the UK and
the USA, considerable investment has already been
made in the areas of developing leadership education
courses and competency guidelines (NHS Leadership
Academy 2011, American Association of Colleges of
Nurses 2013), which serve to increase the leadership
ability of individual nurses across all grades. However,
the Center for Creative Leadership (2016) in a White
Paper on Addressing the Leadership Gap in Health-
care, argues that in times of economic constraint
health care organisations cannot afford to pour
resources into generalised leadership development but
instead need to focus their efforts on targeted leader-
ship initiatives. Whittle et al. (2012) discuss how
organisations that are constituted from a hierarchy of
capacities (p.15) should consider adopting a frame-
work for capacity building that reflects the hierarchies.
In nursing, whilst leadership development is relevant
across all grades of nurses, there is a general consen-
sus within the international nursing profession that
the advanced nurse practitioner/nurse practitioner/
nurse consultant role represents the highest grade of
clinical leadership in nursing (Delamaire & Lafortune
2010). Within policy guidelines on the advanced nurse
practitioner/nurse practitioner/nurse consultant roles,
leadership is identified as a core dimension of the role
alongside clinical practice, education and research
(e.g. Canadian Nurses Association 2008, National
Council for the Professional Development of Nursing
2016 John Wiley & Sons Ltd
Journal of Nursing Management, 2017, 25, 7781

and Midwifery 2008, The Scottish Government 2010,
Nursing and Midwifery Board of Australia 2014). As
such, advanced nurse practitioners are ideally posi-
tioned to act as clinical and professional leaders inso-
far as they have clinical expertise in their area of
specialist practice and are educated, at a minimum to
Masters degree which usually includes change man-
agement and research projects. The organisations
strategic plan for leadership development, therefore,
should include a focus on building leadership capacity
within advanced practitioner-level nurses and put in
place appropriate support structures and mechanisms
that will enable them to fulfil their potential as
leaders.
Support structures and mechanisms for building
leadership capacity
The process of building leadership capacity in a mul-
ti-profession, multi-layer health care organisation is
complex. The literature on leadership development
abounds with recommendations for best-practice,
however, it is important to identify supports that are
appropriate and relevant to the advanced practi-
tioners context. Evaluation research on the advanced
nurse practitioner role provides a useful evidence-base
for exploring which supports are considered appropri-
ate in advanced practitioner contexts. From the avail-
able research evidence, a number of support
structures and mechanisms that facilitate advanced
nurse practitioners to enact their leadership role are
identified that may help organisations to build leader-
ship capacity and advance the level of nurse leaders.
They include:
Defined leadership role. Having clarity on the
advanced nurse practitioners role and function both
in nursing and across the multi-disciplinary team, so
that their leadership role is clear and they are iden-
tified as leaders of practice development initiatives
within the health care organisation (Manley et al.
2008, Simmons 2010, Franks 2014);
Director-level accountability. Having the advanced
nurse practitioners position within the management
structure of the organisation at the level of report-
ing to a director, means they are in a position with
direct access to executive decision-makers and bud-
get-holders, are accountable for achieving their per-
formance targets and for demonstrating outcomes
relating to improved quality of patient care delivery,
evidence-based innovation and practice development
(Mullen et al. 2011, Bahouth et al. 2013);
2016 John Wiley & Sons Ltd
Journal of Nursing Management, 2017, 25, 7781
Commentary
Leadership mentoring. Having mentors in the form
of leadership brokers to guide advanced nurse
practitioners on using/ developing the particular
skill-sets that are needed for successful implementa-
tion of innovation and practice changes in multi-dis-
ciplinary and business-orientated health care
organisations (Donald et al. 2011, Franks 2014,
Leggat et al. 2015). Leadership mentoring in the
form of advising advanced practitioners on effective
ways of raising their profile in arenas external to
the organisation and establishing alliances with
national and international centres of excellence
(Abbott 2007, Begley et al. 2014);
Membership of strategic committees. Being nomi-
nated by organisation-level management on to clini-
cal and strategic committees at local, national and
international levels, so that advanced nurse practi-
tioners can impact decision-making regarding ser-
vice delivery and are visible as leaders beyond their
immediate clinical practice area (Donald et al.
2011, Higgins et al. 2014);
Networking. Providing support for networking to
enable advanced nurse practitioners build up strate-
gic alliances within and external to the workplace
organisation, so that they can collaborate with
others to act as change agents and address key
issues in advancing practice (DiCenso & Bryant-
Lukosius 2010, Simmons 2010, Helen & Michelle
2012, Higgins et al. 2014);
Formal health careuniversity links. Establishing
formal links with universities for research can
increase the number of research applications by
advanced nurse practitioners and success rates in
research funding. The clinical research function of
advanced nurse practitioners can add value through
supporting evidence-based practice, and disseminat-
ing best practice and innovation (Mullen & Gavin-
Daley 2010);
Administration/clerical/information technology sup-
port. Resourcing the advanced nurse practitioners
clinical work by providing clerical/administration/
information technology support in order to free-up
time for leadership, practice development and
research activities (Guest et al. 2004, Donald et al.
2011, Gerrish et al. 2012, Hourahane et al. 2012).
Conclusion
Building leadership capacity requires a long-term
strategic approach and a sustained commitment from
the organisation in the form of providing appropriate
79
Commentary
support systems and resources. Given that advanced
nurse practitioners are ideally positioned within
health care organisations to act as clinical and pro-
fessional leaders, the organisations strategic plan for
building leadership capacity should include them as
part of a targeted leadership development initiative.
From the available research evidence, the support
structures and mechanisms that health care organisa-
tions can put in place to build leadership capacity in
advanced nurse practitioners and to enable them to
fulfil their potential as leaders include having: a
defined leadership role, director-level accountability,
leadership mentoring, membership of strategic com-
mittees, networking, formal health careuniversity
links, and administration/clerical/ information tech-
nology support.
Implications for nursing management
Executive-level nurses have a vital role in influencing
the organisations strategic plans, identifying key pri-
orities and forward planning so that the organisation
will be able to respond to future changes in health
care delivery. Nurse executives are ideally positioned
to make a business case for including leadership
capacity building as a priority and focusing on the
advanced practitioner-level nurse for targeted leader-
ship development initiatives. The value of having this
as a named priority in the strategic plan is that
through the governance structures, the organisation is
held accountable for implementing leadership capacity
building and for making progress reports on leader-
ship development targets as part of the organisations
annual reports. The challenge for nurse executives
involves strategic decision-making regarding whether
the advanced nurse practitioners role is limited to ser-
vice delivery or whether its potential as a force
majeure in leading health care reforms can be
realised.
Source of funding
No funding was received for this study.
Ethical approval
Ethical approval was not required for this paper.
NAOMI ELLIOTT P h D , R G N , R N T
Associate Professor, School of Nursing and Midwifery,
Trinity College Dublin, The University of Dublin, Dublin,
Ireland
80
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