Keywords

1 Introduction

Leadership competency frameworks for professional nursing practice offer a way to make the vision for nursing concrete and visible for practicing nurses. Competency frameworks specify the expected competence levels of novice nurses and advanced beginners, competent and proficient level nurses and nurses practicing on advanced practice level. The professional competence profiles of healthcare practitioners are changing constantly. Therefore, healthcare leaders lead the redesign of personnel’s work roles on organizational level. This is imperative in order to face the challenges of society in an appropriate manner.

2 Competence Framework for Professional Nursing Practice

Development of a competency framework for professional nursing practice to promote nurses’ career advancement started in Finland at Helsinki University Hospital in the 1990s (Fig. 9.1). Some international development projects in this field were reported at that time, mostly from the United States. This framework includes competency descriptions for registered nurses, licensed practical nurses, laboratory nurses, radiography nurses and physiotherapists. The five competency levels are based on Patricia Benners’ theoretical model [1, 2]. Selected publications from 1995 to 2018 related to the development of competence framework are reported in detail in the Appendix. Professional nursing practice competence infrastructure consists of interventions for developing knowledge, skills, attitudes and values in professional nursing practice to promote the quality and efficacy of patient care. It offers a practical tool for nurse leaders and supervisors to develop professional practice in a systematic manner. Leaders encourage and support the development of skilled nursing professionals. This framework enables nurses, supervisors and leaders to reflect on professional practices and develop them further. Self, supervisor, manager and peer evaluations are based on professional competency descriptions. Manager reviews are conducted on a yearly basis. These reviews are based on the evaluation of nurses’ actual competence levels, which are further reflected to optimal competence profiles defined for specific clinical settings [3]. This information is used in planning in-hospital educational interventions, career planning and when recruiting new personnel.

Fig. 9.1
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The nursing staff professional career model ©HUS [1]

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A transformative leadership culture is fundamental in order to systematically assess and vitally develop nursing competencies in changing environments. That enables continuous professional development and the use of nurses’ full competency potential to provide high-quality, safe and effective patient care. Nurse leaders need valid information on nurses’ competence profiles in clinical settings. Systematic competence assessments provide evidence for nurse leaders on when to implement training and mentoring interventions and how to create organizational culture and conditions to motivate nurses to increase their clinical expertise.

3 The Nurse Competence Scale

The generic Nurse Competence Scale (NCS) [4] was designed for the purposes of systematic competence management in nursing. Instrument formulation was conducted to overcome the shortcomings of competence instruments [5,6,7,8]. Generic instruments allow comparisons between clinical settings. Other generic instruments are the Competency Inventory for Registered Nurses [9], the European Questionnaire Tool [10,11,12] and the Holistic Nursing Competence Scale [13].

Indicators for competent nursing practice were defined by experts in clinical nursing and management when we started to develop the professional practice framework in Helsinki University Hospital [14]. Instrument development, testing and usage have been reported in scientific and professional journals (Appendix). The NCS measures nurses’ generic competence defined as functional adequacy and capacity to integrate knowledge, skills, attitudes and values in specific contextual situations [15]. The theoretical framework of the 73-item NCS is based on Benner’s [2] From Novice to Expert framework [16] and its seven theoretical categories: helping role, teaching-coaching, diagnostic functions, managing situations, therapeutic interventions, ensuring quality and work role competencies. Two assessment scales are used. The level of competence is measured with a visual analogue scale (VAS, 0 = very low, 100 = very high). The relevance of the competences across settings is measured by the frequency of use: 0 = ‘not applicable in my work’; 1 = ‘used very seldom’; 2 = ‘used occasionally’; and 3 = ‘used very often in my work’.

The NCS is currently the most widely used generic instrument to measure registered nurses’ competence in different settings and career phases. We reviewed 20 studies from Europe and 10 from outside Europe from 2004 to 2015 [16]. These replicative or intervention studies were reported in 43 publications and consisted of more than 11,000 competence assessments (from nurse students to very experienced nurses), mainly in hospital settings. The length of work experience, age, higher education, permanent employment and participation in educational programmes correlated positively with competence. Leadership variables like encouraging nurses’ empowerment and professional commitment, good practice working environment and good quality of patient care are associated with higher competence [16].

4 Leadership Interventions for Nurses’ Professional Development

4.1 Novice Nurses and Advanced Beginners

Clinical skills, critical thinking, effective communication skills and overall readiness for practice are essential prerequisites for novice nurses at the beginning of their career. They are often expected to be job-ready, competent in evidence-based care, independent, accountable and responsible for their own actions [17]. In reviewed articles, internship and residency programmes, mentorship and preceptorship and simulation-based programmes have been seen as vehicles to increase novice nurses’ perceived competence. Internship and residency programmes and orientation programmes increase their knowledge, confidence and job satisfaction and decrease perceived stress. The effects of these programmes on novice nurses’ retention rates are conclusive. However, there is no evidence to indicate which programmes are more effective than others [18, 19].

During the stressful transition phase, orientation models, mentor and peer support opportunities make a difference in novice nurses’ experiences of nursing profession. Mentors can be seen as stress reducers; they provide support and guidance to novice nurses, while peer support gives them opportunities to reflect on their own emotions during the orientation process [20]. A longer orientation period increases their professional satisfaction and enhances their ability to relate to their patients, other professionals, their support system and their jobs. A communal commitment to the orientation process, strong professional orientation know-how and supportive leadership are the elements of a successful orientation period. With these elements we can ensure a supportive transition to clinical practice for newly graduated nurses and give them opportunities to develop their professional competence [21]. Novice nurses are encouraged and given support to become skilled professionals. The first two levels of the competence framework concentrate on novice nurses and advanced beginners (Fig. 9.2).

Fig. 9.2
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Leadership elements for professional nursing practice

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The transition phase from novice nurses to competent professionals is supported by an intensive orientation period including organizational orientation programmes and clinical specialty orientation programmes at unit level as well as mentoring programmes. The orientation period lasts from 1 week to up to 6 weeks, depending on the clinical setting. The orientation period focuses on clinical skills and mentoring on professional development by improving nurses’ critical thinking skills and decision-making skills. During the first year of practice, nurses have an opportunity to take part in unit-level clinical mentoring programmes. Mentors provide support and guidance to novice nurses, and peer support gives them an opportunity to reflect on their own emotions during the transition phase. Mentoring may last from several months to up to 1 year depending on nurses’ clinical background, professional needs and clinical settings.

During the second year of practice, advanced beginner nurses gain special support and guidance on professional development by attending advanced orientation programmes. These nurses are already experienced in multiple nursing tasks. They already show clinical competence and have mastered skills related to guidance of novice nurses and students. To further improve their professional competence and to recognize a more holistic approach to patient care, the hospital provides advanced orientation programmes on intensive care nursing, general nursing and psychiatric nursing. These programmes comprise training modules, which include self-learning tasks, simulation cases, lectures and teamwork rehearsals, and they are carried out within 1 year. The aim of these advanced orientation programmes is to deepen nurses’ knowledge on evidence-based nursing practice, clinical and ethical decision-making skills and skills in guiding patients and students. Advanced beginner nurses are given support to reach competent level within two or 3 years, and they are expected to maintain this level during their working career. This requires nurses to continuously update their professional competences and take part in further education.

4.2 Competent Professional Practice

A competence framework creates opportunities to broaden job roles and to increase expertise. A nurse practicing at competent level should be able to master tasks related to their specialty area and have the knowledge, skills and evidence-based knowledge to perform daily nursing practices capably in changing clinical situations. Nursing practice on competent level should be theoretically well-grounded and autonomously well-planned and carried out. Competent nurses are encouraged to commit to the strategic goals and values of the organization. They share their professional expertise as part of a multi-professional team, are committed to continuous reflection and improvement of their own professional competence, are motivated to guide and to support co-workers and students and improve the processes of patient care.

During the third year of practice, competent level nurses participate in charge nurse training programmes. Charge nurse is a new work role for competent level nurses. Charge nurses practice as front-line team leaders. They have a central role in patient outcomes and safety, the well-being of nursing staff, liability prevention and managing a multidisciplinary team [22, 23]. Charge nurses are expected to quickly manage changing situations, understand broader viewpoints to organize daily work and support clinical nurses. Frequent decision-making situations, regular interruptions and high expectations of constant availability and assistance make it one of the most stressful roles in nursing [24]. In order to prepare charge nurses to cope with these stressful situations, leadership training and ongoing mentorship should be provided. Investment in front-line leadership education will benefit patients, staff teams, the organization and the profession [25].

In-hospital training programmes support clinically competent nurses to take over the daily leadership roles assigned by the hospital (see Fig. 9.2). Investment in the charge nurses’ training programmes brings benefits to the hospital in terms of nurse empowerment and the acquisition of leadership skills. This charge nurses’ training programme started in 2013. Clinical nurse specialists are in charge of the programme. The first module focuses on charge nurses’ work role competencies, employees’ occupational health and safety, the organization’s privacy policies and risk management. The second module concentrates more on daily leadership skills and managing challenging situations, offers vehicles to implement evidence-based nursing practice and improves critical thinking skills and the skills needed in daily leadership practices.

4.3 Proficient Nurses, Experts in Evidence-Based Nursing

Progression to a proficient nurse is based on individual nurse’s professional goals, motivation and the needs of the organization, and it requires additional specialist training (see Fig. 9.2). According to the ICN definition, ‘a nurse specialist is a nurse prepared beyond the level of a nurse generalist and authorized to practice as a specialist with advanced expertise in a branch of the nursing field’ [26]. Competent level nurses can apply for 2-year in-service specialization on proficient level. Proficient nurses have broad professional competence that is based on theoretical knowledge and research competencies, additional professional training and clinical experience. Proficient nurses are capable of developing the processes of nursing care based on research evidence and are able to unify nursing practices. They adapt evidence-based knowledge into practice in their own specialist field. Proficient nurses keep their knowledge updated on evidence-based nursing practice in their clinical practice settings. They work as consultants within and outside of their own unit according to their area of responsibility.

According to the Finnish Healthcare Act, nurses are expected to build decisions upon scientific evidence [27]. Special competencies for the implementation of evidence-based practices offer nurse methods to use critically appraised and scientifically proven evidence for delivering quality healthcare to a specific population [28]. Proficient nurse training programme offers experienced nurse opportunities to broaden their job roles and to increase their expertise, particularly in developing evidence-based nursing practices. The first proficient nurse training programme started in 2009. Since then, several clinical specialty programmes have been offered to nurses: intensive care, perioperative care, medical-surgical, neonatology and oncology nursing. Currently this in-hospital training programme lasts 2 years and consists of theoretical training, an evidence-based nursing online course, practical training and evidence-based practice development project. The trainees are all very experienced clinical nurses, and they are required to have interest in self-development and self-management. After the completion of the training programme, nurse leaders and clinical nurse specialist tailor a new role for proficient nurses to increase evidence-based nursing practices in the hospital. Proficient nurse training programmes are designed and carried out by clinical nurse specialists. Currently we have 400 proficient nurses in Helsinki University Hospital, and a strategic goal is that, by 2025, 20% of nurses will reach the proficient level of nursing. An example of the outcomes of the surgical proficient nurse training to nurses’ competence level is described in Fig. 9.3. The proficient training courses are spreading nationwide; the first national proficient neonatal nurse training started at university hospitals in 2014.

Fig. 9.3
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Competence outcomes from the surgical proficient nurse training programme utilizing the NCS instrument (VAS 0–100)

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5 Advanced Practice Nursing and Academic Partnership

Advanced practice nursing roles have recently been implemented in many countries worldwide, and each country has its own idiosyncrasies to best fit individual contexts [29]. Advanced practice nursing roles such as clinical nurse specialist and clinical nurse consultant have evolved globally in a variety of specialty clinical areas. ICN [26] defines an NP/APN ‘…a registered nurse who has acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/or country in which s/he is credentialed to practice. A Master’s degree is recommended for entry level’. In Finland, clinical nurse specialists are registered nurses with a Master’s degree in nursing. The first five clinical nurse specialists began to practice in Helsinki University Hospital in 2000 [30], and now, in 2018, we have a total of 25 CNS (Fig. 9.2). In 2006, CNS colleagues started to practice at Turku University Hospital. At the moment 86 clinical nurse specialists are working in Finnish hospital districts (30.5.2018), and the number of these positions is increasing every year. Although the titles are not yet regulated, work is currently ongoing in realizing regulation in Finland [31]. A national CNS network, set up in 2007, organizes annual symposia to share best practices and to support the professional development of clinical nurse specialists in Finland [32]. The global ICN/APNN network is also vitally important for Finnish clinical nurse specialists to exchange and share information in Finland and in ICN/APPN network.

In 2009, the Finnish Ministry of Social Affairs and Health published the first national model entitled to define the different expert roles of nurses in implementing evidence-based practices: nurses in clinical care, specialized nurses in clinical care, clinical nurse specialists and specialists in clinical nursing science [33]. In 2016, the Finnish Nurses Association set up a task force to support the development of advanced practice nursing nationally. This model includes three competence levels: registered nurse, specialized nurse and advanced practice nurse. It is useful in assisting the mutual acknowledgement and implementation of these roles. The goal of this work is to ensure high-quality, evidence-based nursing. In the future, knowledge management will be facilitated by information management, intelligence and robotic utilization, which sets new demands for competencies [31]. In the future, the advanced practice nursing roles will become even more recognized as an important and growing trend among healthcare systems worldwide [34,35,36]. In order to support Finnish nurse leaders to create these new advanced nursing positions and to evaluate the outcomes of this investment, we formulated a practical competency framework for clinical nurse specialists in Helsinki University Hospital. This framework defines four strategic competency categories: clinical practice, leading change, staff competence and evidence-based practices. These competencies were further tested with Finnish clinical nurse specialists [37]. Clinical nurse specialists play an important role in competence management, and their impact to evidence-based nursing practices is evident.

6 Conclusions

Nurses’ professional inspiration and career opportunities are related to the quality and efficacy of patient care. Innovative practices and rethinking are needed to improve competence management in healthcare. Nurses’ full competency potential should be implemented in clinical patient care. A fundamental starting point for leaders in nursing is to define and put to practice the most relevant competencies to meet the organizational strategy targets. Systematic competence assessments create evidence on when to implement programmes for professional development and how to create organizational culture to increase the expertise in nursing. Special support and training during the first 2 years can make a difference in nurses’ transition experiences. A communal commitment to the orientation process, strong professional orientation know-how and supportive leadership are the elements of a successful orientation period. Investment in the charge nurse training brings benefits in terms of empowerment and the acquisition of associated leadership skills.

Development of nurses’ professional competence builds on continuous evaluation of current practices. The changes in society create new challenges for proficiency and for advanced practice nursing. There is a pressing need for competency frameworks for nurse leaders to guide the development of professional nursing practice. Comprehensive strategies for building evidence-based practice implementation competencies through special post-graduate training are needed. Proficient nurses are experts in developing quality patient care. In implementation of academic evidence-based nursing practices, the role of the clinical nurse specialists, together with nurse leaders, is fundamental.