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Management and leadership Management

and leadership
competence in hospitals: a competence
systematic literature review
Vuokko Pihlainen 95
Central Finland Health Care District, Jyväskylä, Finland
Received 6 November 2014
Tuula Kivinen Revised 23 March 2015
9 June 2015
Department of Health and Social Management, Accepted 24 August 2015
Central Finland Health Care District, Leppävesi, Finland, and
Johanna Lammintakanen
Department of Health and Social Management,
University of Eastern Finland, Kuopio, Finland

Abstract
Purpose – The purpose of this study is to describe the characteristics of management and leadership
competence of health-care leaders and managers, especially in the hospital environment. Health-care
leaders and managers in this study were both nursing and physician managers. Competence was
assessed by evaluating the knowledge, skills, attitudes and abilities that enable management and
leadership tasks.
Design/methodology/approach – A systematic literature review was performed to find articles that
identify and describe the characteristics of management and leadership competence. Searches of
electronic databases were conducted using set criteria for article selection. Altogether, 13 papers
underwent an inductive content analysis.
Findings – The characteristics of management and leadership competence were categorized into the
following groups: health-care-context-related, operational and general.
Research limitations/implications – One limitation of the study is that only 13 articles were found
in the literature regarding the characteristics of management and leadership competence. However, the
search terms were relevant, and the search process was endorsed by an information specialist. The
study findings imply the need to shift away from the individual approach to leadership and
management competence. Management and leadership need to be assessed more frequently from a
holistic perspective, and not merely on the basis of position in the organizational hierarchy or of
profession in health care.
Originality/value – The authors’ evaluation of the characteristics of management and leadership
competence without a concentrated profession-based approach is original.
Keywords Health care, Health leadership competencies, Leadership, Hospitals, Management,
Literature review
Paper type Literature review

Introduction
The requirements for, and contents of, health-care management and leadership Leadership in Health Services
competence are constantly changing due to several contemporary and future challenges. Vol. 29 No. 1, 2016
pp. 95-110
Examples of factors promoting the need for competence development in management © Emerald Group Publishing Limited
1751-1879
and leadership include: transition and reform in the delivery of services by health-care DOI 10.1108/LHS-11-2014-0072
LHS organizations, increasing demands for performance improvement and performance
29,1 profile comparisons, changed expectations of patients and, in the European Union, the
issues of health-care integration and cross-border care (Wismar et al., 2011; Busari, 2012;
Tchouaket et al., 2012). Additionally, the expectations of a new generation of employees
differ from older generations’ expectations, and therefore, the future workforce requires
a novel managerial approach (Stanley, 2010; Piper, 2012; Coulter and Faulkner, 2014).
96 The aim of this study is to describe the characteristics of management and leadership
competence in health-care leaders and managers, especially in a hospital setting, from a
holistic perspective. Health-care leaders and managers included both nursing and
physician managers. Therefore, this paper focuses on a competence-based approach of
managers and leaders instead of merely the profession-centered viewpoint, even though
the profession-centered approach is dominant in previous studies.
Management and leadership competence in this study signifies knowledge, skills,
abilities and attitudes that are necessary for managerial levels and tasks in hospitals or
clinical settings. The definition of competence has become complex, and scientists have
not yet arrived at a general consensus. Various definitions of competence have formed in
several disciplines, and in health care, the definitions have arisen from a professional
perspective. Furthermore, one approach to competence in the literature is context
dependent, and related definitions of competence include personal capabilities to use
and link knowledge, skills and attitudes to develop performance in a particular context
(Laibhen-Parkes, 2014). Usually, to be deemed competent, a person must demonstrate a
master set of skills; however, scholars have not reached an agreement on this definition
(Thistlethtwaite et al., 2014). Knowledge and skills are overtly and indisputably stated
as inherent components, while abilities and other attributes are merely implied. In sum,
attitudes, abilities, values, judgment and personal or character attributes are considered
characteristics of competence. Additionally, two divergent conceptions about the
utilized components of competence by a competent person were found. One conception
focuses on selected, individual components of competence in a specific situation. The
second describes a synergistic combination of the components in a given situation
(Fernandez et al., 2012). One definition of competence concentrates on the interaction
between the person working and abilities actually applied while at work, but this varies
because of the possibilities and limitations of the work environment (Ruohotie, 2006).
The recent need for management and leadership competence in health care and the
appeal of management and leadership as a career choice are contemporary challenges
(Ackerly et al., 2011; Enterkin et al., 2013; Yoder-Wise, 2014). Attempts to develop
health-care managers and leaders have been described as inadequate and contradictory
(McCallin and Frankson, 2010; Ackerly et al., 2011; Townsend et al., 2012). Management
and leadership exceed the scope of the physician’s role especially; thus, management
and leadership competence proves to be deficient (Dickinson et al., 2013; Kuhlmann and
von Knorring, 2014). In recent decades, studies have demonstrated numerous
approaches to and theories of management and leadership involving personal
characteristics, behaviors, styles, models, theories and functions. At present,
process-based management with the lean approach and competence-based management
are emphasized (Hasna, 2014; Tevameri, 2014). Supportiveness and functionality in the
work environment of health-care professionals can be achieved by effective clinical
leadership, but as a conception, it has no clear definition (Mannix et al., 2013).
 Typically, management and leadership roles in health care are profession-based; Management
physicians and nurses receive a different education, and they learn unique models of and leadership
leadership and management. Additionally, studies of management in hospitals or
clinical settings across the globe produce critical results, demonstrating inadequate
competence
management and leadership competence, which have been under discussion worldwide
(Pillay, 2008; McCallin and Frankson, 2010; Ackerly et al., 2011; Townsend et al., 2012).
Deeply institutionalized organizational routines, professionalism and growing 97
specialization within the boundaries of clinical departments are absolutely strong
cultural features in hospitals that affect management and managerial work (Fältholm
and Jansson, 2008). As a solution, organizational management and leadership trainee
programs and clinical supportive supervision have been implemented to promote the
management and leadership role. In challenging professions, managerial work requires
indispensable management skills. Also, clinical expertise needs to be strengthened by
management and leadership competence (McCallin and Frankson, 2010). Conflictingly,
the competence-based approach to leadership and management has not been
unconditionally accepted. Formal programs to develop management and leadership
competence have not been as remarkably influential as informal approaches used, for
instance, by mentors and coaches (Pillay, 2008; McCallin and Frankson, 2010; Straus
et al., 2013). Competence-based leadership development programs for clinicians have
been established in Europe, the USA and Canada (Jahrami et al., 2008; Ackerly et al.,
2011; Berkenbosch et al., 2013b), as exemplified by the Medical Leadership Competency
Framework (MLCF) and the Royal Australasian Medical Management Framework.
In sum, literature about the characteristics of management and leadership
competence in health care is surprisingly limited. So far, systematic reviews that
combine the views of professional groups in this field are scarce. In this paper, our
approach to management and leadership competence, in light of a modern
organizational theory, is to explore and discuss them from a holistic perspective.

Methods
We used systematic literature review to identify studies that described diverse types of
management and leadership competence in health care, particularly those carried out in
hospitals, during a certain time period. Data collection included searching and selecting
articles from relevant electronic databases, as comprehensively outlined by Fink (2005).
An information specialist was consulted about search terms and the process. After
careful consideration and some initial searches, the following electronic databases were
selected: Cinahl, PubMed, Cochrane, Scopus, Web of Science and Finnish Medic. The
search period spanned a decade (2003-2013) because during this period, literature
regarding the competence-based approach to management and leadership increased
dramatically. The past decade provided opportunities to compare the studies and
explore noticeable trends and trajectories regarding management and leadership
competence.
The search limits included reviews or research articles in English and Finnish with
titles related to the study topic. After evaluating studies with relevant titles and
abstracts (if they were previously available), the search outcome decreased from 1,451 to
253 papers. The studies remaining, which comprised empirical research, theoretical
models of the characteristics of competence or literature reviews, described diverse
characteristics of management and leadership competence in hospitals or clinical
LHS settings (see inclusion criteria in Figure 1). A more detailed examination of the abstracts
29,1 and full texts of these papers revealed those that offered a diverse range of descriptions
of knowledge, competence or skills needed in management. Criteria were set to exclude
editorials, evaluations or descriptions of management and leadership competence
education or developed models and papers with constricted perspectives of

98 Databases:
Search terms:
CINAHL (307) PubMed (303)
Leadership*, manage*, competence*, skill*,
Cochrane (22) Scopus (502) hospital, hospital administration
Web of Science (249) Medic (68)

1,451

Limits:
Period 2003-2013
Research article or Literature Review in Finnish or in English
Abstract available
Inclusion criterion that title and abstract pertain to research question or topic

253

Inclusion criteria: Based on abstract or on full text, Research or literature review,

Several characteristics of management competence or leadership
skills are described, Article is available

Exclusion criteria: Editorial article

Describes a certain characteristic of management competence or
leadership skill
Describes an education framework or an education model or
Evaluates an education model

74

After excluding duplicates and carefully reading articles, 13 papers were included in the systematic
literature review
Figure 1.
Process of data Databases in final search outcomes: Cinahl (6), PubMed (2), Scopus (2), Medic (1) and Web of Science
collection (2)
management competence. Because our focus was on the characteristics of management Management
and leadership competence and how to describe and identify them, studies concerning and leadership
models or evaluations were excluded if they lacked descriptions of diverse
characteristics of management and leadership competence. Replicating the search in
competence
each electronic database using combined search terms produced the same outcomes.
Figure 1 describes the search process used, along with inclusion and exclusion criteria,
and the outcomes after each stage. 99
The number of search outcomes was curtailed from 74 to 13 after thoroughly reading
the papers in full and eliminating duplicates. However, surprisingly, the fewer outcomes
were appraised carefully and the selected papers, from PubMed (two), Cinahl (six),
Scopus (two), Web of Science (two) and Medic (one), met the criteria precisely. Later
examination of the selected studies identified mainly surveys, four of which were
executed with the Delphi method, and one study design was a structured interview.
After the search process, the findings were accepted as focused and precise content for
the aim of this paper, with accompanying discussion. The papers included are presented
in chronological order in Table I.
The material was subjected to inductive content analysis to assess the data on the
diverse characteristics of management and leadership competence, especially in a
hospital context. During the first stage, competence and skills, identified as
characteristics from the studies, were classified into concepts using words that
described the data (Elo and Kyngäs, 2008). Many words and even short phrases, such as
“using financial information”, were used, and several similarities were found during
analysis. These words and clauses were organized into synonymous groups and, then,
further analyzed and regrouped into 13 separate sub-categories. Finally, the
sub-categories were assigned to three major categories relating to the characteristics of
management and leadership competence.

Findings
In this study, three main categories of leadership and management competence
emerged: health-care context-related, operational and general. Each category consisted
of sub-categories of related sections.

Health-care context-related management and leadership competence

The health- care context-related competence category was broken down into four
sub-categories: social, organizational, business and financial competence. Social
competence included knowledge and understanding of the laws, roles and different
functions of the political, social and legislative systems. The level of a manager or leader
in the organization, characterized by varying degrees of rigor and scope, determined
whether any of these systems formed part of managerial operations. Social competence
was observed mainly in European studies (Hennessy and Hicks, 2003; O=Neil et al., 2008;
Berkenbosch et al., 2013a). Additionally, Sinkkonen and Taskinen (2003) showed that
the health services quality and cost efficiency approach to investigating health policy
and health-care development proved a topical challenge in Finland.
Organizational competence and related skills are more obviously related to
management and leadership. This sub-category included managers’ organizational
tasks and work content. In the studies analyzed, competence was represented as
knowledge and understanding of organizational functions, relationships and
 29,1
LHS

100

Table I.

studies of

competence
management
Summary of previous
Authors Aim Design and respondent pool

1. Conelly et al. (2003) USA To identify charge nurse competencies Interviews Charge Nurses, Head Nurses, Staff Nurses,
Delphi Supervisory personnel
n ⫽ 42
2. Hennessy and Hicks (2003) UK To identify the most relevant characteristics considered necessary for Delphi 15 key experts in each of 22 European countries
working as a Chief Nurse to inform and systematize recruitment Round 1 n ⫽ 330
Round 2 n ⫽ 180
3. Kleinman (2003) USA To obtain perceptions of the roles, competencies and educational Survey questionnaire
foundation required from nurses in mid-level and senior nursing n ⫽ 35 Nurse Managers,
management roles n ⫽ 93 Nurse Executives
4. Sinkkonen and Taskinen (2003) To identify and figure out management competencies needed at Survey Nurse Managers in Primary and Secondary
Finland different management levels for developing nursing management and n ⫽ 604 Health Care
management education
5. Sherman et al. (2007) USA To explore the contemporary nurse manager role and to gain A structured face-to-face interview Nurse Managers
perspective on the critical leadership skills and competencies required n ⫽ 120
to build a nursing leadership model
6. O=Neil et al. (2008) USA To ensure that assets are used in the most effective manner and Two types of data: Chief nursing leaders in three broad settings:
required skills and expectations to lead are used A telephone survey Hospitals (n ⫽ 20),
n ⫽ 27; Education (n ⫽ 16),
A paper survey Public health (n ⫽ 18)
n ⫽ 54
7. Palarca et al. (2008) USA To forecast relevant competencies and important skills, knowledge Delphi ⫺ Senior Navy Nurses holding the rank of Captain
and abilities for Navy Nurse Executives in the next five to ten years 2 iterations: 0-6
An electronic questionnaire
n ⫽ 38
Questionnaire via email n ⫽ 93
8. Furukawa and Cunha (2011) To characterize the profile of nurse managers at accredited hospitals, Questionnaire Nurse Managers,
Brazil identify strategies used to select these professionals and compare the n ⫽ 24 (13 ⫹ 11) Directors
opinions of nurse managers and those hierarchically above them
relative to the competencies of these nurse managers as viewed by
their superiors
9. Kang et al. (2012) Taiwan To assess the level of and the differences in managerial competencies, Cross-sectional survey, self-administered Head Nurses,
to determine the best predictors of managerial competencies for NAS questionnaire supervisors,
n ⫽ 330 Deputy Directors,
Directors of Nursing in 16 acute hospitals
10. Lorber and Savič (2011) Slovenia To compare nursing leaders and employees’ perceptions of leadership Structured questionnaire survey Employees in Nursing,
style, personality characteristics and managerial competencies and to n ⫽ 509 Nursing Leaders
determine the associations between these factors
(continued)
Authors Aim Design and respondent pool

11. Citaku et al. (2012) Australia, To identify and empirically investigate the dimensions of leadership Questionnaire via email survey Educators,
Canada, Germany, Switzerland, UK in medical education and health-care professions n ⫽ 229 Physicians,
and USA Nurses,
Other health professionals with academic
positions
12. Berkenbosch et al. (2013a) To investigate how medical specialists perceive the managerial Questionnaire via email survey Medical specialists
Netherlands competencies of medical residents and their need for management n ⫽ 129
education
13. Hazelbaker (2013) USA To begin to explore the knowledge, skills and abilities needed in the Directed surveys, Delphi Athletic Trainers working as Hospital or Health
emerging practice settings of health-care management n⫽8 care Managers

Table I.
101
competence
and leadership
Management
LHS decision-making systems (Connelly et al., 2003; Kleinman, 2003; Sinkkonen and
29,1 Taskinen, 2003; Hazelbaker, 2013). Business competence, a notable sub-category,
included knowledge, understanding and practice of business skills in clinical and
cultural contexts as well as different types of processes, such as changes, services,
development, resources and planning (Kang et al., 2012; Hazelbaker, 2013). Some studies
demonstrated an awareness of health care as a business or industry, and in a wider
102 context than finance, including development of services and resources, productivity and
effectiveness (O=Neil et al., 2008; Berkenbosch et al., 2013a). Financial competence
included knowledge and understanding of, and skills related to, financial, marketing
and budgeting issues and the ability to manage them successfully; these components
emerged from several studies (Connelly et al., 2003; Kleinman, 2003; Sinkkonen and
Taskinen, 2003; Sherman et al., 2007; O=Neil et al., 2008; Palarca et al., 2008). Financial
competence was considered essential for nurse managers’ work (Sherman et al., 2007).

Operational management and leadership competence

The second category, operational competence, encompassed the following sub-
categories: process, operation, clinical and development competence. Process competence
comprised items such as improvements in quality and service processes and
management of and focus on patients (Connelly et al., 2003; O=Neil et al., 2008; Furukawa
and Cunha, 2011, Lorber and Savič 2011; Berkenbosch et al., 2013a).
Operation competence included the ability to manage a ward using clinical skills
(Berkenbosch et al., 2013a). The importance of thoroughly knowing and understanding
operations and available resources, executive tasks and abilities to delegate were
constituent attributes of this sub-category (Furukawa and Cunha, 2011; Lorber and
Saviè, 2011). Leadership skills (Hennessy and Hicks, 2003; Furukawa and Cunha, 2011;
Kang et al., 2012; Berkenbosch et al., 2013a; Hazelbaker, 2013) and operational
management abilities, such as resource allocation (Berkenbosch et al., 2013a), were also
included in this sub-category.
Clinical competence included the knowledge and skills of professional and clinical
operations issues and professional credibility (Connelly et al., 2003; Hennessy and Hicks,
2003; Sherman et al., 2007), specialists’ requirements and current medical knowledge
(Berkenbosch et al. 2013a). Professional ethics and learning from mistakes and failures
were also included (Sherman et al., 2007; Berkenbosch et al., 2013a).
Development competence encompassed staff development and improvement abilities
in work. It involved the ability to obtain and use information (Connelly et al., 2003;
Sinkkonen and Taskinen, 2003; Palarca et al., 2008; Furukawa and Cunha, 2011; Citaku
et al., 2012). A proactive approach to unit, clinical and organizational changes and
impacts was also included (Sherman et al., 2007; O=Neil et al., 2008; Palarca et al., 2008).

General management and leadership competence

The third category, general management and leadership competence, was common to all
the health-care professionals, and included the following sub-categories: time
management, interpersonal skills, strategic mindset, thinking and application skills and
human resource management. Time management involved scheduling ability and skills
in managing both time and tasks (Sinkkonen and Taskinen, 2003; O=Neil et al., 2008;
Kang et al., 2012; Hazelbaker, 2013). Interpersonal skills were strongly linked to
management and leadership, and included communication and the building and
maintenance of interpersonal relationships. These were described mainly as Management
management and leadership competence in all studies, but descriptions varied and and leadership
consisted of elements such as: teamwork skills, decency, integrity, inter-personal skills,
relationship building, relating to people and development of collaborative relationships
competence
within the organization. In nine papers, communication skills were described with
diverse attributes like: communication, conformation to the flow of information,
networking, written and oral fluency and clarity and active listening to and facilitation 103
of discussion (Connelly et al., 2003; Hennessy and Hicks, 2003; Sinkkonen and Taskinen,
2003; Sherman et al., 2007; Palarca et al., 2008; Furukawa and Cunha, 2011; Lorber and
Saviè, 2011; Citaku et al., 2012; Kang et al., 2012). Additionally, O=Neil et al. (2008) listed
communication skills in conjunction with strategy, vision and mission.
Strategic mindset entailed notable competence in strategic thinking, strategic process
and vision and strategy development. The word “strategic” was combined with
“thinking”, “planning”, “task management”, “view”, “goals”, “vision” and “mission”,
and in a few papers, neither “strategy” nor “strategic” were observed (Sinkkonen and
Taskinen, 2003; Connelly et al., 2003; Kang et al., 2012; Berkenbosch et al., 2013a;
Hazelbaker, 2013). The strategic mindset sub-category also highlighted the level at
which the manager operated, which varied from motivating staff to accomplishing the
mission and strategic planning. Analytical thinking, achievement orientation and
ability to communicate strategy, vision and mission were all included in the strategic
mindset sub-category (Hennessy and Hicks, 2003; Kleinman, 2003; Sherman et al., 2007;
O=Neil et al., 2008; Palarca et al., 2008; Furukawa and Cunha, 2011; Lorber and Savič,
2011; Citaku et al., 2012).
Thinking and application competence contained abilities to think critically, prioritize,
multi-task and use information in decision-making and problem-solving. Abilities to
receive and present constructive feedback and skills in conflict resolution were also
described in studies, and were sub-categorized in the general competence of
management and leadership category. Personal development skills, such as
self-awareness, strategic focus, upheld integrity and personal mastery, were also
mentioned in papers (Hennessy and Hicks, 2003; Sinkkonen and Taskinen, 2003;
Sherman et al., 2007; O=Neil et al., 2008; Citaku et al., 2012; Kang et al., 2012; Hazelbaker,
2013).
Human resource management (HRM) involved the development and management of
human resources and mastery of personnel. HRM was usually described as one of the
main aspects of management and leadership competence, and was most often
demonstrated in nursing management studies (Sinkkonen and Taskinen, 2003;
Kleinman, 2003; Sherman et al., 2007; Palarca et al., 2008; Lorber and Savič, 2011; Kang
et al., 2012).

Discussion
The objective of this study was to describe the characteristics of management and
leadership competence as seen in health-care leaders and managers, especially in
hospital environments. The approach included contemplation of the perspectives of
several health-care professions as well as health management science. For this study,
competence included knowledge, skills, attitudes and abilities that enable management
and leadership tasks. The literature review was limited to the years 2003-2013 when
competence-based research approaches became more frequent in management and
LHS leadership contexts. This period provided opportunities to compare the studies and to
29,1 explore noticeable trends and trajectories for management and leadership competence
in health care.
We used inductive content analysis to gather data from 13 papers that were selected
using systematic literature review. Based on our findings, competence could be broken
down into three main categories: health-care context-related, operational and general
104 competence. Knowledge was the most frequently described characteristic, but skill,
ability and attitudes were also depicted, albeit not as clearly.
Managerial roles requiring health-care context-related competence comprised social,
organizational and financial dimensions. Health-care reforms have been implemented in
several countries. Because of the restructuring of public services, many European
countries have adopted market-like mechanisms and managerial models and techniques
from the private sector. This new managerialism, which enhances innovation,
creativity, competencies and staff participation in strategic issues, has made knowledge
of rules or bureaucratic procedures less relevant (Byrkjeflot and Jespersen, 2014).
Additionally, contemporary integration objectives (Wismar et al., 2011) and trends to
reorganize hospitals as process-based structures are challenging the traditional course
of action (Tevameri, 2014). In sum, managerial roles and the development of
management and leadership competence have been under discussion in many countries
with divergent health-care systems and funding.
Within the category of operational competence, process, operation, clinical and
development competence proved important for the managerial role, based on analysis of
different functions described in the selected literature. However, a common
unsatisfactory experience of new nurse managers has been an appointment to the
management role without possession of adequate skills (Townsend et al., 2012). Similar
to this, the majority of medical residents in The Netherlands, Denmark, Canada and
Australia needed training to develop management competence (Berkenbosch et al.,
2013b). According to one nursing science study, systematically observed strategies for
enhancing nursing management and leadership competence are lacking (Kleinman,
2004). Seven years later, as Kantanen et al. (2011) have shown, the situation remains
unchanged. However, the challenges proved similar when both medical and nursing
studies were observed. For example, managerial positions and roles were described
quite differently from clinical roles, and the need for knowledge, skills and attitudes was
identified (Ackerly et al., 2011; Townsend et al., 2012).
General management and leadership competence, which comprised time
management, inter-personal skills, strategic mindset, thinking and application skills
and human resource management, was notable and common to all the studies. Findings
about industry-specific, technical and general types of competencies also fell into this
category (Aitken and von Treuer, 2014). Because tasks and responsibilities vary by level
within the organization, the need for and application of competence also vary for
different managers (McGurk, 2010). At all organizational levels, managers require
leadership skills to motivate employees and inform them of objectives. Development
programs pertaining to managerial levels and organizational strategy are shown to
increase the impact of management and leadership (McGurk, 2010). Perspectives on
leadership and management education and development in the most recent studies
analyzed centered on profession-based and individual approaches (Furukawa and
Cunha, 2011; Lorber and Savič, 2011; Citaku et al., 2012; Kang et al., 2012; Berkenbosch Management
et al., 2013a; Hazelbaker, 2013). and leadership
Boundaries between professions have been a strong cultural feature primarily found
in hospitals and clinical settings (Fältholm and Jansson, 2008). Additionally, boundaries
competence
were observed between medical specialties in Sweden during the implementation of
process orientation. One visible effect of boundaries is that it has been more difficult to
change professional cultures than to transform management structures (Ackroyd et al., 105
2007). As a signal of changing convention, hospital reforms in Norway have
increasingly aimed to create stronger management positions with less professional
influence, and the managerial role has become more of the focus (Nordstrand Berg,
2014). Evidently, the tradition of the medical profession has not involved support for
physicians related to management and leadership competence (Clark and Armit, 2008).
Physicians value their professional work more so than management, but the perceptions
of management as a temporary appointment or a career trap decreased after hospital
reform in Norway (Nordstrand Berg, 2014).
The trajectory of the competence-based approach to management and leadership has
become noticeable. Our findings from the period we examined demonstrate that in the
beginning, the objective of published studies was to identify the characteristics of
management and leadership competence, characteristics and different roles needed in
nursing managerial positions (Connelly et al., 2003; Hennessy and Hicks, 2003;
Sinkkonen and Taskinen, 2003; Kleinman, 2003). Although the study perspectives
varied, the objective was common to them all. In Finland, particularly, the managerial
involvement of the physician and his or her need for training in managerial skills were
apparent (Kumpusalo et al., 2003). In studies published during 2007 and 2008, the aim
was to improve the identified characteristics of management and leadership competence
by education and training, and to construct a leadership model (Sherman et al., 2007).
Moreover, these studies sought to forecast relevant characteristics of management and
leadership competence and important skills, knowledge and abilities (Palarca et al.,
2008); additionally, the interest in improving management and leadership competence
widened, especially in medicine. With the exception of systematized management and
leadership education and training, measurement and evaluation of competence also
occurred in the research field (Jennings et al., 2007; Calhoun, 2008; Ackerly et al., 2011).
Management research extended to health sciences (Citaku et al., 2012; Hazelbaker, 2013),
and particularly in medicine, the need for management education has been recognized
(Ackerly et al., 2011; Berkenbosch et al., 2013a).
Nowadays, the development of management and leadership competence by formal
education is prevalent. However, according to Mintzberg (2004), manager development
occurs abundantly through experience and practice, which denotes learning by
performing managerial work. The successful managerial role requires change in
mindset and attitudes toward skill and knowledge advancement by informal modes. In
line with this, informal learning is achieved collectively, with mentors, peers or coaches,
and is a method for building the organizational capacity and managerial strategies of an
organization (McGurk, 2010) or promoting interactive and problem-based didactics
(Taylor et al., 2008). Development, support and training provided to leadership and
management roles confirm physicians’ abilities to perform managerial work (Dickinson
et al., 2013; Straus et al., 2013). In response to a need in the USA and other countries,
developed models were published that aimed to concurrently improve the abilities of
LHS health-care leaders and managers at different levels while they work (Batcheller, 2011)
29,1 or to include studies as pathways to clinical management and leadership (Ackerly et al.,
2011). Systematic production of the best organized leaders and managers is necessary
for the future of health care, and requires a plan for achievement (Yoder-Wise, 2014).
From organizational and strategic perspectives, the more important question is
management and its systematic processes and flexibility, not which profession holds the
106 management position.
Several factors restrict holistic approaches to developing management and
leadership competence in health care. Instead of representing managerial work as a task
list or profession-based question, a shared strategic mindset in management and
leadership at all organizational levels enables managers and leaders to observe
management and leadership in health management science from a holistic perspective.
Developing a framework for learning in which managers and leaders can work in the
organization with adequate support and opportunities to reflect and to evaluate success
in their role is a globally shared challenge for health care in the future. Recently, Straus
et al. (2013) studied the impact of leadership training programs for medical centers; they
found modest effects and identified the need for rigorous evaluation of these programs.
Essential points to consider include unifying the individual and organizational
approaches to developing leadership and management competence, and improving
managerial effectiveness in line with the strategies of the organization.
The study design and the methods were carried out rigorously, but the majority of all
papers described diverse characteristics of required competence in nurse managers and
leaders, reflecting the fact that a larger body of research on management and leadership
exists for nursing than for medicine. From the physician managers’ and leaders’
perspective, the required characteristics of management and leadership competence are
similar, but a few papers were found that corroborated this perspective, suggesting a
need for further study.

Conclusions
As implied above, the individual approach to leadership and management competence,
as well as to organizational and strategic styles, requires an integrated, unified
perspective of management that was deficient in the studies analyzed. Furthermore, the
majority of the analyzed studies described diverse characteristics of required
competence in nurse managers and leaders. Nevertheless, the management and
leadership competence required from physician managers are similar, but studies
integrating both nursing and physician managers’ perspectives were not found,
suggesting a need for further studies from a health management sciences approach.
Therefore, developing a framework for learning in which managers and leaders can
work in the organization, with adequate support and opportunities to reflect and
evaluate success in their role, is a globally shared challenge for health care in the future.
The framework must include common, non-professional-based elements of
management and leadership competence to promote a shared understanding of
management and leadership throughout the organization.
In sum, the development of management and leadership competence will
strategically and systematically improve general organizational performance and
essential managerial functions, and will produce new, motivated, potential managers
and leaders. The characteristics of leadership and management competence required for
the future comprise a captivating direction and challenge for further study using novel Management
research methods. Multi-professional groups of experts in the health-care field that and leadership
would serve as subjects of study might offer more information and varied perspectives competence
on the required characteristics of management and leadership competence methods for
developing them in the future.

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