It has been suggested that leadership in nursing plays a key role in interprofessional collaboration. The development of nursing leadership is multifaceted and includes the initiation and implementation of a leadership program. This initiative supports the professional activities of nurses in promoting higher education standards, increasing autonomy, responsibility and recognition of the profession. Leadership plays a big role in team building and teamwork. A lot of things depend on personal qualities and traits of character, style of the relation, microclimate, psychological atmosphere in team – all of these in many respects are defined by leadership skills of the executives . The purpose of this article is to describe leadership skills of the nurse executives' and thus, to extend the knowledge of those skills needed in nursing leadership. This can serve as the basis for further development of the capacity of nurse executives. To achieve these goals, a review of research results in international literature was conducted. The literature review was conducted through searches from the CINAHL database and the Janet e-library. For reviewing, 28 peer-reviewed articles in English and 5 books published between 2000 and 2017 were chosen. As a result of the study, it can be stated that the role of nurse executives' leadership skills involves cultural awareness, strategic thinking, interpersonal skills, and effective relationships. Nurse executives need to develop leadership skills. Nine core leadership competencies have been identified that are crucial for nurse executives in increasing their capacity as leaders and executives.
Introduction. It has been suggested that leadership in nursing plays a key role in interprofessional collaboration. The development of nursing leadership is multifaceted and includes the initiation and implementation of a leadership program. This initiative supports the professional activities of nurses in promoting higher education standards, increasing autonomy, responsibility and recognition of the profession. Leadership plays a big role in team building and teamwork. Many things depend on personal qualities and traits of character, style of the relation, microclimate, psychological atmosphere in team – all of these in many respects are defined by leadership skills of the executives .
In the history of nursing, there have been many prominent leaders among nurses who influenced the course of nursing care and helped its development. Florence Nightingale is one of them. She founded the first nursing school and is now recognized as the founder of modern nursing. This outstanding nurse played an exclusive role in developing policies and reforms in nursing. She possessed many leadership skills including being an effective communicator, and courageous, creative and collaborative in taking risks such as carrying out political lobbying . In history, individuals such as Florence Nightingale are regarded as leaders because of the qualities they possessed and the decisions that they made. They often had a vision of change, and they sought it out by setting a new course and inspiring their followers to share their vision .
Nursing in Kazakhstan has not reached necessary recognition as an important profession. Moreover, nurses still do not have the proper motivation to make changes in nursing and enhance the image of the profession. Therefore, in Kazakhstan, there is a need to promote and strengthen nursing leadership, since leaders play a key role in supporting professional care, promoting higher standards of care and recognizing nursing as a prestigious profession.
In this review, the term “executive” refers to individuals in formal management roles and includes administrators, directors, managers, head and senior nurses.
This research will analyze the role of leadership skills in the work of head and senior nurses in medical organizations to further extend theoretical and practical knowledge about leadership in nursing. This study can serve as a basis for the further development of the abilities and skills of nursing executives, which will help develop a vision of nursing care and show its value as a profession in order to make changes and improve health care in Kazakhstan.
Methods. A review of the literature was conducted to describe leadership skills of the nurse executives' and thus, to extend the knowledge of those skills needed in nursing leadership. Literature was collected using CINHAL database and the Janet e-library. For reviewing, 28 peer-reviewed articles in English and 5 books published between 2000 and 2017 were chosen.
Results. Analysis of the scientific literature has shown that the main themes of the research concern such aspects as definitions of leadership in nursing, leadership and management, leadership competencies. The main results are described below.
Definition of the concept of leadership in nursing. Leadership is a complex process with a multitude of different dimensions. There are many definitions that describe the complex nature of leadership, the following four concepts crucial to leadership: the leadership process involves some form of influence over people in groups and includes common goals .
Maccoby & Scudder describe leadership as a process that involves the ability to influence and motivate people or groups to achieve general goals. The quality of leadership can influence both the success and failure of an organization .
Leadership is like a complex of skills for a promotion team to achieve a certain goals .
Leadership means trust, human dignity, and respect. It means to listen, inspire and encourage, to be attentive and to maintain trustful relationships. It means comprehensive management which constantly focuses on quality. Leaders in nursing usually are heads such as administrative directors or managers. These roles are important in creating a vision ofwhat is high-quality healthcare for employees. Nurses in leadership are role models for their followers. Bravery is especially important for a leader. The nurse executive earns the status of a leader in order to become a role model .
Leadership is a complex concept, comprising of various qualities. One of the definitions of leadership in nursing is a multifaceted process of identifying a goal, motivating other people to act, and providing support and motivation to achieve mutually negotiated goals. The essence of leadership in nursing is to motivate, inspire, and promote the values of public health to empower and create a consistent focus on the needs of the patients whom the nurses serve. A nurse leader's role is to elicit effective performance from others. This involves leading and influencing the development of shared values, vision and expectations to enhance their organization's planned goals, and overall effectiveness .
Grimm has described leader traits as confidence, purposefulness, bravery, ethics, and the ability to prioritize. In particular, nursing leadership is characterized by direct involvement in clinical care and constant influence on other people to improve their care .
It is necessary to define what it means to be the leader in clinical settings, namely in nursing. The literature has many definitions of leadership in nursing, but only a small part considers clinical leadership in nursing [9–11]. Although the term clinical leadership in nursing is used in many contexts, there is not enough agreement on the definition. The description of the term clinical leadership in nursing in some literature revolves around the use of describing clinical leadership programs or evaluations of clinical leadership programs. These programs are generally used to train or develop nurses with leadership potential or nurses in leading positions . Since the literature is unclear on the concept of clinical leadership in nursing, defining a leadership in nursing would be a sensible place to start.
Nursing is a people-oriented profession with emphasis on humanism which probably influences leadership in nursing. In times of organizational changes in health systems, leadership in nursing is a complex and difficult task. Leadership in nursing is important for the employees for them to accept changes and in motivating them to achieve high quality care .
Cook and Holt  declared that leadership in nursing demands skills of leadership for team building, confidence, and respect. Lett  claims that nurse leaders provide vision to their followers. Clinical leaders are also skilled nurses who make their followers the best at their jobs.
Stanley  suggests a new definition claiming that clinical leaders in nursing can be defined as experts in their area because they are effective communicators and are able to act as role models, motivating others, and corresponding to their values and beliefs about the nursing practice. Leaders in nursing should have expert knowledge and skills to stimulate reform and change in the nursing practice.
To be effective in any area of leadership or human resource management, it is important to make sense of who you are as well as understand the personalities and abilities of the people in your team .
Nursing leadership has a crucial impact on the trustful and respectful relationship between nurses and other individuals, on creating incentives for productive work and creating an empowering working environment. The role of leadership in the field of nursing is the creation and maintenance of quality healthcare .
Leadership unlike management. The head and senior nurse, whose work already comes out of a framework of nursing duties, should also be a manager and a leader. However, unlike the manager, the leader does not have to apply his or her will or power over others for them to do something. Leadership is more about how people behave and how people interact with others. Leadership is about leading active implementation of change, solving complex issues to shape organizational questions, creating trust and building healthy relationships between nurses and patients. In healthcare, the nurse can be the head of group, someone who takes the lead in work. Some theorists of management believe that leadership and management differ considerably and can be separated completely from each other. This means that not all managers are leaders and not all leaders are managers. An old proverb says that leaders do the right thing, and managers do the thing right. This means that they have very different qualities and skills. In human resource management, leadership is one of many skills that a manager needs .
The literature makes a distinction but also points out a similarity between leadership and management. For example, Ellis described leadership as an art, and management as a science, consisting of calculations, methods, and statistics . While management is focused on consistency and order in the organization, leadership is focused on dealing with change. Despite these different approaches, they are similar in that they include deciding what should be done, creating a group of people to achieve goals . Each approach performs these tasks in unique ways. For example, managers cope with complexity by setting goals to be achieved. Then they set out a plan and get the resources to achieve these goals. Leaders develop a vision and create the strategies necessary to implement change and achieve a vision . Managers create their groups by creating an organizational structure staffed by qualified people who know the plan and have delegated authority to implement it. Leaders bring people together, sharing their vision and forming coalitions that are committed to achieving a vision. For the execution of the plan, managers control and solve problems. They track results and identify deviations, and then develop a plan to solve problems [14.] Leaders turn to the emotions, values and needs of their followers to inspire and motivate them to realize their vision .
Core leadership competencies. One should suggest that nurse executives should acquire leadership skills, which lead to positive behavior and improvement of the quality of project execution, which can ultimately help enhance professional development. This section discusses leadership skills and describes in detail elements of some core competencies that nurse executives can develop, including strategic thinking, organizational skills, time management, decision-making, leadership skills, conflict resolution and strategies for performance improvements. There is an assumption that if leadership skills or leader competence is inadequate, then the role of the nurse executives in relation to their subordinates may not be optimal . There are different competencies and leadership styles in each nursing leader that can contribute to success or failure. Many of these competencies can be reached by various actions, such as organization and simplification of meetings, organization of network, development of instruments to increase productivity, communication and drawing up a policy, and other procedures. The quality remains the main goal of any nurse leader in healthcare. When the leadership in nursing works, the quality of leadership needs to continue to improve. However, irrespective of the skills of the leader of healthcare, there always needs to exist an intact and effective system to support quality .
Let's consider the core competence of leadership in little more detail.
Leadership skills. Effective leadership demands that the potential leader has a number of key skills. These skills are necessary in modern organizational structures and allow leaders to have an opportunity to motivate and exert impact on various groups of employees to increase productivity. Some of these skills include confidence, integrity, inspiration, communication and commitment. The leader has to have integrity and adhere to the highest moral standards of honesty, transparency, and accountability. They need to inspire and motivate employees constantly to make work more efficient. The leader has to also be committed to the purposes and tasks of the organization .
Leadership trait theory. There is a leadership trait theory which is based on the premise that leaders are people with congenital traits of leadership. This means that leaders are born, and these skills cannot be learned or developed. These traits include honesty, decency, charisma, drive, and self-confidence. However, the theory can be challenged since there are no standard values expected from aleader. The leadership trait theory has been utilized extensively in determining candidates for leadership positions .
Strategic thinking. In the healthcare system, strategic thinking plays an important role. Strategic thinking conveys the process of the thinking of an individual when one uses cognitive mechanisms of thinking to achieve a set of purposes. Strategic thinking demands that the individual use new, creative means to nursing and to treat an illness. Strategic thinking allows people to actively look for possible solutions to problems. Finding solutions to problems in the health care system focuses on prevention and not on the treatment of the disease. The leader's strategic thinking supports teamwork, which in turn promotes strategic group thinking. Strategic group thinking ensures organizational survival .
Organizational skills. Organizational skills are necessary for the potential nurse leader to have an opportunity to operate resources and to direct the organization. Resources can include time, physical skills, financial skills, and behavior of the person. These resources are necessary for the nurse leader who has to perform various tasks at the same time. Patients require respective treatment and care, and timely delivery of health care. Failure to manage time properly endangers the lives and well-being of patients. The nurse leader has to be able to manage time and other obstacles. The nurse leader has to establish the purposes of the organization and make decisions which provide achievement of the goals and tasks .
Time management. Management of time is an important resource for medical organizations since in medicine, time is a limited resource. It is necessary to manage time correctly for effectiveness. The greatest losses of time occur in the following cases: the inability to delegate, lack of the accurate guidelines for specific duties, micromanagement, bad planning, and unnecessary meetings. Nurse leaders have to be able to operate these resources if they want to operate time successfully . They should also be able to delegate non-core tasks to other nurses. The nurse leader who insists on micromanagement of all tasks inside the organization demotivates employees. If employees become demotivated, the organization may lose its sense of purpose and direction .
Decision-making and Problem solving. In the field of health care, leaders constantly have to make decisions. These decisions can move the organizations forward or slow down their progress. An ability for decisionmaking is crucial. It is the ability to look through information critically and make a reasonable choice. Leaders have to be able to defend a point of view and define a right choice correctly. Despite the complexity of the issue, good leaders consistently make good decisions. Leaders must be able to reason correctly and decide on the right choice .
Conflict resolution. Conflicts can happen in any organization. Thus, leadership demands the skill of conflict resolution. The leader has to be able to meet people's expectations and to create an environment in which different people can work harmoniously. Resolution of conflicts guarantees that teamwork will be more successful. The ability of nurse executives to successfully solve conflicts can serve as an indicator of their leadership skills in an organization .
Effective teamwork. Teamwork is one of the main components of the modern medical organization. While providing medical services, mistakes are possible and people participating in nursing care can make mistakes. The lack of collaboration can lead to poor communication within the team which can have a negative impact on healthcare. Teamwork increases the safety of the patients and provides higher level of nursing care with lesser possibility of mistakes. Without effective communication and collaboration, which have paramount value in the field of healthcare, the possibility of mistakes is greater .
Risk management. Management of risks means that in the organizational process, risks are identified and analyzed. Risk management allows leaders to define measures, mechanisms, and protocols to reduce risk and its possible influence. Risk management allows organizations to cope with uncertainty which is inherent in corporate and branch environments. Risk management is crucial as it allows service providers of health care to expect certain risks .
In summary, there are various competencies and styles of leadership for each executive. A leader should reflect and estimate independently the conditions of each above-mentioned competency. Supporting competence, training, and self-reflection can help the person to establish a basic set of internal values and principles which can direct them to be more effective leaders.
Role of nurse executives' leadership skills in a working environment. Nowadays, managers, as the biggest decision-makers, play an important role in bringing success to medical organizations. Among executives of hospitals, the head and senior nurses can promote clinical competence of nurses and thus, increase the quality of medical care, applying leadership skills in management and providing several positive consequences. For example, professional improvement of nursing care can create attractive working conditions for nurses because professional nursing care is an important factor for ensuring high-quality medical care .
Leaders in nursing can help create a well- organized working environment to develop general values. A healthy working environment cannot occur without leaders in nursing who maintain its importance and involve others in its success. Leaders in nursing can undertake certain initiatives to improve the health of a working environment. There is evidence in literature that a healthy and favorable work environment is the reason why employees feel support from head and senior nurses. Problems in the working environment interfere with quality of care, safety of patients, and the employee's satisfaction with work .
The strong and supporting leadership skills of head and senior nurses are the key defining factor of motivation of the working staff . To be a leader in nursing is not an easy task, it requires courage. Leaders need not only clinical knowledge but the ability to control, direct and delegate, and to educate and support ward nurses. Their key role is to control all the aspects of taking care of patients. Many senior nurses are clinical leaders as well as managers. As managers, they have to guarantee compliance, operate the budget, and realize other hopes of the clinical organizations .
Literature suggests that head and senior nurses possessing leadership skills are experts in clinical practice who demonstrate clinical competence and clinical knowledge, make decisions, communicate effectively, are open and approachable, empower and motivate others, are visible, and role models to others. Performance of such a role depends on the clinical setting and the size of the hospital, their experience, confidence and support of the managers above them .
The role of lead nurses in an executive position implies continuation of professional growth, such as clinical observation and mentoring, possibilities of a research of postdegree education, and inter-professional cooperation . Head and senior nurses have duties which are not always visible to ward nurses as it may seem that they are always at meetings or in front of computers. However, the fact of the matter is that they are responsible for updating statistics, observing budget, and solving other technical issues such as getting resources for efficient healthcare. Generally, this occurs at board meetings, with written economic justifications in which they need to present weighty certificates to prove that nurses and patients «deserve» necessary resources. There can be ward nurses who later develop into head nurses and seniors at higher positions responsible for managing nursing staff and solving complex issues connected with nursing. If bedside nurses are responsible for directly taking care of patients, nurses in executive positions have a greater role such as protecting the rights of nurses. Kai Tiaki Nursing New Zealand  is one of the organizations of health care which appreciates leadership of the nurse executives. Two new roles have been created for the nurse executives: they are to strengthen practice and care culture and improve the provision of more advanced and effective nursing care. Each nurse plays an important role in providing the best care for patients.
The head and senior nurses with leadership skills can inspire changes and influence the process of developing policies in the field of healthcare and the health of the population. Namely, their participation in developing programs directed to support nurses' active participation in policy making in the field of healthcare guarantees safety, efficiency and availability of medical care .
The head and senior nurses bear responsibility for providing the direction and support for their subordinates. Granting the direction, mentoring and supervision play an important role in studying nursing care practice. Technology and patient care knowledge are dynamic, they change with time. Therefore, the training of nurses is necessary. Involvement of nurses in committees and meetings and conducting open communication also play a vital role in motivating development of potential nurses and personnel since a leader can provide the feeling of value and the importance of the nursing profession. Thus, nursing leadership and leadership strategies are important for expansion of opportunities for nurses and strengthening the development of nursing .
Nursing leadership has been described as essential for promoting evidence-based practice in nursing . The evidence suggests that nurse executives' leadership skills play an important role in successfully transferring research evidence into clinical nursing . Nurse executives are responsible for the professional practice environments where nurses provide care, and are strategically positioned to enable nurses to use research . Leadership factors such as support and commitment of nurse executives have a strong influence on the adoption of evidence-based practice in nursing .
Conclusions. The role of nurse executives' leadership skills involves cultural awareness, strategic thinking, interpersonal skills, and effective relationships. Nurse executives need to develop leadership skills. Nine core leadership competencies have been identified that are crucial for nurse executives in increasing their capacity as leaders and executives.