Aone nurse executive competencies

article

1. April 2017120Nurse Leader
The AONE Nurse Executive
Competencies:
12 Years Later
I
n 2005, the American Organization of Nurse
Executives (AONE) released the AONE Nurse
Executive Competencies (AONE-NEC).
1
A copyrighted
“brain trust” of the organization, the competencies
were released after several years of development and
AONE board work to determine the relevance to nurse
executive practice. In the past 12 years, the competen-
cies have been and are being utilized in hospitals,
health systems, and academic institutions in the
United States and globally. The AONE has positioned
itself as the organization with expertise to provide the
industry and nurse leaders themselves with tools neces-
sary to excel in nurse executive practice and education.
In this paper, evolution of the AONE-NEC and exam-
ples of how they are being used to guide both nurse
executive practice and academics are presented.
KT Waxman, DNP, MBA, RN, CNL, CHSE, CENP, FSSH, FAAN, Linda Roussel, PhD, RN,
NEA-BC, CNL, FAAN, Donna Herrin-Griffith, MSN, RN, NEA-BC, FACHE, FAAN,
and Jim D’Alfonso, DNP(c), RN, NEA-BC, PhD(h), FNAP

2. AONE-NEC: DEVELOPMENT
During the evolutionary period of the early 2000s, the AONE
board clearly understood its role in guiding the field for nurse
executive practice. Many inquiries came to the AONE from
practicing executives and organizations requesting job descrip-
tions and standards for the evolving nurse executive role.
Understanding how the needed tools were developed, the
AONE board gained inputs through board expertise, environ-
mental scans, and members to understand what areas of practice
were evolving and where evolution was anticipated with the
rapidly changing delivery system. The work of the board focused
on broad competency categories that became the five model
components of the AONE-NEC.
2
Details for each competency
area developed over the next 2 years, and the initial document
outlining the AONE-NEC was released in 2005 via various
AONE publications and media. During 2006 to 2009, collabo-
ration with additional professional associations, including the
American College of Healthcare Executives, the American
College of Physician Executives, the Healthcare Financial
Management Association, the Healthcare Information and
Management Systems Society, and the Medical Group
Management Association, formed the Healthcare Leadership
Alliance (HLA). Using the AONE competency model as a base,
these groups jointly developed and published the HLA
Competency Directory.
3
Across the years, the AONE-NEC have undergone several
revisions to stay current or ahead of evolving trends in nurse
executive practice. In Figure 1, the current AONE-NEC
competency areas are outlined. Additional information with
ever-evolving updates is available on the AONE website
(www.aone.org). With evolution in the field, and the AONE
membership from various aspects of the continuum as a
catalyst, the AONE’s leaders set forth with development of 2
additional sets of nurse executive competencies. These
include the AONE Nurse Executive Competencies: System
Chief Nurse Executive,
4
and AONE Nurse Executive
Competencies: Population Health.
5
AONE-NEC: ACADEMIC FOUNDATIONS
The AONE-NEC provide an excellent template for educating
and socializing executive nursing practice. Roussel, Thomas,
and Harris
6
used the competencies to frame their manage-
ment and leadership textbook’s key content areas. The inten-
tion by these authors was to provide guidance, through the use
of the competencies, to align the management and leadership
content and skill set for graduate nursing administrative stu-
dents. The competencies also provide a structure that can be
used to guide nursing leadership fieldwork and internships.
Guided by delineated activities, and areas of responsibility, the
nursing leadership/administrative student has a blueprint (map)
that enables the student, preceptor, and faculty to direct the
mentored practice experience. Additionally, preparing for certi-
fication in nursing administrative practice can also be guided
by study of the AONE-NEC. Specifically, when coupled with
the template, this provides for the educational content, social-
ization of the role, and preparation for certification, the
AONE-NEC are particularly meaningful.
The AONE-NEC conceptual framework provides inter-
connecting concepts that readily guide the underpinnings
for the educational foundation of administrative practice at
the executive nurse level. The intersecting circles are distinct,
yet the overlapping aspects illustrate how together a dynamic
model establishes a solid structure. The intersecting circles
include: communication and relationship management; pro-
fessionalism; knowledge of health care environment; business
skills and principles; and leadership. Each of the circles pro-
vides key constructs that can be explored and expanded to
address specific didactic content, evidence, and tools. For
example, business skills and principles describes the develop-
ment and management of an annual operating budget and
long-term capital expenditure plan and the use of business
models for health care organizations. Using this framework,
faculty can direct students to crosswalk the competency with
fundamental concepts of economics, including interpreting
financial statements, learning how to manage financial
resources, and ensuring the use of accurate charging mecha-
nisms. The graduate nursing administration (NA) student
also focuses on educating patient care team members on
financial implications of patient care decisions. The NA
student participates in the negotiation and monitoring of
contract compliance (e.g., physicians, service providers).
These are examples on how the competencies provide a
structure for the various activities, and tasks included in their
educational administrative program. Roussel, Thomas, and
Harris referenced “Communication and Relationship
Management” in Chapter 15 of Management and Leadership
for Nurse Administrators
6
to cover content specific to manag-
ing messages, to include constructive messaging, messaging
and the creative process, and strategic planning and messag-
ing. Using this competency and content, the student is able
to build a template to make oral presentations to diverse
audiences on nursing, health care topics, and organizational
issues. The graduate NA student will also be able to produce
written materials for diverse audiences on a variety of health
care topics and organizational issues. The chapter on com-
munication, aligning with communication and relationship
management, provides content and tools for facilitating
group discussions, demonstrating skills in interpersonal com-
munication, building collaborative relationships, and exhibit-
ing effective conflict resolution skills. Other chapters in the
Management and Leadership for Nurse Administratorstextbook
focused on communication and relationship building include
leadership as transformational and how coaching, mentoring,
and creating a trusting environment by following through on
promises and concerns are essential to the NA’s role and
responsibilities. As described in the AONE-NEC, learning
communication skills and tools helps the nurse leader to
establish mechanisms to follow-up on commitments by
balancing the concerns of individuals with organizational
goals and objectives, and engaging staff and others in deci-
sion-making. Maintaining credibility and relationships
require exquisite interpersonal skills and communicating in a
way that is authentic and transparent. The concept knowl-
edge of the health care environment entails demonstrating
www.nurseleader.com Nurse Leader121

3. knowledge of current nursing practice and the roles and
functions of patient care team members. This competency
underscores the importance of communicating patient care
standards as established by accreditation, regulatory, and qual-
ity agencies, ensuring compliance with the State Nurse
Practice Act, State Board of Nursing regulations, state and
federal regulatory agency standards, federal labor standards,
and policies of the organization. Knowing the importance of
standards ensures that written organizational clinical policies
and procedures are reviewed and updated in accordance with
evidence-based practice. This is critical content and can be
reinforced in field studies during the NA students’ experien-
tial learning. Knowledge of the health care environment
maintains the importance of adhering to professional associa-
tion standards of nursing practice. Clinical and management
decision making integrates bioethical and legal dimensions
of the health care environment. To this end, the competen-
cies consider the essential nature of ensuring protection of
human subject rights and safety in clinical research.
Leadership involves systems thinking and transformational
change. This specific competency, leadership, is threaded
through this author’s textbook; emphasizing the important of
use knowledge of classic and contemporary systems thinking
in problem solving and decision making. Also, emphasis is
placed on providing visionary thinking on issues that influ-
ence the health care organization, recognizing the contribu-
tion of mental models on organizational culture and
behavior. This gives voice to the need to consider the use of
resources and ways of thinking from other paradigms and
disciplines. This provides context for creative and integrative
thinking. The competency of leadership denotes the need to
promote systems thinking as an expectation of leaders and
staff, considering the impact of nursing decisions on the
healthcare organization as a whole. Professionalism is delin-
eated into personal and professional accountability.
Professionalism is also a strong thread throughout the man-
agement and leadership textbook focused on professional
practice, and professional development. That is, this compe-
tency in particular emphasizes the essential nature of holding
self and others accountable for mutual professional expecta-
tions and outcomes. This provides the backdrop for the
advancement of the profession by participating in and con-
tributing to professional organizations. Lifelong learning and
academic achievement is the cornerstone for advancement
and professional development. Specifically, striving to achieve
and maintain professional certification for one’s self and
promoting professional certification for staff are examples of
how these goals can be reached. Using the professionalism
competency as a template, the NA learns that role modeling
and mentoring of standards for professional practice (clinical,
educational and leadership) for colleagues and constituents is
the important work of the NA. Professionalism also includes
the components of ethics and advocacy. Ethics involves
upholding ethical principles and corporate compliance stan-
dards and hold self and staff accountable to comply with
ethical standards of practice. The NA student through their
academic and experiential learning guided by ethics and
advocacy is able to discuss, resolve and learn from ethical
dilemmas. The NA student learns that advocacy necessitates
promoting clinical perspective in organizational decisions,
involving nurses and other staff in decisions that affect their
practice The NA student (graduate) seeks to represent the
perspective of patients and families, by advocating for opti-
mal health care in the community.
AONE-NEC: ACADEMIC APPLICATION
Immediately following the first release of the AONE-NEC,
AONE and the Council on Graduate Education in
Administrative Nursing convened to outline the future of
education for administration, as there was much debate in the
field about the direction it should take. The groups put forth
a model for education that included 5 domains that align
with the AONE-NEC (business, leadership, environment,
communication, and professionalism), 10 threads (evidence-
based practice, ethics, influencing behaviors, accountability,
clinical leadership, quality improvement, effective communi-
cation, strategic management, teamwork, and mentoring) and
5 competency levels (novice, advanced beginner, competent,
proficient, and expert). Emphasis on the future of masters and
doctoral education were highlighted and innovative teaching
strategies outlined.
7
The AONE-NEC are used across the
United States at the master’s and doctoral levels in a number
of programs that prepare nurse leaders. Detailing that body of
work is beyond the scope of this paper. Some examples of
programs that have been based on the AONE-NEC include
the University of Memphis,
8
University of Iowa,
9
University
of Hawaii at Manoa,
10
Grand Canyon University, Texas
Women’s University, University of California at Davis,
11
the
University of San Francisco,
12
the University of Alabama at
Birmingham,
13
Centura Health,
14
Kaiser Permanente,
15
and
many more.
April 2017122Nurse Leader
Figure 1.The AONE Nurse Executive Competencies
© 2015 American Organization of Nurse Executives (AONE).
Used with permission.

4. In 2007, AONE published a position paper supporting the
doctor of nursing practice (DNP) as a terminal degree option
for practice-focused nursing.
16
Many academic institutions
around the country have embedded the competencies into
their graduate curriculum for both master’s and doctoral
programs. One example of the application in academia
includes the University of San Francisco’s School of Nursing
and Health Professions Executive Leader Doctor of Nursing
Practice Program (ELDNP) where the AONE-NEC have
been incorporated into the curriculum. The program is
aligned with both the American Association of Colleges of
Nursing (AACN) DNP essentials
17
and the AONE-NEC.
Students in the program must demonstrate competence in
the 5 AONE core sets of competency domains for health care
leadership: communication and relationship management;
knowledge of the health care environment; leadership; profes-
sionalism; and business skills and principles. These competen-
cies are validated by various assignments and coursework
www.nurseleader.com Nurse Leader123
Table 1.Curriculum, AONE-NEC Competency, and Demonstrated Outcome for USF’s School of Nursing and Health Professions
Executive Leader Doctor of Nursing Practice Program
ELDNP Course AONE Competency Demonstration
Scholarly inquiry and Communication and relationship Professional writing
evidence-based practice management (1A, 1B)
Project management for the executive leaderCommunication and Oral presentation
relationship management;
business skills and principles
(1A, 1B, 5C)
Quality and patient safety Knowledge of health care Oral presentations; assignments;
environment (2A, 2E, 2F, 2G) papers
Population-focused system Knowledge of health care environment,
evaluation and improvements business skills and principles Oral presentations; assignments; papers
(2A, 2B, 2E, 2G, 4C, 5A)
Qualifying project Leadership (1–5) Professional writing; submit
manuscript to peer-reviewed journal
Legal and risk management in Knowledge of health care environment; Participate in simulation with law
administrative practice professionalism (2D, 2H) students
Strategic leadership, innovation, Leadership; professionalism Oral presentations; assignments;
and entrepreneurship (1A, 1B, 3A, 3C, 3E, 4A, 4B) papers
Advanced financial management Business skills and principles; Oral presentations;
professionalism; communication and assignments; papers
relationship management (5A, 5B, 5C, 2G, 3C)
Health care policy and ethicsKnowledge of health care environment; Oral presentations;
professionalism (2D, 4C, 4D) assignments; papers
Health care informatics Communication and relationship management; Oral presentations; assignments;
professionalism; knowledge of health care papers
environment; (2B, 2H, 5D)
Practicum 1–5: micro, meso,Business skills and principles; professionalism; Oral presentations; assignments;
macro system and synthesis in communication and relationship papers; reflection of experience
complex organizations management (1–5) tied to theory
(Clinical hours focus)
Final ELDNP project and residencyCommunication and relationship Public oral presentation of
management; professionalism; evidence-based change in practice
knowledge of health care project, final scholarly paper
environment (1–5) published in USF library
USF, University of San Francisco. (The table is used with permission.)

5. throughout the program. A breakdown of the ELDNP course
curriculum, the AONE competency, and demonstration of
meeting the competency are shown in Table 1. These doctor-
al courses, including a 1000-hour practicum experience,
prepare students to assume executive roles and articulate the
value of nursing to the executive team. The AONE compe-
tencies, coupled with the AACN essentials, provide a frame-
work for the overall ELDNP curriculum.
AONE-NEC: APPLICATION IN HEALTH CARE
ORGANIZATIONS
AONE-NEC offer a valuable leadership framework for sys-
tem-wide transformation and continuous innovation during a
time of unprecedented change in health care. Informal
reports indicate that many organizations have adopted the
AONE-NEC as the basis for job descriptions, leader recruit-
ment efforts, and performance.
One example of application is in a large integrated not-
for-profit health care system headquartered in Northern
California with over 38 hospitals and 51,000 registered nurs-
es. This organization adopted a comprehensive matrix
approach to competency redesign that included inclusion and
spread of the AONE-NEC. Implementation strategies includ-
ed the alignment of national nursing standards, specialty
organizations accrediting agencies, and internal total perform-
ance core behaviors that support nurse leaders at all levels of
the organization to perform, lead, and grow in an era of
health care reform.
INTEGRATION AND IMPLEMENTATION STRATEGIES
The first step in building alignment and integrating the
AONE-NEC was revision of the national chief nurse execu-
tive job profile, including changes to principal responsibilities
and core behaviors that reflect the most current and
informed leadership best practices, as well as incorporating
the future envisioned by and for nurse executives across the
enterprise. Over a 2-year period, collaboration between
national nursing, human resources, learning and develop-
ment, and regional nurse executive leadership resulted in the
formation of diverse work teams committed to define and
develop foundational and professional competencies for all
nurse leaders. The first goal was to organize and prioritize
the domains for nursing leadership competency across the
organization. The domains of communication and relation-
ship building, knowledge of the health care environment,
leadership, professionalism, and business skills emerged, as
well as a corresponding list of relevant competencies to
support each domain. The essential knowledge, attitudes/
behaviors, and skills required for each competency were
defined and referenced. A list of specific competencies is
outlined and structured to progressively evolve across all
levels of leadership, including strategic, operational, and clini-
cal nurse leader roles. This evolving process resulted in the
development of a standardized nursing professional develop-
ment map, approved by the national nursing leadership
council and made available to nurse leaders through a
detailed implementation guidebook and interactive intranet
tool. A key goal of the leadership competency map was to
provide opportunities for nurse leaders to use the tool as a
guide for new leader orientation, structured mentorship, as
well as coaching for improved performance. A Leadership
Self-Assessment Tool
15
for each level of leadership was inte-
grated into the map, as well as additional crosswalks to sup-
port ongoing professional development through advanced
education and professional certification.
SYSTEM-WIDE STANDARDIZATION AND LOCAL
CUSTOMIZATION
System-wide standardization of nurse executive and nurse
leadership competencies provides an essential mission and
vision-focused strategy for this health system. An important
facet of integrating system-wide competencies is the oppor-
tunity for different regions, including hospitals and clinics
located in other states, to customize or add leadership com-
petencies that best reflect their unique services and practice
environments. Honoring cultural variation, the organization’s
Nurse Executive Development Map (Figure 2) offers nurse
executives a central framework that harmonizes a global
vision, yet allows for inclusion of identified local leadership
competencies or distinct practice variation.
An example of regional customization of nurse executive
and leadership competencies included the addition of a car-
ing science domain entitled “Relationship With Self,” which
focused on the integration of theory-guided competencies
aligned to Jean Watson’s Theory of Human Caring and the
importance of self-care in leading and transforming whole-
person and whole-system environments.
18
Core caring sci-
ence competencies were identified and integrated, which
included the addition of an individual self-care practice
assessment and focused learning labs for nurse executives,
fellows, and candidates participating in nurse executive lead-
ership development programs. This region has well-estab-
lished caring science programs designed to cultivate
self-awareness and inculcate best practices to help mitigate
stress, which served to augment and not detract from the
system-wide competency plan.
19
The journey to integrate the AONE-NEC required teams
to identify competencies and develop a program to support
effective spread. The process also provided an invaluable
opportunity for national and regional leaders to model, expe-
rience, integrate, and validate the AONE-NEC together
during the life of the project.
AONE-NEC: GUIDANCE FOR CERTIFICATION
As previously noted, the AONE-NEC form an excellent
foundation for certification in nursing administration practice.
Though various certification models are designed fitting to
the certifying body’s philosophy, the AONE-NEC are foun-
dational to the nurse leader’s knowledge base for certification
in the specialty. According to MT Meadows, AONE Director
of Professional Practice, the AONE-NEC form the basis for
the National Practice Analysis Study of the Nurse Executives.
This study is done periodically and the findings are incorpo-
rated into the certification exam’s content and item develop-
April 2017124Nurse Leader

6. www.nurseleader.com Nurse Leader125
ment based on established certification industry standards
(Meadows MT, personal communication, 2016).
AONE-NEC: INTERNATIONAL APPLICATION
Leaders of the AONE now have a history of participation in
the global leadership community (see “The American
Organization of Nurse Executives and Global Citizenship”
article
20
in this issue of Nurse Leader). Though not widely
published, use of the AONE-NEC in countries outside the
United States is noted. Through presentations at the
International Council of Nurses (ICN), the AONE partner-
ships in various countries, and personal communications,
nurse leaders point to the AONE-NEC as foundational in
their countries as setting the standard for nurse executive
practice.
SUMMARY
The AONE-NEC are viewed nationally and globally as the
competency standard for nursing leadership practice. The
development, publication, and use of the AONE-NEC have
had—and will continue to have—great influence on the
practice of nurse leaders. The AONE mission “To shape
health care through innovative and expert nursing leadership”
and the AONE vision “Global Nursing Leadership—One
Voice Advancing Health”
21
are exceedingly met and made
visible in the adoption and use of the AONE-NEC, both
nationally and globally.
NL
References
1. American Organization of Nurse Executives. AONE Nurse Executive
Competencies. 2005 http://www.nurseleader.com/article/S1541-
4612(05)00007-8/abstract. Accessed October 13, 2016.
Figure 2.Nurse Executive Development Map—Kaiser Permanente
(Figure 2 is used with permission.)

7. 2. American Organization of Nurse Executives. AONE Nurse Executive
Competencies Assessment Tool
. Chicago, IL: American Organization of Nurse
Executives; 2011.
3. The Healthcare Leadership Alliance. Introducing the HLA Competency
Directory, Version 2.0. 2010. http://www.healthcareleadershipalliance.org/.
Accessed October 13, 2016.
4. American Organization of Nurse Executives. AONE Nurse Executive
Competencies: System CNE. 2015. http://www.aone.org/resources/
nec-system-cne.pdf. Accessed October 13, 2016.
5. American Organization of Nurse Executives. AONE Nurse Executive
Competencies: Population Health. 2015. http://www.aone.org/resources/
population-health-competencies.pdf. Accessed October 13, 2016.
6. Roussel L, Thomas P, Harris J.
Management and Leadership for Nurse
Administrators
, 7th ed. Burlington, MA: Jones & Bartlett Learning; 2016.
7. Herrin D, Jones K, Krepper R, Sherman R, Reineck C. Future nursing
administration graduate curricula, part 2.
J Nurs Adm. 2006;36:498-505.
8. Thomas J, Herrin D. The master of science in nursing program: competen-
cies and learning experiences.
J Nurs Adm. 2008;38:4-7.
9. University of Iowa College of Nursing. Health Systems Overview. 2016).
https://nursing.uiowa.edu/academic-programs/dnp/health-systems/overview.
Accessed October 26, 2016.
10. University of Hawaii at Manoa. Graduate Programs. 2016.
http://www.nursing.hawaii.edu/graduate. Accessed October 22, 2016.
11. Schuettner K, Van Sell S, Sheriff S. Nursing administration degree as the
foundation of practice for future nurse managers.
Nurse Leader. 2015;
13(4):86-97.
12. University of San Francisco. Executive Leadership Doctor of Nursing
Practice. 2016. https://www.usfca.edu/nursing/programs/doctoral/
executive-leadership. Accessed October 22, 2016.
13. University of Alabama. Doctor of Nursing Practice. 2016http://nursing.ua.edu/
?page_id 111. Accessed October 22, 2016.
14. Bernard N. Who’s next: developing high potential nurse leaders for nurse
executive roles.
Nurse Leader 2014;12(5):56-61.
15. Winter P. Competency self assessment. In:
Competency Toolkit. 2016.
http://www.kaisernursing.org/professionaldevelopment/competencytoolkit/
tools/Competency%20Self%20Assessment.pdf. Accessed October 6, 2016.
16. American Organization of Nurse Executives. Consideration of the Doctorate
of Nursing Practice. 2007. http://www.aone.org/resources/doctorate-nursing-
practice.pdf. Accessed October 27, 2016.
17. American Association of Colleges of Nursing. The Essentials of Doctoral
Education for Advanced Nursing Practice. 2016. http://www.aacn.nche.edu/
publications/position/DNPEssentials.pdf. Accessed October 22, 2016.
18. Watson J. Brewer B. Caring Science Research, Criteria, Evidence,
Measurement.
J Nurs Adm. 2015;45:235-236.
19. D’Alfonso J, Zuniga A, Weberg D, Orders AE. Leading the future we envision,
nurturing a culture of innovation across the continuum of care.
Nurs Adm Q.
2016;40:68-75
20. Thompson PA. The American Organization of Nurse Executives and Global
Citizenship
Nurse Lead. 2017;15 (this issue).
21. American Organization of Nurse Executives. AONE 2016-2018 Strategic
Plan. http://www.aone.org/docs/About/aone-strategic-plan.pdf. Accessed
October 2, 2016.
KT Waxman, DNP, MBA, RN, CNL, CHSE, CENP, FSSH,
FAAN, is assistant professor, University of San Francisco, and direc-
tor, executive leader DNP program in San Francisco, California. She
can be reached at [email protected]. Linda Roussel, PhD,
RN, NEA-BC, CNL, FAAN, is professor, University at
Birmingham School of Nursing, DNP program coordinator, in
Birmingham, Alabama. Donna Herrin-Griffith, MSN, RN, NEA-
BC, FACHE, FAAN, is assistant professor at the University of
Alabama Birmingham, and executive consultant for Herrin &
Associates. Jim D’Alfonso, DNP(c), RN, NEA-BC, PhD(h),
FNAP is executive director, Professional Practice, Leadership
Development and Research and the KP Nurse Scholars Academy,
Kaiser Foundation Hospital/Health Plan, in Oakland, California.
1541-4612/2017/ $ See front matter
Copyright 2017 by Elsevier Inc.
All rights reserved.
http://dx.doi.org/10.1016/j.mnl.2016.11.012
April 2017126Nurse Leader