Suggesting a holistic framework for understanding healthcare services leadership competence – a critical interpretive synthesis

Purpose Healthcare providers are under pressure due to increasing and more complex demands for services. Increased pressure on budgets and human resources adds to an ever-growing problem set. Competent leaders are in demand to ensure effective and well-performing healthcare organisations that deliver balanced results and high-quality services. Researchers have made significant efforts to identify and define determining competencies for healthcare leadership. Broad terms such as competence are, however, inherently at risk of becoming too generic to add analytical value. The purpose of this study is to suggest a holistic framework for understanding healthcare leadership competence, that can be crucial for operationalising important healthcare leadership competencies for researchers, decision-makers as well as practitioners. Design/methodology/approach In the present study, a critical interpretive synthesis (CIS) was conducted to analyse competency descriptions for healthcare leaders. The descriptions were retrieved from peer reviewed empirical studies published between 2010 and 2022 that aimed to identify healthcare services leadership competencies. Grounded theory was utilised to code the data and inductively develop new categories of healthcare leadership competencies. The categorisation was then analysed to suggest a holistic framework for healthcare leadership competence. Findings Forty-one papers were included in the review. Coding and analysing the competence descriptions resulted in 12 healthcare leadership competence categories: (1) character, (2) interpersonal relations, (3) leadership, (4) professionalism, (5) soft HRM, (6) management, (7) organisational knowledge, (8) technology, (9) knowledge of the healthcare environment, (10) change and innovation, (11) knowledge transformation and (12) boundary spanning. Based on this result, a holistic framework for understanding and analysing healthcare services leadership competencies was suggested. This framework suggests that the 12 categories of healthcare leadership competencies include a range of knowledge, skills and abilities that can be understood across the dimension personal – and technical, and organisational internal and – external competencies. Research
limitations/implications This literature review was conducted with the results of searching only two electronic databases. Because of this, there is a chance that there exist empirical studies that could have added to the development of the competence categories or could have contradicted some of the descriptions used in this analysis that were assessed as quite harmonised. A CIS also opens for a broader search, including the grey literature, books, policy documents and so on, but this study was limited to peer-reviewed empirical studies. This limitation could also have affected the result, as complex phenomenon such as competence might have been disclosed in greater details in, for example, books. Practical implications The holistic framework for healthcare leadership competences offers a common understanding of a “fuzzy” concept such as competence and can be used to identify specific competency needs in healthcare organisations, to develop strategic competency plans and educational programmes for healthcare leaders. Originality/value This study reveals a lack of consensus regarding the use and understanding of the concept of competence, and that key competencies addressed in the included papers are described vastly different in terms of what knowledge, skills and abilities they entail. This challenges the operationalisation of healthcare services leadership competencies. The proposed framework for healthcare services leadership competencies offers a common understanding of work-related competencies and a possibility to analyse key leadership competencies based on a holistic framework.


Introduction
There are numerous reasons to the increased attention towards leadership competencies over the past decades (Aitken and Von Treuer, 2014;Liang et al., 2020aLiang et al., , 2020b;;Liang et al., 2020aLiang et al., , 2020b;;Murphy et al., 2016;Pihlainen et al., 2016).Health services across the world have been subject to continuous reform, reorganisation and restructuring since the 1980s (Al-Hussami et al., 2017;Ayeleke et al., 2018).In addition, factors such as rapid advancement in medical and information technology (Guo and Anderson, 2005), globalisation, changing demographics and an increasing number of elderly and people with chronic and composite diseases (Heinen et al., 2019), scarce and diverse monetary and human resources (Ayeleke et al., 2018), further increases the organisations' complexity.This complexity makes healthcare systems challenging to manage (Baker and Denis, 2011;Jaafaripooyan et al., 2020).Competent leadership is recognised as decisive for implementing reforms in health services (Ayeleke et al., 2018), and the acquisition, retention and development of leadership competencies have been seen in conjunction with increased quality of services, higher efficiency and effectivity, and better performance and results in healthcare organisations (Groves, 2011;Trossman, 2011).As adequate leadership and managerial competencies are crucial to achieve the organisation's goal, to deliver timely and high-quality services to the citizens (Kruk et al., 2018), insufficient leadership can result in increased costs, reduced efficiency and effectiveness, lack of motivation, reduced job satisfaction and morale and ultimately dissatisfaction of patients as well as employees (Sfantou et al., 2017).Competent leadership is therefore ubiquitous at all levels in the health sector (Stoller, 2017), and identifying the competencies aligned to effective leadership is the cornerstone for leadership development (McClelland, 1973).
As one of the first proponents of the term competence, McClelland defined competence as the "underlying characteristics of an individual, which is causally related to effective or superior performance in a job, role, or situation" (McClelland, 1973).Boyatzis (1982) later defined it as a capability or ability, while in conjunction with this understanding of the concept the KSA approach, entailing knowledge, skills and abilities, gained wide-ranging consensus the following decades.From the 1990s however, the definitions and descriptions of competence have broadened considerably in conjunction with an increased popularity of the concept.Terms such as attributes, capacities, dispositions, attitudes and values (Ellis, 1988) have been added, as well as individual characteristics (Lifrak et al., 1997), personal traits (Veres et al., 1990), personal-and task-oriented skills (Martina et al., 2012) and experience (Liškov a and Tomšík, 2013).
Despite the wide ranged application of the term, less effort has been made to define the concept (Mooney, 2007, p. 110).Emphasised by Françoise Delamare Le Deist and Jonathan Winterton (2005), there is such confusion and debate concerning the concept of "competence" that it is impossible to identify or impute a coherent theory or to arrive at a definition capable of accommodating and reconciling all the different ways the term is used (p.29).The challenge with such lack of consensus is that the users underestimate the complexity of the concept and are in peril of defining and applying the concept through fundamentally different interpretations.Competence is said to be highly context specific (Brownell, 2008), leading to an excessive effort to develop one-dimensional frameworks that assert core competencies and associated descriptions thereof developed for specific contexts (Gunawan and Aungsuroch, 2017;Kantanen et al., 2015;Liang et al., 2020aLiang et al., , 2020b)).Le Deist and Winterton (2005), on the other hand, argued that one-dimensional frameworks of competence are insufficient, and that a holistic framework might be a more adequate approach to identify the combination of competencies necessary for occupations (p. 1).A multi-dimensional holistic approach to healthcare leadership competencies can contribute to a common understanding of the concept as well as be applicable to several contexts and educational backgrounds, as it enables the users to identify combinations of competencies needed for leadership positions in health care that includes several perspectives on leadership competences.The main objective of this study is therefore to contribute to the field of research as well as the practise field by proposing a new understanding of what constitutes healthcare services leadership competence and to suggest a holistic framework for healthcare leadership competence that can be applied and developed further by both researchers, decision-makers and practitioners.Such framework can be used to identify specific leadership competency needs in healthcare organisations, to develop strategic competency plans and educational programmes.

Aims
To achieve its objective, this study aims to answer the following two research questions: RQ1.How are leadership competencies in the context of healthcare services described in empirical research articles, and what do they entail?
RQ2.How can leadership competence in the context of healthcare services be understood and operationalised holistically?
To answer these questions, a critical interpretive synthesis (CIS) was conducted.A CIS has previously been used to address complex issues in health care, such as access to health care (Annandale et al., 2007;Woods et al., 2005), cultural competence (George, 2015;Liu et al., 2021), defining and classifying public health systems (Jarvis et al., 2020) and implementation of evidence informed policies (Bullock et al., 2021).To answer both research questions, competency descriptions retrieved from the included papers was coded, and new categories of healthcare leadership competencies developed.An analysis of the categories was conducted to develop a holistic understanding of leadership competence.To our knowledge, such multi-dimensional or holistic understanding of competence has not been developed for healthcare services leadership.

Study design
Given the heterogeneous nature of the term competence as well as the complex and divergent literature covering leadership competence in the health service, a traditional systematic review was neither a doable nor suitable approach for this study (Grant and Booth, 2009;Newman and Gough, 2020).Developed by Dixon- Woods et al. (2005) as a relatively new methodology with its offspring from the meta-ethnography tradition, a CIS is suitable to examine fuzzy concepts such as "competence" (Dixon- Woods et al., 2006).In addition to producing a summary of the literature, a CIS methodology interprets the evidence, conducts appraisal and critique of the included papers and aims to produce a theoretical output in the form of synthesising argument (Woods et al., 2005).To support the aim of theory generation, CIS uses some of the principles of grounded theory (Newman and Gough, 2020).As opposed to a traditional systematic review, this method aims for a comprehensive rather than exhaustive search of the literature (Dixon- Woods et al., 2006).
Aiming to generate a new understanding of leadership competence in the healthcare services, this study can be characterised as a configuring review; aiming to understand the phenomenon under investigation by interpreting existing descriptions of competencies to develop new concepts (Voils et al., 2008).

Search strategy
The search was conducted in two separate phases in March 2021 and August 2022 for the time January 2010-January 2022 using the databases Web of Science and CINAHL.Studies were limited to date and language, but not limited to study design.As it was the phenomenon leadership competence that was to be subjected to critical interpretation, synonyms such as skills, abilities and attributes was not included in the search.The final search string was AB ¼ "manage* competenc*" OR AB ¼ "leader* competenc*" AND AB ¼ health sector OR AB ¼ health service OR AB ¼ health care OR AB ¼ healthcare.

Study selection
Papers were excluded based on titles and abstracts if they (1) did not have leadership competences in the health service as main objective, (2) did not give descriptions, characteristics and/or identification of leadership-or management competencies in the health service, (3) addressed education or development of competencies, (4) were not peer reviewed empirical studies or literature reviews and (5) were composed in other languages than English.The inclusion of papers was not restricted by profession, sector or country, as a general picture of how leadership competencies in the health service are described was the main objective.In accordance with the inductive approaches used in a CIS methodology, papers that met some of the inclusion criteria but not all were included in the early stages of analysis.This was also a consequence of the premise that it can be challenging to assess whether a paper would give actual descriptions of the competences or not based solely on the title and abstract.

Data analysis
Inspired by Strauss and Corbin (1990), three phases of coding, namely, open-, axial-and selective coding, were conducted.The three steps of coding were completed repeatedly, moving back and forth between the steps.During the open coding, approximately 2,500 statements and keywords describing leadership competencies for the health sector were extracted from the data material and coded.This was a tedious process where each statement was discussed addressing the compass question: What knowledge, skills and LHS 37,5 abilities does this competency-description entail?The descriptions of the competencies were separated from the original code to avoid the original conceptualisation influencing the generation of a new categorisation.The axial coding consisted of putting the data back together in categories, where the coded material was reinterpreted.The main objective of this categorisation was to address what the competency descriptions comprising the concepts entailed.For example, the concept strategy entailed descriptions of strategic and analytical thinking which was categorised as cognitive abilities.Descriptions of ability to communicate the organisation's strategy and vision to the staff and motivate them to work in accordance with the strategy were categorised as influencing and motivating staff.To prepare and implement strategy on the other hand was categorised as skills and abilities that described the steering part of leadership.A full table of the competence categories with subcategories and examples of descriptions can be found in the supplementary material, and a short overview is provided in the result section below.Following each step, the categories were systematically collated, compared and refined (Strauss, 1990).Near 60 pages of competency descriptions were cut out manually and sorted in new categories.After four rounds of coding, 12 categories with sub-categories were developed and as they were not challenged significantly in the fifth round, a satisfactory saturation was reached.The categories were then abstracted to produce a holistic understanding of what healthcare leadership competencies implies, by identifying a storyline of the phenomenon described in the material.

Search results
Electronic database searches resulted in 544 hits.After reading headlines and abstracts, 138 papers were read in full text and 41 papers were included in the study.A flow diagram outlining the search strategy and results is depicted in Figure 1.The first step started with a search in the database Web of Science in March 2021, which was concluded in June the same year.This resulted in 249 papers.Forty-three papers were subjected to data extraction and analysis.The second step started in January 2022 using a similar search strategy in the database CINAHL that was concluded in August the same year.One reviewer conducted the same procedure as in Step 1, resulting in eight included papers.In case of doubt, the other reviewer was consulted.All included papers from both searches were then read thoroughly again, resulting in 10 excluded articles from the first search due to lack of explicitly describing the competencies or not investigating leadership of professionals.
Of the 41 included papers, 31 were published in 2016 or later.Fourteen papers used quantitative methods, while 11 had a qualitative design, 11 used mixed methods and 5 were literature reviews.There was an uneven distribution in the included papers when it came to sector investigated: 19 papers examined hospitals, as opposed to only two examining primary care centres and six named primary health care as their main objective.Thirteen papers did not mention a particular sector.Most papers that investigated a certain profession studied nurses.Seventeen papers investigated nurse leaders, six studied physicians, three addressed several professions, and 15 papers did not specify any professional discipline.Of the 41 included papers, 18 based their empirical studies on an established competency framework or theory of leadership competency.A full overview of the included papers can be found in Appendix.

Review of the literature
The data analysed in this study included several professions, public and private healthcare organisations, primary health care as well as hospitals, leadership levels from first line managers to senior leaders, and were conducted in 22 different countries on 6 continents.A systematic comparative analysis to investigate contextual differences in competence descriptions between countries, leadership level or profession was not conducted.During the coding of the descriptions of competencies the similarities were however striking as a clearer distinction between contexts was expected.There seem to be an agreement across papers regarding several key competencies such as communication skills, financial and business abilities, teamwork skills, knowledge of the health care and organisation, and professional knowledge, ethics and values amongst others.There are, however, some variations in the descriptions of the competencies.For example, all included papers except three explicitly named communication as an important leadership competency in the health service.Still, some describe communication as writing newspapers articles (Dikic et al., 2020), while others describe it as listening and emphasising skills (Kakemam et al., 2021) or preparation and delivery of business communications (Lopes et al., 2020).According to the results from this study, these descriptions entail different kinds of skills and abilities and were therefore coded and placed in different categories.
12 Categories of healthcare leadership competence Twelve different competence categories were developed, all separate and distinct.Some authors accentuate that the categories should be mutually exclusive (Patton, 1990), but even though there are clear distinctions between the categories, they do not meet the criteria of mutually exclusiveness.This is due to the descriptions that comprise each category can entail several aspects of knowledge, skills and abilities:

LHS 37,5
Character: Involves competencies that are tied to personal skills and abilities, such as individual cognitive ability, personality and manners.This category has five subcategories.( 1) Includes self-awareness and be aware of own strengths and weaknesses.( 2) Involves to control and manage own emotions, as well as understanding others' emotions, behaviour and attitudes.(3) Are personal characteristics such as to work hard, solve problems and use good judgements.( 4) Are characteristics such as being genuine and creative, have integrity and make decisions under extreme ambiguity.( 5) Are mental abilities and cognitive skills such as abilities for critical and analytical thinking as well as problem-solving.Interpersonal relations: Entails skills and abilities to build and maintain relations with others, such as cooperation and understanding others' needs and emotions.Four sub-categories were detected.( 1) To create functional collaboration and teamwork, relating and working well with people, and interprofessional collaboration.( 2) Abilities to develop interpersonal and effective relationships, establish mutual trust and respect and demonstrate listening skills.(3) To facilitate effective communication to enhance interpersonal relationships, to resolve communication barriers and to provide effective and constructive feedback.( 4) To negotiate effectively and resolve conflicts, deal with difficult patients and their relatives and ability to reach consensus when discussing issues.Leadership: Entails competencies describing direct influence on others, such as being a mentor or a role model, to communicate the organisational vision and mission convincingly and influence the staff to believing in and wanting to achieve the organisational goals.Four sub-categories were identified.( 1) Involves to influence subordinates, peers, and superiors in the realisation of organisational goals, and influence people to work together as a team.( 2) Being a role model and a mentor, supporting and mentoring high potential staff, give advice and coach.(3) Includes descriptions of leadership actions that involve the staff directly in their work such as to delegate and assign tasks and responsibilities to staff based on their abilities, to realise the potential development of the work community and hold oneself and others accountable.( 4) Involves skills and abilities to communicate organisational strategy, vision, mission and goal to the staff convincingly.Professionalism: Involves competencies specific to exemplary professional practice, professional development as well as values and professional ethics.Three subcategories were detected: (1) Involves to work actively to develop, contribute to and enhance the professions, as well as own and staff's professional knowledge, skills and abilities, ensure that the staff receive ongoing in-service training.( 2) Includes ensuring ethical practise, that the right values are fostered and practised and to sustain a commitment to the community.(3) Contains skills, abilities and practices to be patient centred, improve patient care and quality of services, to go above and beyond expectations to focus on patients/patient care and developing quality assurance and improving patient safety.Soft HRM: Entails skills and abilities to organise staffs' workday, to create a good work environment, and to arrange for staff's development and education.This category contains four sub-categories.(1) To facilitate and take responsibility for the development, education and training of staff, provide a professional career ladder and focus on enhancing the skills of employees.( 2) Facilitating the professional practice and welfare of the staff, to provide sufficient staffing, make flexible staffing plans and ensuring that staff are knowledgeable about what is expected from them.(3) Taking responsibility and action to create a safe and thriving work environment, monitor the work environment for potential safety issues and maintain a climate in which team members feel heard and safe.( 4) Involves personnel management, recruitment and retention of personnel, and to use a supportive and collegiate management style.Management: Involves the steering part of leadership, such as directing and control, and target-oriented management, as well as implementing policy.Five subcategories were identified.( 1) To be result-oriented, to manage, ensure and evaluate performance and accomplishments, and to identify key criteria for performance evaluation.( 2) To develop and implement strategies, visions and goals, setting the direction and to translate broad strategies into practical terms for others.(3) Includes resource allocation, financial management, business literacy, to mobilise processes to acquire resources and ability to use resources effectively and efficiently.( 4) To ensure an efficient and effective organisation and improve processes, analysing the workflow of unit, identifying errors and ability to coordinate individuals and activities.( 5) Includes administrative tasks such as establishing policy, systems and structures, and establishing rules and regulations, getting and administer human, financial, material and information aspects of the healthcare business.Organisational knowledge: Entails knowledge of own organisation, and ability to exploit internal knowledge in the purpose of organisational improvement.Includes four sub-categories.( 1) Knowledge of own organisation's rules and regulations, like the institution's standard operating procedures, rules and the institution's services.
(2) Knowledge of the internal life and activities in the organisation, have organisational awareness and possess adequate knowledge of organisation issues.
(3) Knowledge of how the organisation is structured and thereby how it functions, be able to effectively navigate organisational structures, roles and relationships and ability to create an understanding between working departments.( 4) Involves abilities to coordinate operations, knowledge of operations, develop plans for operations in the organisation and knowledge of sequential and reciprocal task interdependencies.Technology: Includes skills and abilities to know of and be able to use information technology.This category has two sub-categories.(1) Involves to use and manage information technology, to use information technology in patient care management and delivery and practice, and be aware of ethical issues regarding information technology.( 2) Development and improving services using new technologies and appreciate the need for development and modernisation of the system of communication to keep up with rapidly evolving technologies.Knowledge of the healthcare environment: Contains knowledge of how politics, other healthcare organisations, the community or municipality influence and affect own organisation.Three sub-categories comprise this category.( 1) Involves abilities to envisaging potential impacts of decision making on operations, health care, human resources and quality of care, to implement plans and projects and to analyse and understand demographic, political, social, technical, cultural and economic factors and their impact on the organisation.( 2) Understand how organisations in the healthcare sector interact and are interdependent, and to demonstrate understanding of the roles of key stakeholders in health care and how they interact.LHS 37,5 (3) Entails knowledge and understanding of the situation in the healthcare sector, how it works and identify development trends that can affect the organisation.Change and innovation: Includes to identify and respond to challenges and changes in the health service.Four sub-categories comprise this category.( 1) Includes to lead and manage change successfully, to accommodate resistance, involving key stakeholders in designing and implementing change and practise shared decisionmaking in the process of change.(2) To identify the need for change and be able to analyse environmental developments that will necessitate change, have foresight and to anticipate resources needed to carry out initiatives.(3) Being able to initiate change to improve the organisation and services, like implementing improvement activities gradually over time, and be willing to challenge prevailing practice.( 4) Taking initiative and facilitate for change and innovation, to be enthusiastic local "change agents", and ability to use novel thinking in managerial planning.Knowledge transformation: Entails using knowledge from both internal and external sources.Competencies include to actively seek knowledge and information, to be enquiring and to learn outside of own context.This includes three subcategories.(1) To facilitate for spreading knowledge to and among staff, to effectively share information and responsibility at different organisational levels and promote an openness to real interchange with those involved in the organisation.(2) To acquire knowledge from different sources, to use this knowledge in practice, produce knowledge, benefit from others' experiences in the field of health and ability to collect and analyse valid information in an appropriate time.
(3) To use knowledge and own and others' experience, to implement best practice procurement, conduct evidence informed decision-making and to gather information to produce an evidence-based challenge to systems and processes to identify opportunities for service improvements.Boundary spanning: Involves competencies to coordinate and cooperate beyond the boundaries of own organisation.Three sub-categories constitute this category.(1) Includes creating and maintaining personal and organisational networks regionally, nationally and internationally, ability to understand stakeholder need and to maintain effective stakeholder relationships.(2) Involves to collaborate and build cooperative relationships with stakeholders or other organisations, to communicate and interact with external organisations and build constructive collaboration between new divisions and across agencies.(3) Includes being able to communicate to the environment through media or other channels and provide necessary information about the organisation to stakeholders, other organisations and the community.

Discussion
The objective of this study was to contribute to the field of research as well as the practise field of healthcare services leadership with a new understanding of what constitutes healthcare services leadership competencies and to suggest a holistic framework for healthcare leadership competences that can be applied by both researchers, decision-makers and practitioners for further theoretical and practical development.To answer the research questions, a CIS of the literature was conducted to gather descriptions of healthcare leadership competencies.The result of the literature search provided a rich material to be analysed.Despite including papers from different contexts such as countries, organisations, professions and leadership levels, as well as a diversity in study designs, the retrieved descriptions of competencies resembled.Given that competencies are stated to be highly contextual (Brownell, 2008;Pihlainen et al., 2016), this seems to be contradicted by the similarities in the descriptions across contexts found in this study.Several competency frameworks developed in one context were also confirmed in seemingly highly different contexts.This does not mean that healthcare leadership competencies are not contextual.It may however be an illustration of how challenging it is to identify specific competencies when dealing with such a broad concept in the context of the complex healthcare sector.The fact that many of the reviewed studies used competency frameworks developed in other countries may have contributed to concealing actual differences in competency needs.The competencies described in the material were also quite vague.For example, stating communication as a key competency for healthcare services leadership do not offer any guidance for practitioners as the descriptions given of this competency entail a wide range of highly different skills and abilities.This may therefore elucidate that one-dimensional frameworks for healthcare leadership competencies are not an adequate approach dealing with such a complex phenomenon, especially not if it is meant to be used across contexts.For example, if a healthcare leader wishes to apply research on healthcare leadership competencies to develop competencies in own organisation, it would be an insurmountable task to navigate the literature and get guidance on how to operationalise the frameworks to meet the needs of own organisation.Based on the review of the literature it can therefore be argued that a multi-dimensional holistic framework can be a more suitable approach.To try to accommodate this challenge in practise, this study aimed to develop a common understanding of healthcare leadership competencies based on what knowledge, skills and abilities the research studies describe them as.This resulted in 12 competence categories that describe healthcare leadership competencies and a suggestion of a tentative holistic framework for understanding the concept.

Development of healthcare leadership competence categories
To answer RQ1, how leadership competencies in the context of healthcare services are described in empirical research articles and what they entail, descriptions of competencies were coded and categorised resulting in 12 competence categories.Although the amount of support for each category in the data differs, each category is assessed to have sufficient data to support them and it would make the category too diverse if it was to be merged into another category (Braun and Clarke, 2006).It has however been a question of discussion during analysis whether the categories with the lowest consensus in the included literature should and could be merged into other categories.But as this analysis was guided by the compass question "what knowledge, skills and ability do this competency description entail?" the eventual merge created too much diversity and are not in line with the inclusion/ exclusion criteria of the existing categories.It is also a fair point that the included literature in this study is not exhaustive, hence there are probably leadership competency descriptions missing in the analysed data that could strengthen some of the categories or even contradict some.The categories presented in this study serve as a basis for further development and refinement.In addition to possible deficiencies in the sample, other significant changes in the environment can affect the competencies needed for healthcare leaders.
The competency descriptions were coded and categorised in several rounds that resulted in a continuous rearrangement of where the descriptions were placed.Several of the descriptions can also be interpreted to fit more than one category.For example, the description "interprofessional collaboration with trust, respect and ethical manner" (Gunawan et al., 2019) entails skills and abilities suited for several categories.

LHS 37,5
Interprofessional collaboration is prominent in ( 4) professionalism where interprofessional collaboration is interpreted as a part of developing and facilitating for professional practice.Trust is included in (1) character; to act and be trustworthy, and able to gain trust, (2) interpersonal relations; to be able to build trust and collaborative relationships, and (12) boundary spanning; ability to maintaining mutual understanding and trust with clients, communities, and other team members through effective communication.Whereas ethical manner is coded in (1) character; behaving in an open, honest and ethical manner, and (2) interpersonal relations; interprofessional collaboration with trust, respect and ethical manner, most descriptions involving ethics are coded in ( 4) professionalism where ethics and values is a sub-category.For practical implications, to identify specific competencies needed for successful interprofessional collaboration, these will be found in several of the categories.
Suggesting a holistic framework to understand and operationalise healthcare leadership competence RQ2 asked for how leadership competence in the context of healthcare services can be understood and operationalised holistically.This was answered by an inductive analysis technique.During the selective coding, the content of the 12 categories was analysed at a higher level of abstraction that resulted in some central overall characteristics of the categories.As the categories were compared to each other, these abbreviated characteristics were identified as personal-, technical-, organisation internal-and organisation-external competencies.The personal competencies are personal characteristics, interpersonal skills and abilities, and skills and abilities to influence and motivate others.Technical competencies are knowledge, skills and abilities that enable a leader to conduct tasks such as clinical and professional abilities, budgetary skills, strategy development or ability to apply information technology.Some of the competencies were relevant for practicing within the organisation, while others were tied to the external environment of the organisation.For example, descriptions like "building constructive collaboration between new divisions and across agencies" were placed in (12) boundary spanning with emphasis on organisational external competencies, and not in (2) interpersonal where most of the descriptions including collaboration were placed.This way of interpreting the categories also made the distinction between, for example, (6) management and (3) leadership clear, where (6) management is comprised of technical skills tied to the steering part of leadership (e.g.establishing policy, systems and structures), and (3) leadership consists of personal skills to influence and motivate staff (e.g.create and communicate a shared vision for the future and inspire team members to achieve it).The categories are however not exclusively personal, technical, organisational internal or -external, but can be interpreted as dimensions along those axes.This is depicted in Figure 2.
Figure 2 illustrates that the 12 competence categories can be predominantly personal (1. character, 3. leadership, 2. interpersonal relations), predominantly technical (6. management, 8. technology) or have an even distribution of personal and technical competencies (12.boundary spanning, 9. knowledge of the healthcare environment, 11. knowledge transformation, 4. professionalism, 5. soft HRM, 7. organisational knowledge).They can be predominantly tied to the organisation (2. interpersonal relations,3. leadership,5. soft HRM,10. change and innovation,7. organisational knowledge,6. management,8. technology), predominantly tied to the external environment of the organisation (12.boundary spanning, 9. knowledge of the healthcare environment) or be evenly tied to both internal and external A holistic framework the organisation (4.professionalism, 11. knowledge transformation).The competence categories include multiple competency types, such as behavioural, functional, personal and cognitive competence.
For practical utilisation of the holistic framework suggested in this study, one needs to map the competency requirements in the unit, department or organisation in question.At different leadership levels as well as in different contexts, the emphasis of each category will differ and all may not be relevant at all.The degree of technical versus personal, internal or external can also vary depending on which competencies are needed.

Strengths and limitations
This literature review was conducted with results from only two databases.In this study, identifying the right leadership competencies was not an aim, but rather to establish a general picture of how competencies in the context of health care are described in empirical research articles.Therefore, a quite wide net was cast using a search string that allowed hits for all peer-reviewed research articles published from 2010 until 2022 that included leadership or management competence in health care.Because it was the term competence that was under investigation in this study, synonyms such as skills, abilities, characteristics, knowledge and other terms alike were excluded.Because of this, it is likely that there exist empirical studies that could have added to the development of the competence categories or could have contradicted some of the descriptions used in this analysis that were assessed as quite harmonised.A CIS also opens for a broader search, including grey literature, books and policy documents, but this study was limited to published empirical studies.This limitation could also have affected the result.
The results of this study indicate that the descriptions of healthcare services leadership competencies are somewhat general and contradictory to the statement that competences are highly contextual.This might also be a result of the search string used in this study that was shaped in a general manner excluding synonyms of the comprehensive term competence.Conducting searches investigating professions, sectors and leadership levels separately could have revealed clearer contextual differences than this study intercepted.In other words, a generic search for leadership competencies in the health service might have led to a generic result of descriptions of such.The 12 competence categories developed in this study must therefore be considered indicative in line with the inductive and explorative approach in this review and as a consequence of the limitations in the search strategy.The strength of this study is however that the data retrieved from the included papers was exposed to a thorough and iterative coding and analysing process guided by grounded theory.The suggested framework represents a new understanding of how both researchers and practitioners can operationalise healthcare services competencies.

Conclusions
This study is an effort to tentatively suggest a holistic framework for healthcare services leadership competencies to clarify the overarching usage of the concept.This study suggests 12 competence categories that offer a new understanding of healthcare leadership competencies.This framework can support a unifying understanding of how healthcare services competencies can be understood, contributing to a common language handling a concept filled with diversity of views and making it possible to operationalise the competency needs in a healthcare organisation.A holistic framework

Figure 1 .
Figure 1.Process of study selection and search results Figure 2. A holistic framework of healthcare leadership competence