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Originally published and now reprinted with permission from JONA, 2022;52(1):19-26.

JONA • Vol. 52, No. 10 • October Supplement 2022

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 partnered to conduct a Delphi study to identify current
NALS research priorities. Research priority areas identi-
fied through the Delphi survey are reported in an earlier
publication.5 The purpose of this article is to present
findings from the study's open-ended questions, describe
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how they relate to the identified research priorities, and
provide future direction for building the science to guide
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nursing administration and leadership practice.
Nurse leaders' decision making should be guided
by best evidence from NALS. Achieving this goal re-
quires that leaders have: 1) a robust, relevant body
of evidence to inform their practice; 2) essential resources
and organizational support to sustain continual dis-
covery; and 3) proficiency in implementation science
(IS). Although progress is occurring in each of these
areas, challenges remain.
Relevant Research to Inform Leadership Practice
Evidence-based leadership and administrative practice is
only possible when nurse leaders have access to a rele-
vant, robust body of evidence. Although a growing vol-
ume of nursing research is published every year,6 it is still
difficult for many nurse leaders to find evidence suit-
able for their situation and context. Although nurse
researchers strive to generate clinically relevant evi-
dence, many are trained to prioritize internal validity
over external validity in their work,7 meaning that gen-
eralizability across situations is rarely addressed. As a
result, research findings may not adequately account
for the many contextual factors that influence implemen-
tation and effectiveness, thus limiting their utility in prac-
tice.8 For example, nurse staffing models validated in
large, academic medical centers may not be applicable
in smaller community hospitals or rural critical access
hospitals. In other cases, a well-studied clinical intervention's
complexity or cost may make it impractical to implement
where resources are scarce.7 Furthermore, expectations
of academe dictate that nurse researchers publish findings
in research journals, resulting in evidence that may not be
accessed by nurse leaders in practice. There are many
challenges, such as time and attention, that arise in
the robust dissemination of evidence.
Currently, concerted efforts are being made to es-
tablish and enhance academic-practice partnerships
by the American Association of Colleges of Nursing,
ALSN, and AONL. These academic-practice partner-
ships present promising opportunities to leverage the
expertise of NALS researchers and nursing leaders
in practice to generate research evidence that is robust,
readily available, and relevant. Such partnerships can
advance the field of NALS research and evidence-
based leadership by ensuring that NALS researchers
ground their work in the broad context of everyday
practice, resulting in relevant evidence that is ready
for implementation.8,9
20
Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.
S4
Resources and Organizational Support
Sustaining evidence-based leadership requires es-
sential resources and organizational support such
as adequate time, competent employees, and a sup-
portive organizational culture and policies.10 Funding
is also critical for researchers working to advance nurs-
ing leadership science.11 Without adequate funding,
resources, and organizational support, evidence-
informed decision making may become short-term
and reactive versus deliberative and proactive in im-
plementing change.
Proficiency in Implementation Science
Nurse leaders need to be proficient in Implementation
science (IS). The field of IS aims to reduce the 17-year
gap between evidence generation (research) and its use
in evidence-based practice.12 Implementation scientists
understand that efforts to systematically adopt evidence-
based practices are especially complex, given the numer-
ous, interrelated contextual factors (eg, organizational
culture, resource availability, features of the physical
environment) that must be considered.13 Nursing ad-
ministration and leadership science researchers also un-
derstand and embrace the importance of context, thus
often turning to research methods such as qualitative
description and survey data to describe the nursing
practice environment and factors associated with
nursing leadership. Few nurse leaders in practice or
academe are aware of the field of IS, and therefore have
yet to leverage the theoretical frameworks and associated
research methods to understand and test determinants of
adoption, implementation, and sustainability of evidence-
based practice. Although Doctor of Nursing Practice
(DNP)-prepared leaders have a strong grounding in
quality improvement and evidence-based practice, a
gap remains in providing a systematic understanding
of how to implement the evidence into practice. Profi-
ciency in IS and practice is needed to close the gap be-
tween what is known to be effective (research evidence)
and what is needed to ensure its application in every-
day practice.14
Despite a history of NALS research of 30+ years,
significant gaps remain in translating this research
into daily practice. As part of a larger study,5 we sought
to understand from ALSN members, AONL members,
and NALS experts what areas have limited evidence to
guide leadership practice and what are the current chal-
lenges to conducting NALS research.
Methods
This study used a Delphi-type descriptive survey de-
sign. The Delphi survey was administered to ALSN
2019 conference attendees (n-47), AONL 2020 con-
ference attendees (n = 107), and a panel of experts
JONA  Vol. 52, No. 1  January 2022
JONA • Vol. 52, No. 10 • October Supplement 2022
 (n = 21). The panel of experts was selected based on
their areas of expertise with attention to creating a di-
versified sample. The details of the Delphi methods
was used in this study was reported in an earlier pub-
lication.5 In addition to the survey items, participants
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were asked to respond to 2 open-ended questions: 1)
“What areas of NALS have limited evidence to guide
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your decision making?” and 2) “What are some of
the barriers and challenges associated with conducting
NALS research?”
Analysis
Direct content analysis was conducted.15 The open-
ended responses from the 3 participating groups (ALSN,
AONL, and national experts) were imported into an
Excel spreadsheet for manual coding. Two teams of
3 members each individually coded the raw data. Each
coder read the data from beginning to end and identi-
fied key concepts. The unit of analysis was a word or
phrase that answered the specific question. After the
initial open coding, preliminary codes were assigned,
and subcategories were identified. Categories were then
sorted into order (axial coding) and categorized with
labels titled super categories. This process ensured de-
pendability of findings. Four members of the research
team engaged in peer debriefing to ensure confirmability
and concordance of findings and to compare the super
categories with the research priority areas identified
through the quantitative Delphi survey results.
Findings
The quantitative portion of the Delphi study identified
6 top NALS research priority areas—in priority order:
1) nurses' health, well-being, and resiliency/safety in
the workplace; 2) developing and managing a nursing
workforce to meet current and future healthcare needs;
3) healthy work and practice environments for direct
care nurses; 4) healthy work and practice environ-
ments for nurse leaders; 5) quantification of nursing's
value across the healthcare delivery system; and 6)
nurse leaders' development and essential competen-
cies.5 In this study, 3 super categories emerged related
to areas with limited evidence to guide leadership prac-
tice, and 5 super categories emerged related to the chal-
lenges of conducting NALS research.
Areas With Limited Evidence to Guide
Leadership Practice
Three super categories emerged from the data on areas
of NALS that have limited evidence to guide decision
making (Table 1): 1) quantifying the impact of nursing
service; 2) staffing models for point-of-care services;
and 3) nursing leadership development.
JONA  Vol. 52, No. 1  January 2022
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JONA • Vol. 52, No. 10 • October Supplement 2022
Quantifying the Impact of Nursing Service
Quantifying the impact of nursing service was a su-
per category that includes the value of nursing and
the financial justification for the work of nurses.
Respondents expressed a need to provide evidence
of nursing's contribution to an organization's bot-
tom line. This evidence is needed to support nurse
leaders' decision making by “being able to explain
in hard numbers the ‘value of nursing care.’” Hav-
ing this evidence would support nurse leaders in el-
evating “nursing status within organizations, value
proposition for nursing, [and] effective advocacy.”
As one respondent shared, “Nursing research (is
needed) to explore the benefits of business intelligence
supporting frontline and mid-level nurse leaders.”
This super category highlights the financial pressures
realistically encountered in practice.
Staffing Models for Point-of-Care Services
The need for research on new staffing models to guide
point-of-care services emerged as another super category.
Respondents shared, “Patient acuity and staffing models
are old and need revision. They do not match our current
reality.” A need for new acuity-based staffing models
that take into account multidisciplinary teams, pandemic
staffing, and care across the continuum of care (eg,
hospital-at-home, hospice, outpatient/ambulatory) was
noted by several respondents. This super category re-
flects the historical and ongoing pressures for workforce
management and evolution of effective deployment.
Nursing Leadership Development
Development of nurse leaders was the 3rd super category
identified by respondents as having limited evidence to
guide decision making. Several respondents noted more
evidence was needed on the impact of leadership training
and DNP preparation on staff and patient outcomes,
including “instruments for measuring leadership effec-
tiveness and effectiveness of development programs.”
“Futuristic thinking/foresight leadership,” “systems
thinking,” and “ability to assess IQ in leadership” were
also identified as areas with limited evidence. Respon-
dents also noted a lack of evidence on the effectiveness
of online versus classroom education, as well as the
“use of simulation to teach or validate nursing leader-
ship competencies.” This super category directs atten-
tion to developing skills in the vital skill of leadership
in complex healthcare organizations, perhaps intensi-
fied by social and healthcare challenges nationally that
have demonstrated the visible results of the difference
effective leadership makes.
Challenges to Conducting NALS Research
Five super categories emerged from the data on bar-
riers and challenges to conducting NALS research
21
S5
 Table 1. Areas of NALS With Limited Evidence for Decision Making
Super Categories Supportive Quotes

Quantifying the impact 1. “Being able to explain in hard numbers the ‘value of nursing care’”
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of nursing service 2. “Value of nurses in healthcare”

3. “Nursing status within organizations, value proposition for nursing, effective advocacy”
4. “Finance and business acumen”
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5. “Nursing research to explore the benefits of business intelligence supporting frontline and mid-level
nurse leaders”
6. “How to support the financial justification for the work of nurses”
Staffing models for point- 1. “Patient acuity and staffing models are old and need revision. They do not match our current reality.”
of-care services 2. “Acuity-based staffing including multidisciplinary teams”
3. “Staffing and daily work life of bedside staff/time studies”
4. “Acuity based staffing models and quality of care impact and expense impact”
5. “Staffing and daily work life of bedside staff/time studies”
6. “Staffing Models looking across the Continuum of Care—hospital-at-home; hospice; SNF etc”
7. “Pandemic staffing”
8. “Staffing models for outpatient treatment areas”
9. “Staffing and the emerging ‘new’ team-based models of care—impact on patient outcomes and staff
satisfaction”
Nursing leadership 1. “Systems thinking”
development 2. “The impact of DNP education on the quality of graduate leadership education and leadership science”
3. “Academic preparation in nursing leader decision making”
4. “Instruments for measuring leadership effectiveness and effectiveness of development programs”
5. “Impact/outcomes of DNP roles in organizations”
6. “Online education effectiveness vs. traditional classroom”
7. “Futuristic thinking/foresight leadership”
8. “Development of APRNs and CNLs to become leaders, beyond clinical bedside leaders. Need more
information on how their educational preparation prepares them (or doesn't) to advance in nursing
leadership.”
9. “Use of simulation to teach or validate nursing leadership competencies”

(Table 2): 1) personnel with research competencies; 2)
time; 3) lack of leadership support; 4) methodologi-
cal challenges; and 5) funding.
Personnel With Research Competencies
Many respondents reported a lack of personnel with
research competencies necessary for conducting NALS
research as a significant challenge. The lack of ade-
quately prepared researchers was viewed as stemming
from a lack of faculty mentors to train junior faculty
and/or clinical nursing scientists in NALS and a lack
of PhD nursing students interested in NALS. As one re-
spondent shared, “A significant barrier would be clo-
sure of graduate level MSN leadership programs. This
decreases the supply of future potential doctoral stu-
dents and graduates interested in conducting research
specific to nursing leadership and administration.”
Respondents also pointed to a “disconnect between
academic environments and clinical practice settings”
explaining, “researchers don't work as leaders in hos-
pitals and vice versa.”
Time
Time to either conduct or foster a research climate was
a frequently cited constraint. One respondent stated,
“Because I work in practice, creating the time to focus
on research will be difficult.” Nurse leaders are con-
sumed with day-to-day decision making and strategic
management. Little time is left to set a research agenda,
although research could lead to better decision making.
Lack of Leadership Support
Another super category that emerged as a challenge to
conducting NALS research was a lack of leadership
support across the organization, from nursing leaders,
senior managers, and other executives. One respondent
identified that research might not be a priority for the
chief nursing officer if they did not have a doctorate.
Another shared, “In an organization that is not based
in an academic environment, there can be limited exec-
utive support for a robust nursing research program.”
“Achieving operational buy-in and commitment of re-
sources” were identified as significant barriers.
Methodological Challenges
Nursing administration and leadership science research
takes place in complex, uncontrolled environments. As
one respondent stated, “Complexity is not studied using
traditional research methodologies, yet evidence-based
practice (EBP) level of evidence tables state traditional
research methodologies are the highest level of evidence.”
Studies are often qualitative in nature. If quantitative re-
search is conducted, sample sizes are often small, leading
to lack of generalizability. Even if variables could be
controlled, each organization has a different set of com-
plexities that makes applying research findings difficult.

22 JONA  Vol. 52, No. 1  January 2022

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S6 JONA • Vol. 52, No. 10 • October Supplement 2022

 Table 2. Barriers and Challenges With Conducting NALS Research
Super Categories Supportive Quotes

Personnel with research 1. “Decreases supply of future potential doctoral student and graduates interested in conducting these
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competencies kinds of studies”

2. “Lack of faculty to teach research in many organizations”
3. “Junior faculty having difficulty finding faculty mentors”
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“Having an adequate supply of qualified nurse researchers”

4. “Increase PhD outcomes researchers”
5. “Knowledge of research methods and analysis”
Time 1. “Limited time”
2. “Because I work in practice, creating the time to focus on research will be difficult”
3. “Time perspectives”
4. “Time tradition”
5. “Time and work environment: cultural norms”
6. “Time for nurse leaders to participate and engage in research”
Lack of leadership 1. “Lack of support”
support 2. “Senior manager and organizational support”
3. “Support from non-nursing leaders”
4. “Not a priority for the CNO if she is not doctorally prepared”
5. “Achieving operational buy-in and commitment of resources”
6. “In an organization that is not based in an academic environment, there can be limited executive
support for a robust nursing research program.”
Methodological 1. “Complexity is not studied using traditional research methodologies yet EBP level of evidence tables
challenges state traditional research methodologies are the highest level of evidence. Do we need evidence tables
specific to nursing administration and leadership research?”
2. “Controlling for other variables (ie, models of care have confounding variables with nurse experience,
education, size of unit, nurse leader impact)”
3. “Typically research is qualitative, not quantitative...lack of control group etc.”
4. “Willing participants”
5. “Attaining the necessary sample sizes for quantitative studies”
6. “Large variability in practice environments”
Funding 1. “Lack of funding and available grants”
2. “Funding is required to get release time from teaching in order to conduct research.”
3. “Federal agencies do not support work environment research.”
4. “No funding from nursing as an AMC with no nursing school affiliation”
5. “Funding and philanthropy”
6. “The limited NIH funding for nurse and health services research has reduced the number of researchers
who study these critical topics.”

As one participant recognized, “Large variability (ex-
ists) in practice environments.”
Funding
Finally, lack of funding was frequently reported as a
challenge for conducting NALS research. Respondents
shared a variety of contributors to the lack of funding,
including limited funding from the National Institutes
of Health and other federal agencies, philanthropy,
and lack of funding support for nursing research from
hospitals with no affiliated nursing school. This lack
of funding impacts both practice and academia. As
one respondent noted, “Funding is required to get re-
lease time from teaching in order to conduct research.”
Alignment Across Research Priorities and
Open-Ended Questions
There was alignment of findings between the 3 research
priority areas identified in the quantitative portion of
the Delphi study and the super categories that emerged
from the 2 open-ended questions (Table 3). Research
priority 2, “Developing and Managing a Nursing
Workforce to Meet Current and Future Health Care
Needs,” aligns with the super category of limited evi-
dence for staffing models and point-of-care services.
Research priority 5, “Value of Nursing,” aligns with
the area of limited evidence for quantifying the impact
of nursing services. Finally, research priority 6, “Nurse
Leaders' Development and Essential Competencies,”
aligns with the area of limited evidence on leadership
development.
Discussion
Our analysis identified key areas that have limited ev-
idence to support nurse leaders' decision making and
current challenges to conducting NALS research.
What is striking about the areas identified where lim-
ited evidence exists is that much research has already
been conducted that might assist nurse leaders in their
day-to-day activities. For example, 2 searches limited
to research articles were conducted in the CINAHL
database from peer-reviewed journals from 2000 to

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JONA • Vol. 52, No. 10 • October Supplement 2022 S7

 Table 3. Similarities Between Priority Areas and Open-Ended Responses
Priority Areas
1. Nurses' health, well-being, resiliency/safety in the workplace
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2. Developing and managing a nursing workforce to meet current
and future healthcare needs
3. Healthy work and practice environments for direct care nurses
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4. Healthy work and practice environments for nurse leaders
5. Quantification of nursing's value across the healthcare delivery system
6. Nurse leaders' development and essential competencies
2021 (Table 4). A combination of appropriate subject
terms and free-text words were used to locate litera-
ture about nurse staffing models, which yielded more
than 350 records. Literature about the relationship
between nurse staffing and patient outcomes yielded
more than 1450 records. Certainly, the rapidly chang-
ing healthcare environment, amplified by the pandemic,
natural disasters, and mass casualty events, requires
new and adaptive staffing models. Yet, the fact that
2 decades of literature on staffing models and leader-
ship development exists and NALS experts still report
a lack of evidence to guide decision making supports
that there continues to be a gap between the generation
of new knowledge and the adoption of new knowledge
in nursing leadership practice.7,8
Barriers and challenges for NALS research include
a lack of organizational support, insufficient employees
with research competencies, and methodological chal-
lenges in the conduction of research. Challenges in
accessing willing participants, variability in practice
environments, and the inability to control for many
confounding variables contribute to more qualitative and
descriptive studies versus higher level evidence (quasi-
experimental and experimental studies) and multisite
studies with larger sample sizes. Insufficient support
and employees with research competencies may contrib-
ute to a dearth of NALS research. Nursing administra-
tion and leadership science needs to evolve by expanding
the complexities of research methodologies to achieve
higher levels of evidence so as to best understand what
Table 4. CINAHL Search Strategy
CINAHL Search Strategy for Staffing Models (4/7/21)
(MM “Nursing Manpower+” AND MH “Personnel Staffing and
Scheduling+” AND (TI model* OR AB model*) OR (TI nurs*
AND TI staff* model*))
Filters applied: peer reviewed, research article, publication date
from 2000-2021 = 355
MM = major subject, MH = subject heading, TI = title field
24
Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.
S8
Super Categories
Not applicable
Limited evidence: staffing models for point-of-care
services
Not applicable
Not applicable
Limited evidence: quantifying the impact of nursing
services
Limited evidence: nursing leadership development
works, for whom, and under what conditions. By devel-
oping this type of evidence base, NALS researchers and
leaders can speak in hard numbers about the value of
nursing and NALS research, in turn garnering organiza-
tional support, time, and funding to continuously drive
NALS research and practice.
The alignment across the research priority areas
and qualitative open-ended questions is an interesting
finding that provides additional credibility and is im-
perative to these findings. The barriers and challenges
to conducting NALS research may explain reasons
for limited areas of evidence but simultaneously may
pose an opportunity for stimulating partnerships across
academe and practice, and expanding studies to include
multiple sites.
Implications for Practice and Research
Brand Image of Nursing and Nursing Leadership
A domain of professional identity in nursing is knowl-
edge that is defined as the application of information de-
rived from nursing and other disciplines, experiences,
critical reflection, and scientific discovery.16 If nurse
leaders do not fully embrace the use of scientific dis-
coveries of NALS, this may be problematic for nursing
leadership's brand image. An inconsistent brand image
of nursing has been shown to impact the amount of
resources allocated to the nursing profession. This in-
consistency may be a detriment to nursing's perceived
value and its impact on the nation's health.2,17,18
CINAHL Search Strategy for Staffing and Outcomes (4/7/21)
(MM “Nursing Manpower+” AND (MH “Outcomes (Health
Care) +” OR MH “Treatment Outcomes+” OR MH “Outcome
Assessment”) OR (TI nurs* AND TI staff* AND TI outcome*))
Filters applied: peer reviewed, research article, publication date
from 2000-2021 = 1468
MM = major subject, MH = subject heading, TI = title field
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JONA • Vol. 52, No. 10 • October Supplement 2022
 Academia and Practice Collaborations
The COVID-19 pandemic served as an important re-
minder of the crucial role of evidence to guide organi-
zational leadership to prepare, prevent, and respond
to emerging issues within health systems.19 The sud-
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den severity of this crisis brought into focus the cru-
cial need for prepared nurse leaders armed with the
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latest evidence base. The absence of evidence to support
leadership decision making on new ways to manage pa-
tient care surges, staffing models, staffing shortages, and
new clinically complex care situations was highlighted.20
This reinforces the need to embrace NALS research.
Nursing leaders cannot afford to be constrained by
limited evidence that neglects to drive the science or prac-
tice forward. If nurse leaders neglect to tackle the barriers
that could advance nursing leadership science, then
the profession could remain stagnant. It is imperative
that academic-practice partners coalesce around the
goal of building the nursing profession by moving nurs-
ing leadership science forward.
Limitations
One limitation of this study was the COVID-19 pan-
demic. The pandemic emerged during data collection
and may have influenced respondents. Another limi-
tation is that the study used a convenience sample of
individuals who attended either the 2019 ALSN con-
ference or the 2020 AONL conference. Individuals who
attended the conferences may differ from those who did
not, and thus, the findings may not be generalizable to
all ALSN members, AONL members, or other nursing
leaders beyond these organizations. Finally, the panel
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Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.
JONA • Vol. 52, No. 10 • October Supplement 2022
of experts was purposively selected. Although the re-
searchers attempted to generate an expert panel of in-
dividuals with diverse backgrounds and diverse areas
of practice, experts outside this panel may have pro-
vided a different perspective.
Conclusion
This Delphi study used a consensus approach to final-
ize 6 priority areas for NALS research. The emergence
of reoccurring nursing challenges associated with NALS
research suggests that nurse leaders need to decipher
what issues have sufficient evidence to warrant transla-
tion into practice from what challenges require sustained
and systematic research evaluation. Findings from this
study illuminate important challenges and opportunities.
Although many of the barriers to NALS research are not
new, solutions for moving forward through academic-
practice partnerships, IS, and attention to dissemination
of research findings can advance the field of NALS re-
search, improving evidence-based leadership decision
making, advancing the nursing profession, improving
the brand image of nursing leadership, and ultimately,
achieving the health goals of the nation.
Acknowledgments
The authors would like to thank the American Organi-
zation for Nursing Leadership Foundation for funding
this study. They also would like to thank the board
members of the Association for Leadership Science in
Nursing and the American Organization for Nursing
Leadership Foundation for their support of this work.
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JONA  Vol. 52, No. 1  January 2022
JONA • Vol. 52, No. 10 • October Supplement 2022