Challenging traditional leadership models: a narrative review of advanced practice provider integration in health system governance.

Abstract

Purpose: Advanced practice providers (APPs) are essential to health system capacity yet remain underrepresented in governance and executive leadership. This narrative review synthesizes existing peer-reviewed and organizational evidence into a five-domain framework for APP leadership integration and assesses its implications for organizational performance.

Design/methodology/approach: A targeted narrative review was conducted, drawing from peer-reviewed literature, organizational case reports, and industry analyses published between 2013 and 2025. Sources were identified through PubMed, CINAHL, Google Scholar, discipline-specific journals and professional organizations. Inclusion criteria focused on governance, leadership, and organizational integration of Physician Assistants and Advanced Practice Registered Nurses. Given the applied focus on governance, selected grey literature was included to capture emerging practices. Evidence was synthesized thematically into five domains of APP leadership integration. This approach emphasizes conceptual clarity rather than exhaustive coverage.

Findings: Five interdependent domains of APP governance integration emerged: (1) governance inclusion and medical staff structures, (2) leadership development and career pathways, (3) operational alignment and role optimization, (4) culture, scope, and policy enablement and (5) measurement, accountability and the business case. Together these domains provide a framework for intentional inclusion of APPs in health system governance. Evidence indicates that APP leadership integration supports workforce retention, improves efficiency, and contributes to financial sustainability. Distinctions were noted between public and private health systems, with mission-driven organizations emphasizing equity and access, and private systems prioritizing return on investment and margin recovery.

Research limitations/implications: As a targeted narrative review, this study does not claim exhaustiveness and may be subject to selection and publication bias. The existing literature is largely descriptive, with limited comparative studies or standardized outcome measures. Future research should evaluate governance models across diverse systems and establish benchmarks for measuring the impact of APP leadership.

Practical implications: Health systems can strengthen organizational performance by embedding APPs into governance structures, developing leadership pipelines, aligning roles operationally, fostering inclusive cultures, and implementing measurement frameworks. These strategies reduce turnover, improve collaboration and enhance financial and clinical outcomes. While public sector systems may emphasize access and equity, private sector systems may prioritize return on investment and margin recovery, making APP governance integration a valuable strategy across contexts.

Originality/value: While prior reviews have cataloged factors influencing APP workforce integration, this is the first narrative review to focus specifically on governance and leadership structures. By consolidating fragmented literature into a five-domain framework, the paper advances the discussion from whether APPs should be included in governance to how their inclusion can be intentionally structured and evaluated to improve system performance.