Leaning Into Transformation:

Investment In Nurse Managers

One Solution To The Nurse Reckoning And The Demand For Healthcare Transformation

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Part 1: The Nursing Reckoning– Is it Good or Bad? 

A reckoning is happening across the nursing profession.

Anyone who has opened the internet or watched the news over the last couple of years recognizes that the nursing profession is going through a wave of change. In fact, it is hard not to notice with all the negative media attention the nursing profession is receiving these days. Despite this, nursing was once again ranked the most trusted profession by Gallup, placing nursing at the top of the list, marking the 20th year in a row. This draws into question whether the negative media attention is really the right message, especially for healthcare leaders. Let’s break down what is really occurring, as it all might not be as it seems on the surface.

  • A call to action to provide excellent, safe, effective care delivery. 
  • Changing workforce needs and expectations. 
  • Increasing workload burden leading to burnout. 
  • Acute care nursing - historically the backbone of nursing - is now seen as a steppingstone. 52% of new-graduate nurses leave the hospital bedside within two years of graduating. 
  • New graduate nurses desire to enter the workforce in nontraditional roles. 
  • New graduate nurses are underprepared for today’s complexity and pace. 
  • Calls to radically redesign the role of the RN, noting that RN-dependent care models are unsustainable for the future of healthcare. 
  • An expectation that we demonstrated tangibly the value of the nurse. 
  • Evolving nursing education curriculum and licensure to meet the ever-changing healthcare environment. 
  • Unresolved healthcare ecosystem structural issues. 
  • A radical call for diversity, equity, and inclusion. 

Stepping back, the oversimplified negative narrative regarding nursing does not represent the complexity of what is occurring, nor does it represent the possibilities for the future of nursing and the greater healthcare community. Without the recognition of complexity, the healthcare community and healthcare leadership may fail to provide the correct solutions and the correct leadership to lead through the reckoning.

The truth is, this reckoning, if leaned into correctly – correctly, meaning allowing transformation to occur– could actually be positive for the nursing profession and the greater healthcare community. A further review of the word reckoning, according to Collin’s Dictionary, means a time to fulfill one’s promises or obligations. When pondering reckoning in the nursing profession from this perspective, it is easy to see that all healthcare professionals, including nursing, have more to do and more to fulfill when it comes to delivering on our promise for better health and better communities.

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We must deliver increased value on rising healthcare costs, improve patient outcomes, improve patient experience, and we must eliminate health disparities. 

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The collective call to transform healthcare was placed years ago, yet so much improvement is still needed. In some ways, perhaps the nursing reckoning is simply another call for transformation across the complex healthcare ecosystem. Could this be a call in which excellent clinicians demand transformation for their profession in order to bring about high quality, low-cost care for populations focused on experience and an elimination of disparities? Instead of focusing on the negative of what is happening across the nursing profession, a courageous leadership action would be to lean in, listen empathically and enable transformation. When times become difficult and uncomfortable, our natural human response, even as leaders, is to pull away and attempt to control the chaos; said differently, to return the system to the status quo. However, in order for transformation to occur, we need to lean in and become comfortable with the uncomfortable chaos and create conditions of success for our teams. This leadership behavior will allow transformation to emerge.

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Part 2: The Nurse Reckoning and the Role of the Nurse Manager

One-way managers can lean in is to contemplate one of the most important nursing leadership roles – the nurse manager.

How are we to come through the reckoning stronger and more successful without the core group of nurse leaders - nurse managers - at the forefront of the transformation? Likely, we would not.

The nurse manager’s role is far too valuable and important in the day-to-day operations, leadership, and culture of individual organizations and the collective profession. Seeking to create transformation and strength through the role of the nurse manager is a vital step toward improving the nursing workforce, nursing outcomes, patient outcomes, patient experience, and overall organizational success. However, the data regarding the role of nurse managers demonstrates a similar phenomenon occurring within the nurse manager workforce, as well as the greater nursing workforce. The recently released American Organization of Nurse Leaders (AONL) / Joslin Longitudinal Nurse Leader Survey1 results examined nurse leaders, and the results underscore this phenomenon:

45% of nurse managers are considering leaving.

38% of nurse managers are
considering or intend to leave
within the next 6 months.

35% of nurse managers who intend to leave in the next 6 months intend to leave the profession altogether.

Nurse Managers Also Reported Also Reported The Following As Their Top Challenges

  • Emotional Health and Wellbeing
  • Retention Furloughs and Layoffs
  • Travelers and Contingent Labor
  • Finances

Based on these results, a crisis is brewing among nurse managers that mirrors the crisis amongst the greater nursing profession. Healthcare cannot afford for this talent to leave nursing leadership. We especially cannot afford for our nurse managers to leave the nursing profession. In fact, if this trend continues, it will be detrimental to the nursing profession and the delivery of healthcare. 

It is hard to say which came first in this reckoning: a cry from the greater nursing profession, or a cry from nursing leadership (the chicken or the egg?)

It is also hard not to take note that the nursing reckoning occurs at a time in healthcare where we have yet to achieve healthcare transformation; a call which was placed over 20 years ago. However, what is clear is that without strong nursing leadership, this reckoning could easily become a toxic factor in the healthcare ecosystem instead of a catalyst for transformation. 

This leaves us with a question: how did we get here?

The often-undiscussed truth is the lack of leadership educational underpinnings and investment in the professional development of new and experienced nurse managers.

A national study conducted in 2019 by Nora Warhawks, Ph.D., RN, NEA-BC, FAAN and Emily Cramer, Ph.D.2, found that it takes new nurse managers seven years to develop proficiency when there is no formal professional development plan in place. Time-to-proficiency is one of the major catalysts in nurse managers’ perceptions of success or failure in their role. It also impacts their perceptions of stress, well-being, and their own internal perceptions of mission and purpose. The other catalyst is the complexity of the healthcare world in which we all live and practice today. These two simple facts are likely the ingredients for the perfect storm for nurse managers. To be clear, it’s important to note that many of these nurse managers do have the intellect, fortitude, as well, as many other innate characteristics necessary to lead. However, expecting nurse managers to lead without intentional professional development and education is setting everyone – the nurse manager, the nurses they serve, our patients, and the organization – up for failure. For whatever reason, we underestimate the importance of formal and informal leadership development and education in healthcare. Leadership is both an art and a science. As a result, leadership is a skill that is learned like any other skill or profession.

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Ponder this question as we examine an analogy: 

Would a traditional healthcare leader with a Master’s Degree in Healthcare Administration (MHA), or Master’s Degree in Business Administration (MBA), be capable of taking on a new role in an operating room, serving in a clinical capacity because they have a deep understanding of healthcare operations?

Of course not. The traditional healthcare leader/administrator does not have the educational underpinnings or skillset to be a clinician.

They are capable with their intellect, abilities, and background to learn a clinical skill, but in order to be successful in a clinical role, they need formal and informal education and development. Despite this, each and every day we do this exact thing to nurses and other clinicians when we take them out of their clinical roles and place them in leadership roles without a professional development plan. In some ways, this displays the lack of respect, and even importance, we place on leadership in healthcare. 

Nurse managers have an incredibly difficult role. Serving as the bridge between clinical care delivery and the C-suite requires a unique competency of being able to manage up and down. It has also been noted in significant healthcare literature that in many ways, nurse managers serve as the lynchpin in the organization. In fact, nurse managers make up the largest sector of middle-level leadership in healthcare organizations. Therefore, nurse managers carry much of the organizational burden for effective execution of healthcare delivery operations, as well as organization culture cultivation. 

Nurse managers influence care delivery, quality outcomes, patient safety, organizational culture as well as nurse retention and recruitment. 

They also must manage day-to-day activities such as payroll, internal quality auditing, scheduling, assignments, and many other important tasks. As a result, nurse managers have the unique position in the organization of both needing to be expert at managing and at leading. They must know and understand the difference between managing and leading and successfully apply the right skillset to the right situation. 

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As noted, nurse managers are integral to both the success of the organization and to patient care outcomes. However, it must be underscored again that few new nurse managers have the educational underpinnings in leadership to be successful. Compounding this issue is the lack of organizational professional development programs to support these new nurse leaders. It is difficult to understand why the healthcare profession has failed to implement standard requirements and professional development for such an instrumental group of leaders within the organization. However, this likely falls into the category of “this is how it has always been,” or the minimum expectations for the role are too high leading to a lack of qualified applicants. Instead, we promote an amazing nurse to a nurse manager role, put tremendous pressure on them to be successful and hope they eventually are. We have all been told that hope is not a strategy, yet many fall into the trap of hoping new nurse managers are successful or hoping the right nurse has been promoted to nurse manager. Historically, the strategy of hope has left it up to nurse managers to sink or swim in their new roles. 

This historical perspective may have been good enough in an era where organizations had the time to wait on a new nurse manager to eventually learn and develop their leadership skillset on their own accord. It also may have been okay when the healthcare ecosystem lacked the complexity and even chaos that is prevalent today. But in today’s complex, chaotic, ever-changing world, healthcare organizations no longer can take the risk or the time to allow nurse managers to “sink or swim.” The pressures on the move to value, quality, safety, and complicated workforce dynamics no longer allow organizations the capacity to have this viewpoint. The overarching goal of healthcare transformation does not allow organizations to have this viewpoint. In fact, the data from the AONL Longitudinal study, as well as the current state of the nursing workforce, demonstrates the current strategy is detrimental to our goals of healthcare transformation. 

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Part 3: Leaning into Transformation – Through the Lens of Nurse  

We are at a watershed moment in healthcare. 

We must move to value. 

We must achieve the quintuplet aim, which is: 

improved quality outcomes for the population, improved patient experience, and improved clinician experience, all while lowering costs, addressing health equity, and eliminating health disparities. We will not achieve these goals without nursing, the largest sector of healthcare, at the forefront of this transformation. They are integral to the delivery of care in virtually every healthcare setting. Nurse managers, intuitively, are integral to the success of the nursing workforce and to overall healthcare operations and delivery. Therefore, in today’s tumultuous environment, the role of the nurse manager is even more important and difficult than at any time in history.

The complexity facing a new nurse leader today is quite the conundrum. Learning to navigate this complexity, in today’s ever-changing and challenging environment is an enigma for everyone but even more difficult for a new nurse manager. Remember, nurse managers serve as the bridge between clinical care delivery and the C-suite, which requires a unique competency of being able to manage up and down. They also sit in the sweet spot in the organization where they are responsible for both managing and leading. As a result, nurse managers are unique, and we must intentionally think about their professional development. 

Unfortunately, many times, the nurse manager does not have anywhere to turn for support and mentorship. It is time we rethink nurse manager development, and the role of the nurse manager, and set them up for success in their new roles; thereby, setting the nursing workforce and the organization up for success. Some of the skills that are necessary in both leading and managing for the nurse manager to develop are: 

Leading : 

  • Situational Awareness
  • Relational Coordination
  • Emotional Intelligence
  • Visionary
  • Coach and Mentor – Promotion of human flourishing
  • Navigating Critical
  • Collaboration and Influence
  • Promotion of DEI – promotion of bringing authentic self to work
  • Self-Boundaries
  • Systems Thinking and Complex Adaptive Thinking
  • Influencing Others
  • Ability to connect the dots and translate organizational goals into department goals
  • Managing ambiguity and complexity
  • Connecting and Conflicting
  • Navigating today’s political environment effectively
  • Mindfulness – Introspection and Retrospection

Managing : 

  • Quality and Safety
  • Accreditation
  • Finances
  • Human Relations
  • Productivity
  • Pay Role
  • Schedule

There are many ways these skills can be learned and developed. As an adult learner, one of the most effective ways for skill development is through immersive experiential learning.

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There are many ways these skills can be learned and developed. As an adult learner, one of the most effective ways for skill development is through immersive experiential learning.

Experienced interim nurse executives are one resource that could be effective in providing and supporting new nurse managers in this immersive learning and skill development. Interim nurse executives have the skills and expertise to support the development of new nurse managers through coaching and mentoring, informal didactic education and lessons, prospective & retrospective review of current experiences and opportunities, and onsite support. Simply providing each nurse manager with a formal professional development plan inclusive of an expert coach and mentor, as well as shared goals and outcomes, can exponentially increase their time-to-proficiency and most importantly improve outcomes – for the nurse leader, the nursing workforce, patient outcomes and overall organization outcomes. 

Reflecting back on the top four challenges for nurse managers today: emotional health & wellbeing; retention, furloughs, and layoffs; travelers and contingent labor; and finances. We would be amiss is we did not take notice of the alignment between a manager’s top challenges and challenges for the organization and the C-Suite, overall. Further demonstrating the necessity in investing in nurse managers as a path to organizational success, the enablement of the nursing profession’s transformation and the enablement of the greater healthcare transformation. 

If we can take the time to focus on shared goals, develop strong nurse managers, and all become comfortable with the uncomfortable, we will see transformation. 

Interim nurse executives are an excellent asset and a fiscally responsible way to deliver measurable leadership development outcomes for nurse managers. They have the experience and the relational ability to both teach and coach a new nurse manager. They understand what it is like to sit in the space of managing up and managing down of both managing and leading Interim nurse executives understand firsthand the unique challenges a nurse manager will face. Interim nurse leaders can fulfill the needs of the nurse manager through professional development, and simultaneously, the needs of the organization by providing short term fiscally responsible solutions to the gaps in nursing leadership. In fact, as the organization’s breadth and depth of nursing leadership grows, the interim nurse executive can assist in strategically designing and implementing a sustainable model of internal mentorship that can be scaled and sustained throughout the organization.

About The Author

Amy D. Wilson, DNP, RN, CHPQ, is a leading voice in the healthcare community with 20+ years of Director and C-Suite level experience, shaping operational efficiencies and employee relations within some of the largest healthcare systems in the United States. 

Amy was recently named as one of 2021’s Most Influential Clinical Executives by Modern Healthcare, and also on “Becker’s Hospital Review 66 Chief Nursing Officers of Hospitals and Health Systems to Know.” 

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