Frontline nurse manager responsibilities are extensive. Nurse managers are torn between the demands of clinical nurses, physicians, patients, and administration, which require a blend of clinical skill, leadership ability, and managerial knowledge.1,2 Nurse manager competence and retention can be improved by creating structured leadership development programs that better prepare nurses to lead in today's complex healthcare environment.3-6
Many hospitals have poorly designed nurse manager orientation and professional development programs, or none at all.6,7 The primary reason many nurse managers aren't prepared to successfully lead in our current multifaceted healthcare environment is a lack of formal leadership training.6 Often, RNs who demonstrate outstanding clinical skill, knowledge, and behavior are promoted to nurse manager positions despite a lack of formal leadership and management preparation.7-9 Unfortunately, good clinicians don't necessarily develop into good nurse managers. Nevertheless, 61% of nurse leaders are internally promoted.10
Nurse managers who've been in their position 5 years or less have turnover rates as high as 50%.11 It's estimated that in the next few years, 75% of nurse manager positions will be vacant.12 These statistics create an urgent need for developing current and future nurse leaders at every level.13 The first step in preparing future nurse managers begins with an organizational commitment to nurture and develop the next generation of leaders.
We present a model for evaluating and improving current nurse managers' leadership and management competency at a community hospital, including the experiential learning activities developed based on an evaluation of competency gaps and the resulting competency of nurse managers following the training. A pretest/posttest descriptive study was conducted to assess current nurse manager perceived level of leadership competence. Program evaluations occurred immediately after the experiential learning session and at the end of the study. For this study, the nurse manager was defined as a unit-based nurse leader with 24-hour responsibility for the financial and operational aspects of an inpatient nursing unit.
Benner's novice to expert theory provided the framework for this study.14,15 The theory hypothesizes that nurses move through five stages of competency while gaining and developing skill through experiential learning: 1) novice, 2) advanced beginner, 3) competent, 4) proficient, and 5) expert. Literature supports this theory as a foundation for nursing leadership development and competency measurement.16,17
Although there's no specific definition for nurse manager competency found in the literature, it has been referred to as the ability of nurse leaders to use the nursing process to evaluate the efficiency and effectiveness of patient care delivery by the nursing staff to support optimal patient outcomes.3 Our study demonstrates an increase in nurse managers' competence as they gain experience. (See Figure 1.) With experience, a nurse manager acquires peer admiration, respect, and direct reports' trust; this occurs as they move through the novice to expert stages.18
The setting for the study was Community Hospital in Munster, Ind. Institutional Review Board approval from the University of Southern Indiana and Community Hospital was obtained. Community Hospital is a 458-bed, not-for-profit, tertiary facility that provides comprehensive health services. The hospital is part of the three-hospital healthcare system in northwest Indiana. Community Hospital's mission is to provide the highest quality care in the most cost-efficient manner, respecting the dignity of the individual, providing for the well-being of the community, and serving the needs of all people, including the poor and disadvantaged. The hospital's values are dignity, compassionate care, community, quality, and stewardship.
All current nurse managers were eligible to voluntarily participate in the project regardless of their number of years in nursing leadership. Twenty-eight nurse managers were brought together, had the purpose of the study explained to them, and consented. Participant demographics are outlined in Table 1. The majority of the participants were female (96%) and the median age was between 41 and 50. Seventy-nine percent had a BSN degree or higher. Eighty-six percent reported that they had received no formal leadership development when they first became a nurse manager.
The Nurse Manager Skills Inventory (NMSI) was used to evaluate the participants' perceived level of competence in three leadership domains: the science (business management), the art (leading people), and the leader within (self-reflection).19 Participants self-rated their experience in each domain on a scale of novice (1 point), advanced beginner (2 points), competent (3 points), proficient (4 points), and expert (5 points).
All 28 nurse managers were asked to complete the NMSI via an online survey within 1 week. The results of the initial NMSI were assessed to determine the domain(s) in which the greatest number of nurse managers indicated that they were less than competent. Most of the 28 nurse managers rated themselves as less than competent in the financial management areas of the science domain. (See Table 2.) Financial areas included understanding healthcare economics and policy (14/28), expense forecasting (14/28), concepts of capital budget (15/28), and concepts of cost-benefit analysis (15/28).
Based on these findings, experiential learning activities were developed that consisted of group work; case studies; and exercises in financial analysis, budget practice, and cost-benefit analysis scenarios. Each participant was provided resources, including 1) articles specific to nursing finance; 2) cost-benefit analysis methods; 3) a glossary of financial terms; and 4) healthcare financial formulas, such as nursing hours per patient day, occupancy rate, and average daily census. Following the experiential learning activities, the participants resurveyed the NMSI domain for which the experiential learning was conducted. Additionally, the nurse managers who attended the training completed a postprogram evaluation.
Following the targeted experiential learning activities, the financial management areas of unit department budget, creating a budget, monitoring a budget, and analyzing a budget demonstrated a rise in the median self-ratings. The scores increased from less than competent (median, 2 to 2.5) to competent (median, 3) (p = 0.009). Median self-ratings on the financial management areas of understanding healthcare economics and policy, expense forecasting, concepts of capital budget, and concepts of cost-benefit analysis were also significantly improved after training (p = 0.009). This improvement reflected a shift from novice to advanced beginner as opposed to a shift to competent. Significant improvement from the novice to advance beginner level was also observed for reporting on budget variance, revenue forecasting, and interpreting financial information (p = 0.009). (See Table 3.)
Further research involving both qualitative and quantitative data may be more meaningful to understand barriers to education and reasons for nurse manager turnover. A longitudinal study would be beneficial to see if nurse managers continued to improve in their leadership abilities over time with additional experiential learning. This study was limited due to the small sample size. The data would be more significant if it were obtained from a larger sample size and included more than one hospital within a multifacility system.
The Institute of Medicine report “The Future of Nursing: Leading Change, Advancing Health,” recommends that nurses should be prepared to lead and advance the future of our healthcare system.13 However, research suggests that high-functioning clinical nurses are often promoted to nurse manager roles for which they lack preparation to be successful as a leader.7-9 For this study, 86% of the nurse managers lacked formal training in leadership before becoming a nurse manager. There's an abundance of literature regarding the turnover rate of nurse managers as it relates to lack of formal training. The anticipated nurse manager shortage indicates a need to assess, prepare, and support our nurse managers in an effort to recruit and retain them in leadership. Creating a strategic and personalized development plan for nurse managers may improve their competency and potentially decrease nurse manager—and even clinical nurse—turnover.
1. Cziraki K, McKey C, Peachey G, Baxter P, Flaherty B. Factors that facilitate registered nurses in their first-line nurse manager role. J Nurs Manag
2. DeCampli P, Kirby KK, Baldwin C. Beyond the classroom to coaching: preparing new nurse managers. Crit Care Nurs Q
3. Hawkins A, Carter K, Nugent M. Nurse manager orientation. AACN Adv Crit Care
6. Doria H. Successful transition from staff nurse to nurse manager. Nurse Lead
7. Fennimore L, Wolf G. Nurse manager leadership development: leveraging the evidence and system-level support. J Nurs Adm
8. Cathcart EB, Greenspan M. A new window into nurse manager development: teaching for the practice. J Nurs Adm
9. Espinoza DC, Lopez-Saldana A, Stonestreet JS. The pivotal role of the nurse manager in healthy workplaces: implications for training and development. Crit Care Nurse Q
10. Westphal JA. Characteristics of nurse leaders in hospitals in the U.S.A. from 1992 to 2008. J Nurs Manag
11. Kallas KD. Profile of an excellent nurse manager: identifying and developing health care team leaders. Nurs Adm Q
12. Wendler MC, Olson-Sitki K, Prater M. Succession planning for RNs: implementing a nurse management internship. J Nurs Adm
14. Benner P. From novice to expert. Am J Nurs
15. Benner P. From Novice to Expert: Excellence and Power in Clinical Nursing Practice
. Menlo Park, CA: Addison-Wesley Publishing; 1984.
16. Titzer JL, Shirey MR, Hauck S. A nurse manager succession planning model with associated empirical outcomes. J Nurs Adm
17. Butts JB, Rich KL. Philosophies and Theories for Advanced Nursing Practice
. 2nd ed. Burlington, MA: Jones & Bartlett Learning; 2015.
18. Duffield CM, Roche MA, Blay N, Stasa H. Nursing unit managers, staff retention and the work environment. J Clin Nurs