Studies report that nursing leadership will be essential to a redesigned healthcare system. In 2010, the Institute of Medicine's The Future of Nursing: Advancing Health, Leading Change landmark report recommended nurses prepare for leadership positions to more effectively lead change and advance health in today's complex healthcare environment.1 In 2015, the Robert Wood Johnson Foundation's Report in Brief: Assessing Progress on the Institute of Medicine Report: The Future of Nursing recommended that preparing and enabling nurses to lead change and advance health continue to be a critical component for the future of nursing.2
The Advisory Board Company shared that impending baby boomer retirements may lead to disruptive leadership turnover in healthcare organizations.3 Nurse manager (NM) turnover is expected to impact 67 000 leadership roles by 2020.4 It is important to understand role-related leadership does not automatically develop nursing leaders with the competencies to achieve organizational goals and meet the demands without appropriate development or experience in their organizations.5 Nursing leaders of today must prioritize and invest in leadership development to ensure effective succession planning.6 Future nurse leaders must be prepared to meet the growing demands of quality care. Nursing leadership development programs must be a priority in high-performing organizations.6
Nursing Leadership Development Program
Healthcare organizations have developed a myriad of approaches to develop future nurse leaders by utilizing both internal and external resources to the organization. Internal resources include leadership activities developed by healthcare organizations. An NM residency and leadership development program are examples of internal resources. External resources include courses, fellowships, or webinars by professional nursing organizations and active partnerships with nursing schools.7,8
The American Organization of Nurse Executives (AONE), Sigma Theta Tau International, the American Nurses Association, the Association of periOperative Registered Nurses (AORN), and the American Association of Critical-Care Nurses (AACN) have developed nursing leadership education courses, fellowships, and webinars for the nurse next-generation of leaders.9 The Nurse Manager Leadership Collaborative developed by the AACN, AONE, and AORN is an evidence-based approach reported to result in increased levels of nursing leadership competencies.10 Preparing future nurse leaders translate into improved work environments and better patient outcomes.10
Nursing Leadership Competencies
Leadership organizations have identified competencies related to nursing leadership training and development and extensive literature related to nursing leadership competencies.6 The AACN, AONE, and AORN initiated the Nurse Manager Learning Partnership, which developed the NM competencies that are based on the NM Learning Framework. The NM Learning Framework has 3 domains: the science, the art, and the leader within.10 The science domain addresses financial management, human resources management, performance improvement, foundational thinking skills, technology, strategic management, and clinical practice knowledge. The art domain is composed of the human resources (HR) leadership skills, relationship and influencing behaviors, diversity, and shared decision making. The leader-within domain focuses on personal and professional accountability, career planning, personal journey disciplines, and internal leadership through reflection.9,10 To measure leadership, Kouzes and Posner11 created the Leadership Practices Inventory Self-assessment to measure nursing leadership competencies described in Burns12 theory. Burns12 defines 5 subscales of leadership competency, which are Model the Way, Inspire a Shared Vision, Challenge the Process, Enables Others to Act, and Encourage the Heart. The 2015 study by Herman et al supports the Burns theory by noting the need for leadership development of nurse leaders. Results denoted that the subscales of Enables Others to Act and Model the Way were strongest and Challenge the Process and Inspire a Shared Vision needed the most improvement.13
Leadership development programs have proven to be effective in developing emerging nurse leaders, and the evidence supports mentoring as valuable to professional career growth for nurses.14 A mentor encourages, inspires, supports, and challenges; this nurturing relationship fosters professional advancement.15 Klein and Dickenson-Hazard16 conceptualized mentorship as planting and cultivating a seed that produces long after the mentorship has ended.
Despite the evidence supporting the value of nursing leadership development programs, healthcare organizations have reported experiencing barriers in developing and sustaining nursing leadership programs. As a result, strong internal bench strength for nurse leadership in many healthcare organizations is minimal. Healthcare leaders may not understand the benefit of competent nurse leaders or the barriers in attaining competence.17 O'Neil and colleagues7 identified budget and release time as the greatest of 7 identified barriers to nursing leadership development programs. Other barriers include lack of interest in leadership, lack of program availability, poor program fit, dissatisfaction with existing programs, and lack of executive support.
Significance of the Problem
A large academic health system in the southeastern United States (The Health System), which includes several hospitals and nursing school within a university environment, has a limited pool of potential nursing leaders for role-related positions. The limited pool led to extended vacancy periods of 3 months to 1 year to replace roles of significant responsibility because of lack of internal bench strength. Some nurse leader positions remained vacant for 2 to 3 years. The vacancy period and interim management presented a challenge to the clinical nurses in trying to sustain quality patient care.
Organizational effects of nursing leadership vacancies include direct costs from recruitment (ie, advertising, interviewing, and relocation expenses), orientation, and outsourcing of interim leaders during the recruitment phase. Recruitment expenses may range from 8% to 15% of the vacant position's salary for in-house recruitment and range from 15% to 30% when contracting with agencies for external recruitment. Expenses are even higher if a recruitment firm is contracted.18 Indirect recruitment expenses are related to the loss of productivity from an experienced organizational leader, patient experience and safety, and work culture. Outsourcing temporary nursing leadership requires additional labor expenses, housing, travel, and management costs at a significant cost to the organization. The cost of a temporary nurse leader acquired through a recruitment agency exceeded $180 000 for a 5-month temporary assignment based on the organization's data.
To determine the full scope of the problem, The Health System nursing leaders were surveyed regarding their views of the nursing leadership development process. Results revealed that 62% of the nursing leaders reported leadership roles were not appealing to potential future nursing leaders, and 56% perceived appropriate training and resources were not available. Succession planning for nursing leadership became a strategic goal for the organization.
The intent of this quality improvement project was to implement a structured nursing leadership development program for individuals in the roles of clinical nurse 3 (CNIII), clinical nurse 4 (CNIV), clinical team leads (CTLs), and surgical team leads (STLs) at The Health System to improve nursing leadership competencies and support succession planning. These specific roles were selected because they are recognized within The Health System as future nursing leaders.
There were 3 aims for this project:
- To develop, implement, and evaluate a structured nursing leadership development program.
- To increase nursing leadership development participants' perceived competency scores from preassessment to postassessment.
- To identify participants' level of satisfaction of the structured nursing leadership development program.
The design was a pre-post nursing leadership competency assessment program. The preassessment perceived competency was completed prior to access to the Essentials of Nurse Manager Orientation (ENMO)19 program, and the postassessment was completed after the implementation of the Nursing Leadership Development Program (NLDP) at 90 days. The nursing leadership competencies were assessed by the NM Inventory Tool, which consists of 67 items that are divided into 3 subscales: managing the business, the art of leading people, and the leader within.20 The ENMO is a comprehensive training program for NMs or future nursing leaders created by experts in nursing management.19 The program consists of 8 modules broken into 3 units that review managing the business, leading people, and personal development. The Health System purchased the ENMO Web-based program from AACN19 with funding provided by The Health System nursing education department.
The NLDP was based on the NM Learning Framework.10 The Health System adopted these nurse leadership competencies. Each participant was provided access to the Web-based program, ENMO, and assigned a mentor. A computer specialist from the education department facilitated the participants' access to the ENMO program and assigned the identified lessons. Three monthly sessions were scheduled to reinforce program content, discussion of lessons learned, and reflections. The participants, nurse executives (ie, mentors), and the NLDP Executive Steering Committee attended the monthly sessions. Participant attendance at the monthly sessions was optional.
The NLDP was implemented with strong support from the chief nurse executive (CNE) and The Health System nursing executive committee. A brief return on investment identified the average salary for an NM at $61 000 and the cost for 25 to 50 participants to access the ENMO was $21 000 in total. The benefits of the program were recognized as positive return of investment for development of future nursing leaders.
The project was introduced to The Health System Nurse Executive Committee, which approved and recommended the establishment of an NLDP Executive Committee to engage key stakeholders. An invitation to join the NLDP Committee was extended to 13 individuals and included chief nursing officers (CNOs) from each hospital, associate CNOs, NMs who had completed a nursing leadership development or fellowship program, the dean of the school of nursing, a chief HR officer, a clinical nurse educator, and the associate director of the learning, organizational, and development department for the university. All invitees agreed to join the NLDP Executive Committee.
The NLDP Executive Committee provided valuable input into the development of selection criteria for program invitees. A communication plan was developed and presented to nursing leadership at each hospital to facilitate communication to possible participants. In addition, a targeted e-mail was sent to all eligible nurses' introduction to the NLDP program. Potential participant pool included 748 CN IIIs, 227 CNIVs, and 118 CTLs and STLs and The Health System nursing leaders (NMs, clinical directors, associate CNOs, and CNOs). Although 25 participants were targeted, 44 applications were received. The CNE approved all applicants once the designated associate CNO endorsed the applicant. Forty-one applicants were approved, and 3 applicants were determined to be unqualified for the program through the review process.
The 41 participants received a congratulatory e-mail, followed by an e-mail with specific information regarding the preassessment survey, program kickoff, and the planned date to access ENMO. Thirty-two participants attended the program kickoff meeting. The session included a general introduction of participants, nurse executives, and the NLDP Executive Steering Committee members. The NLDP process was reviewed with weekly required activities, and assigned ENMO lessons were explained, and the meeting finished with lessons learned from each nursing executive regarding the valuable aspects of their own leadership development experience.
To enhance the benefits of mentorship, each participant was assigned a mentor based on their combination of preferences: a mentor from their specialty, organization, specialty within the health system, no preference, or to continue with a preexisting mentor. The specifics and requirements of the mentoring relationship were developed between mentee and mentor.
Twenty-eight participants (68%) attended the first 90-minute session, which consisted of a discussion of the ENMO modules. In addition, the CNOs shared their leadership journey in a question-and-answer format so participants could ask follow-up questions. The session concluded with a review of the completed ENMO modules and sharing of lessons and experiences from the participants.
The 2nd 90-minute session was facilitated by the associate CNO of nursing recruitment and the chief of HR. Nineteen participants (46%) attended the session, which focused on strategies for career growth. Participants received helpful information regarding resumes, cover letters, networking, and job searches within The Health System. A celebration of the successful completion of the NLDP at the end of the 3rd month included 23 participants (56%). Participants shared lessons learned from the program. The CNO and associate CNO recognized each participant with a leader pin to signify graduation.
Forty participants completed the NLDP. Thirty-three participants (82.5%) completed the preassessment and postassessment, and 7 participants did not complete postassessment data. Personal distractors, such as death in the family, hospitalization of a loved one, forgetfulness of the deadline, or inattention, were reasons for missing assessments.
Results and Findings
Participants completed the preassessment and postassessment surveys to identify their own individual perceived level of nursing leadership competency. To identify participants' level of satisfaction of the structured nursing leadership development program, a post-program 4-point scale of strongly agree, agree, disagree, and strongly disagree survey was completed.
Nursing Leadership Competency Assessment
The NM Inventory Tool consists of 67 items that are divided into 3 subscales: managing the business, the art of leading people, and the leader within.10 The responses were ordinal based using the following scale: no experience = 0, novice = 1, competent = 2, expert = 3. The median of each subscale was computed and then compared from preintervention to postintervention using Wilcoxon signed rank tests. Results revealed a statistically significant increase in reports of perceived competence by the participants on all 3 subscales from preintervention to postintervention (Table 1). The results support the importance of aligning nursing leadership competencies in a leadership development program.
Of the 33 participants who successfully completed the NLDP, only 27 completed the preassessments and postassessments of the NM Inventory Tool. The NLDP program satisfaction survey results indicate that 100% reported their knowledge of nursing leadership increased. One respondent (3.7%) disagreed with the statement, “The ENMO program content was valuable.”
In rating the modules, common response for the most valuable module was “thinking skills for NMs” (n = 7 [25.9%]), followed by “basic finance concepts” (n = 6 [22.2%]) and “key attributes of a leader” (n = 4 [14.8%]). Six respondents (22.2%]) chose both “introduction to healthcare economics” and “overview of HR scenarios” as the least valuable module, followed by “career planning” (n = 4 [14.8%]).
Ninety-six percent of the participants met with their mentors at least once 1 on 1. In addition, 70% of participants communicated with their mentor by e-mail and 40% by phone. All respondents reported that their mentor provided valuable information and/or resources. Approximately one-third (n = 9 [33.3%]) of respondents reported that they plan to seek another job advancement opportunity within The Health System in the next 6 months. Most of those who responded to the item, “I plan to enroll in school to advance my nursing education in the next year,” indicated a master's degree in nursing as their planned degree (n = 9 [33.3%]).
The purpose and goal of this innovation were to determine the utility of a structured nursing leadership development program to increase skills and competency in nursing leadership. In this project, the ENMO19 combined with ongoing nurse executive support was found to be a significant and effective means to enhance perceived competence in a group of emerging nurse leaders. In each of the 3 subscales measured by the NM Inventory Tool, participants reported a significant increase in their perceived level of competence to manage the business, lead the people, and internalize leadership values and belief. This success was achieved via standardized modules in an asynchronous manner at their own pace and in their own time. As a result, barriers, such as a lack of time and availability, were largely removed. The active engagement of the nurse executive team also addressed obstacles reported in the literature. These results promote the use of coaching and feedback from mentors to advance the professional career growth of emerging nurse leaders, facilitate succession planning, and overall benefit the work culture.
Limitations and Recommendations
Implementation of the NLDP may have been affected by a lack of clarity in the original notice of the opportunity to participate, as well as difficulty in accessing the modules. Replication of this project would benefit from clearer communication before implementation by having question-and-answer sessions prior to the application deadline. Better communication related to accessing the modules and specific information about the learning management platform throughout the project would have been beneficial to the participants. Some participants requested more monthly leadership sessions and additional time with the nurse executive team. The scheduled time of the monthly check-in sessions limited attendance for some participants. The utilization of Web-ex connection options and/or multiple offerings of each session should be considered. The conduct of this project in 1 system was also noted as a limitation.
Preparing future nursing leaders is critical to the success of healthcare organizations as pending retirement of nurse leaders creates a strong impetus for the development of nursing leadership development programs. The results from this project provide evidence of the effectiveness and utility of a Web-based modular approach combined with engaged nursing executive mentorship as means of significantly increasing the perceived competence of developing nurse leaders. The approach in this project may prove for a valuable resource for developing future nursing leaders in other healthcare organizations.