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Describing Nurse Manager Role Preparation and Competency

Findings From a National Study

Warshawsky, Nora, PhD, RN, NEA-BC, FAAN; Cramer, Emily, PhD

JONA: The Journal of Nursing Administration: May 2019 - Volume 49 - Issue 5 - p 249–255
doi: 10.1097/NNA.0000000000000746
Articles
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OBJECTIVE The aim of this study was to describe the role preparation and competency development of nurse managers.

BACKGROUND Approximately 70 000 nurses are retiring annually. This represents a significant loss of nursing leadership wisdom. Few systematic studies of nurse manager role preparation and competency development have been conducted.

METHODS An electronic survey was completed by a national sample of 647 nurse managers managing 964 patient care units in 54 hospitals.

RESULTS Findings suggest that nurse managers rate themselves as competent for the 1st 6 years as a nurse manager. They begin to reach proficiency by year 7. Experience had the strongest association with nurse manager competence, followed by graduate leadership education.

CONCLUSIONS Nurse executives need to evaluate the bench strength of their nursing leadership talent pool. They need to develop policies and strategies that promote nurse manager competence.

Authors Affiliations: Professor (Dr Warshawsky), University of Central Florida, College of Nursing, Orlando; Associate Professor (Dr Cramer), University of Kansas School of Nursing.

This study was funded by VCAN (Versant Center for the Advancement of Nursing). The findings do not necessarily represent the views of VCAN.

The authors declare no conflicts of interest.

Correspondence: Dr Warshawsky, 12201 Research Pkwy, UT 473, Orlando, FL 32826 (Nora.Warshawsky@ucf.edu).

Approximately 70 000 nurses are retiring annually. Although estimates of nurses entering the profession may offset much of the loss, nursing leadership will bear a disproportionate loss because a greater percentage of nurse leaders are of retirement age.1,2 Nurse leader retirements represent a significant loss of leadership wisdom in organizations. The impact is trickling down to the nurse manager level where our Millennial nurses are being called to step up and lead.3,4 Given the importance of nurse managers to organizational performance, it is essential that they are competent in their role.5,6 What we need to understand is how nurse managers develop competency for these critical leadership positions.

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Benner's Theory of Competency Development

According to Benner,7 nurses progress through 5 stages of competency development: novice, advanced beginner, competent, proficient, and expert. Nurses advance through these stages as they gain experience and knowledge through nursing practice. Benner7 notes that it takes 2 to 3 years for a nurse to become competent in practice. Benner7 studied nurses in the 1980s; however, nurses today are working in a more complex healthcare environment, and it may prolong nurses' progression to competence. Relying on experience alone for newly graduated nurses to develop competence is inadequate and associated with stress and turnover.8 To help bridge the transition from prelicensure education to practice, residency programs were developed to support nurses as they progress through early stages of competency development. Residency programs can effectively improve nurses' confidence, organization and prioritization of work, communication, and leadership competencies in their 1st year of practice.8

Benner's7 model can also be applied to the development of nurse manager practice. Commonly, nurse managers are selected for their positions based on clinical expertise rather than leadership and management competence. Emerging evidence suggests that, like clinical nurses, experiential learning is an important strategy for nurse managers to develop competence.9,10 In comparison to new graduate entry to practice, the evidence supporting nurse manager role preparation and competency development is sparse.

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Nurse Manager Competency Development

Despite calls for graduate education for nurse managers by professional organizations,11 these recommendations often go unheeded in clinical practice settings. Quite often, nurse managers are “being thrown into the position” and “learning on the fly.”12 It is a highly stressful and haphazard approach to transition new nurse managers to their roles. Nurse managers identified that formal orientation and mentorship would facilitate the transition into their new roles, but again, approaches to role preparation and competency development vary by organization.12,13

Some organizations provide leadership development programs that target either nurse managers already appointed to positions or emerging leaders who are likely to seek nurse leader positions. It appeared that difficulty filling vacant nurse manager positions was a common impetus to develop programs for emerging leaders.14-17 These programs ranged from 3 months to 1 year in duration. The programs all included didactic content in combination with an assigned mentor. The majority utilized the Essentials of Nurse Manager Orientation developed by the American Association of Critical-Care Nurses.18 Additional activities included journaling, mentored evidence-based practice projects, and in 1 residency program a precepted 3-month trial unit leadership experience.14-17 An important outcome of these programs included a reduction in the duration of vacant positions and costs associated with nurse manager turnover.

Other leadership development programs are focused on nurse managers after they assume their positions. The Nurse Manager Fellowship program sponsored by the American Organization of Nurse Executives (AONE) is the most notable example.19,20 The fellowship is a national program offered in the United States where nurse managers apply and pay for participation. The program includes participation in 4 face-to-face didactic sessions, completion of a capstone project, and development of a network of colleagues. As a result of participation in the program, nurse managers reported increased knowledge of the health system, perspective, collaboration, self-confidence, and self-awareness. A healthcare system in New York used a participatory action research model to guide leadership development for 43 nurse managers.21 These managers selected the topics of teamwork, time management, and conflict leadership as the focus of their 1-year program. Three 3-hour sessions were developed using an appreciative inquiry approach to elicit best practices related to each topic among the nurse managers. The participating nurse managers reported that this program resulted in improved knowledge and confidence in addressing the challenges that they face. A 3rd model utilized an academic-practice partnership to provide a 4-month program for 63 nurse managers using an experiential learning model and reflective practice.10 In this program, a faculty member provided 30-minute sessions that described experiential learning and reflective journaling and emails reminding participants to complete reflective journaling activities. Journals were reviewed and discussed with the nurse managers and their directors who served as mentors. The program resulted in improved communication, planning, decision making, development of subordinates, and outcomes evaluation among participants.

These successful programs shared several common developmental strategies: didactic sessions in combination with experience-based learning, mentorship, and reflective practice. Despite their effectiveness, questions remain unanswered. More insights regarding the nature of competency development, role of graduate education, and nurse manager perspectives are needed. The purpose of this article is to describe role preparation and competency development of a national sample of US nurse managers.

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Methods

This study used an electronic survey to collect cross-sectional data between September 25 and November 3, 2017. Three hundred hospitals participating in the National Database of Nursing Quality Indicators® annual RN survey were invited to participate in the study. Of the 150 hospitals responding to the invitation, 80 were selected using a stratified sampling frame. Hospitals agreeing to participate were given materials to encourage nurse managers within their organization to participate in the nurse manager survey. The nurse manager survey was completed by 647 nurse managers, representing 964 nursing units in 54 hospitals. This study was approved by the institutional review board at the University of Kentucky.

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Nurse Manager Competency Assessment

Nurse manager competency was assessed using a new instrument developed based on AONE's Nurse Manager Competencies.22 AONE developed competencies using job descriptions of nurse managers and classified them according to the Nurse Manager Leadership Domain Framework (NMLDF).22 The NMLDF categories include the Science: Managing the Business, Art: Leading the People, and Leader Within: Creating the Leader in Yourself. In order to create an instrument that could be used for research, 27 items were developed by the lead investigator to reflect the main themes of the competencies in the Science (18 items) and Art (9 Items) domains. For example, AONE's Financial Management competency consists of 10 specific skills. These items were collapsed into 2 items: (1) knowledge of healthcare economics and its application to the delivery of patient care and (2) knowledge of the unit and departmental budgeting processes—both capital and operational. The items were reviewed by a PhD-prepared nurse researcher with extensive leadership experience. Participants were asked to “assess your level of comfort with each competency” using a 5-point scale reflective of Benner's stages of competency development: 1 = novice, 2 = advanced beginner, 3 = competent, 4 = proficient, and 5 = expert. Cronbach's α's were .97 for the total scale, .99 for the Science subscale, and .94 for the Art subscale, reflecting excellent internal consistency. The Leader Within domain was measured using demographic questions about education and certification.

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Role Preparation

A variety of questions were asked to understand role preparation. Participants were asked to specify their highest level of nursing and nonnursing education, number of continuing education credits relevant to leadership and management over the past 12 months, completion of any national leadership development programs, and types of nursing leadership certifications. This study focused on nursing and leadership graduate education.

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Qualitative Comments

Participants were provided a free text comment box at the end of the survey. Many participants provided additional comments to illustrate their experiences with role preparation and competency development. These comments were analyzed to identify themes and are presented in Table 1.

Table 1

Table 1

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Analysis

Descriptive statistics were used to examine role preparation and experience of nurse managers and mean self-rated competency scores. Bivariate correlations were run to explore the relationship between nurse manager experience and competency.

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Results

The majority of nurse managers were female (88%), were white (86%), held a BSN degree or higher (62%), and averaged 45 years of age. Table 2 presents data describing the education, experience, and role preparation of nurse managers with published comparisons. The sample of nurse managers averages nearly 20 years of nursing experience and 6.73 years of experience as nurse managers. However, the average time in current nurse manager position is 4.14 years, suggesting that many nurse managers leave their 1st leadership position after 2 years. The majority of nurse managers (59%) have 4 years or less of experience in a nurse manager role (Figure 1). Thirty-nine percent of the nurse managers hold a graduate leadership degree in nursing or some other field, and only 15% of nurse managers hold a nursing leadership certification.

Table 2

Table 2

Figure 1

Figure 1

Overall, nurse managers rated competency on Art domain subscales higher than competency on Science domain subscales. The mean nurse manager competency scores ranged from 2.99 (financial management) to 3.72 (technology) on the Science domain and 3.48 (human resource management) to 3.83 (diversity management) on the Art domain (Figure 2). Nurse managers with less than 2 years of experience rate their competency on both Art and Science domains higher than those with 2 to 4 years of experience, but less than nurse managers with 5 to 7 years and more than 7 years of experience (Figure 3).

Figure 2

Figure 2

Figure 3

Figure 3

The highest correlations between role preparation and competence were between nurse manager experience and the science of competency domain (r = 0.46, P < .05) and experience and the art of competency domain (r = 0.41, P < .05; Table 3). Nursing education has a small but significant relationship (r = 0.23, P < .05) to the science of competency domain, and any graduate-level education is significantly related to both the science of competency (r = 0.29, P < .05) and the art of competency (r = 0.21, P < .05).

Table 3

Table 3

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Discussion

Current State

Overall, this study provides evidence that nurse leaders are retiring. In comparison to prior studies, this sample is 2 years younger with less experience as a nurse manager overall and less tenure in their current positions.23,24 Almost 60% of the nurse managers had 4 years or less of experience as a nurse manager overall. The data also suggest that nurse managers are spending less time in their 1st nurse manager positions: about 2.6 years in this study compared with 4.3 years in 2011 and 2.9 years in 2012. These findings serve as a call for nurse executives to examine the overall bench strength of their nurse managers. What proportion of nurse managers are novice and where can they turn for guidance?

The inexperience of these managers was reflected in their competency scores. The mean competency scores for the Art of Management (mean, 3.62 [SD, 0.73]) were higher than those for the Science of Management (mean, 3.04 [SD, 0.71]). These scores suggest that on average these nurse managers considered themselves to be competent across nurse manager skills. The lowest reported competencies were the organizational systems competencies of finance, strategy, performance improvement, and foundational thinking. These are competencies that are highly valued by executive leaders but less valued by nurse managers.25 The competencies in the Science of Management subscale that were scored higher included human resources management (mean, 3.58), clinical practice (mean, 3.68), and technology (mean, 3.72). In fact, across all competencies, diversity management, technology, and clinical competencies were the 3 highest scored competencies. These findings support the notion that nurse managers are promoted based on clinical expertise. They also reflect our younger nurses' comfort with technology and working with diverse populations.

Of concern is that the competencies with the lowest scores—finance, strategic management, and performance improvement—are critical for leading transformation of the healthcare organization. In fact, a comment from 1 participant highlighted a lack of interest in developing expertise in finance. Fortunately, there were also nurse managers actively seeking to develop business skills by attaining a master's degree in business administration.

A 2nd area for concern is that it seems it takes nurse managers more than 7 years to become proficient. Nurse managers spoke of learning through experience—both positive and negative—reinforcing published evidence.12 Competence scores were lower for those with 2 to 4 years of management experience than those in their 1st 2 years of management. This finding may reflect an overestimation of competence among those with less than 2 years of experience. Alternatively, because nurse managers seem to change positions after 2 years, the reduced competence may reflect the transition to a new nurse manager position, delaying competency development. Amid calls to transform the healthcare delivery system, we need nurse managers to develop expertise at a much faster pace than over the course of 7 to 10 years.

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Solutions

The correlations among role preparation and competency shed some light on how to approach competency development for nurse managers. The findings suggest that nurse managers learn primarily through experience (r = 0.46). Even though the correlations were half that of experience, there were significant correlations between competency and graduate leadership education as well. We included all types of graduate leadership education in the analysis, suggesting that any graduate degree in leadership will increase nurse manager competence. According to our participants, nurse managers may be waiting to be advised to return to school. Increasing the competence of nurse managers begins with professional development plans. Nurse executives need to assess the quality of the onboarding and role development programs and processes in their organizations. Nurse managers are asking for structured orientation and mentor programs. Given that nurse managers are hired despite a lack of leadership education and experience for the role, it is logical that plans be established to help them develop the necessary competencies. Transition programs, fellowships, and coaching programs are viable, cost-effective solutions to facilitate nurse manager transition.19,26,27 Given that the most experienced nurse managers are retiring, creating innovative nurse manager coaching roles may be an effective strategy to delay the loss of nurse manager wisdom and provide novice nurse managers with an experienced coach. Structured continuing education is an important competency development strategy for developing frontline nurse managers, but it varies in scope of content across programs. Graduate education provides a more uniform and comprehensive approach to leadership preparation yet presents challenges as well.

The participant comments indicated that resources—both time and money—are needed to return to school. In particular, workload interferes with completing graduate degrees. Based on these findings, nurse executives need to examine the workload of nurse managers. Do nurse managers have quality work-life balance? There are some nurse managers seeking graduate degrees that would be of benefit to the organization, but their workload interferes with their ability to complete their coursework. In addition to time, nurse managers may need financial support to return to school. They may be repaying college loans for their undergraduate education.28 Organizations may want to examine their education policies in comparison to the tuition costs at local universities. Alternatively, explore opportunities to create an academic-practice partnership that helps healthcare organizations meet educational needs and schools of nursing meet faculty needs.

Perhaps the biggest hurdle in advancing education of your nurse managers are the educational requirements and expectations that are established in organizations.29 Nurse executives need to evaluate the education requirements for nurse manager positions. Graduate degrees should be required either on hire or within a few years of accepting a nurse manager position. Just as we are advancing the education of our frontline nurses, we should expect the same of nurse managers. The competencies needed for successful nurse manager performance are not taught in undergraduate curriculum. The competencies needed to lead a multimillion-dollar corporation are taught at the graduate level.

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Limitations

This study used a cross-sectional design to understand nurse manager competency. This limits the ability to draw inferences. Although causality cannot be established, the study does provide insights from a large, national sample of nurse managers.

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Conclusion

The long-awaited retirements of nurses have begun, creating a significant loss of leadership wisdom in nursing. The current nurse manager workforce has limited experience and competence. In the absence of educational requirements and structured competency development programs, nurse managers are learning solely through experience. Nurse managers are responsible for leading interprofessional teams, managing multimillion-dollar budgets and transforming care delivery models. Reliance on trial and error represents an inefficient and insufficient strategy to develop this vital segment of the healthcare workforce.

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