Nurse managers are the 1st-line leaders responsible for managing departmental operations and leading the frontline nursing workforce.1 They create practice environments to support interprofessional patient care. Their effectiveness can be measured by the quality of their nurse and patient outcomes.2 The complexity of the nurse manager role has increased over the past decade, resulting in job-related stress.3 There is an additional stress burden as the impact of their job performance is far more visible as healthcare systems are benchmarked nationally.2
Nurse manager competence is a critical factor impacting their job performance. The current nurse manager workforce is much less experienced than the Baby Boomer nurse managers they are replacing.4 Today's Millennial nurse managers likely have less than 4 years of leadership experience.5 This limited experience alone may not seem alarming until it is placed in the context of how nurse managers develop leadership expertise. Experience as a nurse manager is the top predictor of nurse manager competence.5 In fact, experience in the role has twice the effect of graduate leadership education on nurse managers' perceived competence.5
Nurse managers often report that they assume these vital leadership roles with little to no leadership knowledge and education. It is not a new phenomenon that nurse managers learn on the fly through experience rather than through intentional role preparation.6,7 Despite calls to improve nurse manager role transition, the practice of learning through experience continues.8,9 Onboarding, role preparation, and transition seem to vary across organizations.5,8 Whereas some nurse managers report assistance and support from their organization, others report learning through trial and error. Given the reports of variation in role transition practices, we sought to understand current organizational practices and how organizations could better prepare and transition new nurse managers to the role.
Selecting nurse managers without the relevant knowledge and skills for their positions and expecting them to learn through experience have been accepted practices. One strategy to increase nurse manager competence is to require graduate leadership degrees for the position.10 Although national recommendations were made, organizations have been slow to adopt graduate level education for nurse managers. Despite the more recent national push for increasing the education levels of direct care nurses to a bachelor of science in nursing (BSN),11 nurse manager requirements largely remain at the BSN level. Following the national vision to increase the direct care nurse minimum education to a BSN, the American Nurses Credentialing Center increased the recommended education standards for nurse managers working in organizations with Magnet Recognition Program®.12 Given organizational desire for Magnet® recognition, more stringent credentialing requirements may help advance the education of nurse managers.
In an increasingly complex and dynamic healthcare environment, nurse leaders in New Jersey (NJ) recognized it was no longer acceptable for novice nurse managers to assume their role with little to no preparation and skills.13 Senior nurse leaders across NJ commissioned a statewide survey to understand nurse manager role preparation. The findings revealed that the nurse manager workforce across the state was largely inexperienced and lacked the fundamental knowledge and skills to perform their jobs. Despite recognition of the need for more competent nurse managers, nurse leaders cited organizational fiscal constraints and operational demands precluded the development of more structured residency programs. To overcome organizational fiscal constraints, the nurse leaders considered partnering with their state nursing workforce center to create a state level residency program. Although this was deemed a viable option, the program was neither funded nor implemented (E. Cadmus, personal communication, July 22, 2019).
The NJ nurse leaders identified a conundrum. Organizational leaders may recognize the benefit of competency development programs but lack either the fiscal means or the strategic priority. Nurse leaders recognize the value in having a prepared cadre of nurse managers-in-waiting ready to assume the role as vacancies occur.14,15 In fact, savings realized from replacement costs likely would offset the cost of leadership development programs.16
Identifying alternative strategies, such as coaching, may provide benefit as well.9,17,18 The coaching relationship supports the nurse manager in achieving proficiency in a set of leadership skills. Critical to the success of the coaching relationship is the ability of the nurse manager to trust their coach. Westcott17 reported that nurse managers preferred their coach to be outside of the reporting chain. Pilat and Merriam9 suggest peer coaching is beneficial. The value of coaching lies in the additional insights to problem solving, yielding greater depth and understanding as nurse managers learn to respond to new leadership challenges.
Although options are available, no single strategy emerged as a best practice for supporting the role transition of novice nurse managers. Therefore, we wanted to describe current organizational policies supporting nurse manager role transition and competency development. In addition, we wanted to identify best practices to support role transition of new nurse managers.
Design and Sample
This cross-sectional study used an exploratory mixed-method design to describe current and ideal organizational practices supporting the role transition of new nurse managers. The study was conducted as a roundtable discussion entitled Evidence-based Nurse Manager Competence Development held at the 2019 American Organization of Nurse Leaders (AONL) annual meeting held in San Diego, California. The study was reviewed and deemed not human subjects research by the institutional review board at the University of Central Florida. Forty-one current nurse leaders self-selected to attend the session. Demographic information was not collected.
Participants of the AONL annual meeting were provided with an infographic of competency, education, and certification information learned from a study of 647 nurse managers.5 Participants were asked to complete a paper survey that asked 4 questions about organizational practices to develop competent nurse managers. Then a focus group interview with the 41 nurse leaders was conducted. The focus group interview consisted of 3 questions (Table 1) to understand their organizations' current role transition support and ideas to design an ideal role transition program.
Blank color-coded Post-it™ notes were provided to each participant. The facilitator of the focus group interview asked the 1st question, to which the participants recorded their responses on Post-it™ notes. The Post-it™ notes were collected and posted to the wall at the front of the group. The facilitator scanned the notes for themes and other points to discuss with the group. The notes were retained for analysis after the meeting. This process was repeated for the remaining 2 questions. The session was concluded by asking participants to share any final comments. These final responses were recorded by the research team.
The responses to the paper surveys were summarized using frequency distributions of the responses to the quantitative survey questions. The survey response data are reported with the responses to the question about current organizational practice. The focus group data were analyzed for themes in response to the specific aims. Four themes emerged from the focus group data: structured onboarding with specialized processes, mentorship and coaching, knowledge development courses, and program evaluation.
Current Organizational Practices
The responses to the surveys were summarized using frequency distributions of responses to the quantitative survey questions. A total of 36 participants completed the survey. Most participants (n = 21, 58%) reported that their organization requires a BSN, with a little more than one-third (n = 13, 36%) saying that a graduate degree is preferred. Most organizations pay for some continuing education (CE) activities, with 30 (86%) offering tuition reimbursement at some level, 24 (67%) paying for certification examinations, and 18 (50%) paying salary support for time spent on CE activities. Far fewer organizations (n = 2, 6%) have a formalized transition program, with most organizations using face-to-face meetings with selected individuals (n = 23, 64%) or department leaders (n = 21, 58%). Similarly, formal mentorship programs are lacking, with no organizations reporting a formal mentorship program. Most organizations have nurse managers mentor one another (n = 21, 58%). (See Table 2 for an overview of the written survey responses.)
Comments from the participants during the focus group interview reflected a range of current practices. Although some described very little role transition, others described strategies that could prove useful in supporting role transition. Current structured onboarding processes ranged in duration from less than a week to a year-long program reported by 1 participant. Two participants reported that their organization used a 30- 60- and 90-day roadmap. Several exemplar programs were described. For example, 1 participant described a quarterly manager boot camp that concluded with a capstone project. Another reported a nurse manager fellowship, 1 reported a leadership development program offered by the Center for Creative Leadership, and another reported a new manager academy. Some of these programs were solely for nurse managers and others were offered to all new managers regardless of department. Several reported that toolkits to support financial, onboarding, and human resource processes were being used in practice. Several used nurse manager competency checklists and competency-based orientation tool developed by the AONL. One participant reported completing a critical care competency checklist.
Many participants reported that they had access to courses to develop basic management competencies. Few organizations offered comprehensive competency programs. The content focused on business skills such as finance, performance improvement, human resources, and labor relations. Others reported classes to develop relational skills such as communication, emotional intelligence, and leadership. The delivery model for these classes varied. Some reported having access to online educational modules and others reported in-house courses offered by their human resources department or system regional offices. Some participants reported competency development through conference attendance.
On the minimal end of the spectrum, 10 participants indicated that no organized transition was provided in their organizations. Participants commented that new managers are thrown right into the role. One participant described “on-the-job training” without further details. A minimal orientation was described as self-directed onboarding with specified individuals to meet, an informal orientation process, or a 1- and 2-day nurse manager orientation. Others reported their role transition was supported by scheduled meetings between directors and new managers. On a positive note, 2 participants described new processes being developed. One organization was developing standard work processes and a 2nd was developing a formal mentor program.
Ideal Role Transition Program
Theme 1: Structured Onboarding With Specialized Processes
The participants overwhelmingly agreed that a structured program to support new nurse managers' role transition was essential for success. In fact, 1 participant commented that organizational leaders need to “recognize that [nurse managers] are the linchpins and make onboarding at least as important as new graduate onboarding.” Participants described a need for a residency-type program with a recommended duration ranging from 100 days to a year. Participants also advocated for organizations to adopt a growth model mindset with real-time coaching. In fact, some advocated for a succession planning model where leaders at all levels were provided with a structured leadership program, including a program to support emerging nurse leaders. Others voiced the need for role transition to start before a novice nurse manager is hired. In other words, organizations should offer emerging leader programs.
Tools to support the process included prehire assessments, checklists, and roadmaps. An innovative recommendation was the development of tools to support analysis and decision-making processes. These tools were designed to support and coach novice managers through the application of new managerial knowledge to management practice. For example, 1 individual described a particularly useful tool that guides novice nurse managers in analyzing budget reports. The tool provides questions for the nurse manager to consider when confronted with budget variances. In other words, the tool offered prompts to help novice nurse managers identify departmental factors influencing the numbers.
Even nurse managers in organizations with structured onboarding process experienced challenges. Operational demands were viewed as a barrier to participating in onboarding programs. When operational demands were high, it was expected that the nurse manager skip scheduled onboarding activities to address operational demands. To combat that experience, the participants felt that senior leaders need to sanction protected time so new nurse managers can fully participate in the program.
Theme 2: Mentorship and Coaching
There was overwhelming support for mentoring and coaching. The participants expressed the need for a structured mentoring program at all levels. They suggested that fellow nurse managers or directors could serve as mentors for new nurse managers. One participant suggested that mentoring could take place in teams with other members of the interprofessional team. Participants agreed that an important consideration in making mentor matches is to develop trust and be able to ask questions without repercussions.
Theme 3: Knowledge Development Courses
Participants all agreed that new nurse managers did not have the competencies necessary for success in the role. Most of the recommendations for didactic courses could be organized according to the Nurse Manager Leadership Domain Framework (NMLDF).19 Business domain topics included finance, evidence-based practice, performance improvement, systems thinking, human resources regulations, and labor law. Art domain topics included emotional intelligence, communication, relationship management, accountability, delegation, and general culture. Leader Within topics consisted of mindfulness, stress management, and personal and professional development.
Management expectations in organizations with collective bargaining unions (CBUs) are a topic not clearly addressed in the NMLDF. One participant who works in an organization with a CBU voiced the need for helping new managers transition from being a member of the CBU to a new management role. The status change takes place overnight, yet the new nurse manager is unprepared for the different role expectations of being a direct care nurse member of the CBU compared with the management perspective.
Recommendations for the delivery of didactic content were also made. For example, self-paced and real-time courses were suggested. Some advocated for programs that included all middle managers from throughout the organization. Some advocated for physician partners to be included. There was general support though for at least a part of the program be provided specifically for nurse mangers because there are unique topics and issues. Recommendations for annual leadership competency courses were made. Some suggested completing courses outside of the organization such as through professional organizations. One participant recommended use of simulation to practice new skills.
Theme 4: Program Evaluation
Participants felt that organizational leaders needed to evaluate their leadership development programs. Participants explained that because healthcare is continually evolving, new competencies need to be updated on an ongoing basis. Leaders need to determine what works well and make modifications for what needs improvement. A critical component was the need for a cost-benefit analysis to support sustained leadership development.
An important responsibility of nurse leaders is to provide sufficient numbers of qualified nurses in all roles. In the case of nurse managers, there is growing evidence that graduate education is necessary for entry to the role.9,10 Nurse leaders need to evaluate job descriptions and policies for accessing education such as tuition reimbursement and CE. A barrier identified to expanding BSN education for direct care nurses was limited financial support from organizations.10,20 As nurse executives participate in strategic planning, consideration to provide adequate financial support to assist nurse managers in obtaining graduate education should be considered. Furthermore, many graduate programs require practicum experiences. Nurse executives must create strategies to incorporate practicums into the organizations (Table 3).
A 2nd important structure is a supportive transition process. An orientation may suffice for experienced nurse managers, but novice nurse managers need formal developmental programs.13 Residency programs provide structured didactic content with mentored application.9,13 Given the limited role development support in general, it may be wise to provide all new nurse managers with a residency program.13 One solution may be a competency-based residency program for nurse managers. An important consideration made by our participants was the need to prioritize the development program despite operational activity. Many commented on being pulled away from development activities and into operations when acuity was high. If role transition programs are to be successful, senior leadership needs to support full participation for novice nurse managers.
Novice nurse managers need to develop new knowledge.9,14,15,21 The topics identified during our focus group session are described in the AONL Nurse Manager Competencies.22 The topics identified were not surprising: finance, budgeting, performance improvement, human resources management, conflict management, and communication skills. Participants recommended that organizations develop programs and supplement content with online resources. The focus group also suggested developing toolkits to help guide new nurse managers with analysis and decision-making.
There was strong support by the participants for a formal coaching and mentoring program. For novice nurse managers be successful, they need assistance in the application of didactic content. Coaches provide this critical link between knowing what to implement and knowing how to implement evidence-based leadership strategies.18 The focus group participants commented that not everyone knows how to mentor and coach so they recommended that training on effective coaching be implemented in organizations. Only half of our participants reported having access to a mentor program yet strongly recommended mentorship for everyone.
There was discussion of the role of professional organizations such as AONL, AONL affiliates, Robert Wood Johnson Foundation action coalitions, and state-level workforce centers. It was felt that these organizations offer CE programs and fellowships to support nurse leaders at all levels offering collaborative approaches to didactic education.13 Another option is to reach out to academic partners for assistance.
Lastly, our group identified the need for rigorous program evaluation. When organizations need to make budget cuts, education is often a 1st target; thus, understanding the return on investment is critical to the sustainability for the program. Sometimes, the answer to sustainability is to partner with other similar organizations or perhaps looking to professional organizations such as AONL.13 Our participants commented that when nurse leaders implement and evaluate role transition programs, they should disseminate their findings. Learning from one another is critical to building successful support for nurse mangers.
Implications for Nurse Executives
Our findings are not new; rather, they reinforce what we have known for quite some time. It is up to nurse executives to lead changes to organizational policies and practices to improve nurse manager role transition and onboarding.
- Nurse executives need to require graduate degrees in leadership for nurse managers. Furthermore, they need to advocate for sufficient financial support for nurse managers to pursue graduate education.
- Nurse executives need to ensure that nurse managers have formal onboarding programs to support nurse manager transition to their roles. Program content and delivery models need to undergo regular evaluation to ensure the intended goals of adequate role preparation and support are achieved.
- Nurse executives need to establish organizational cultures of mentoring and coaching. It should be the norm that everyone has a mentor and is a mentor to someone else. It should not be assumed that everyone knows how to be a good mentor; therefore, attention to the development of mentoring and coaching skills is imperative.
- Nurse executives need to create psychologically safe climates to promote risk taking and learning.
This study used a cross-sectional design and convenience sample to collect data describing current and ideal nurse manager role transition practices. Although the study design limits the generalizability of the findings, this study provides insight into an understudied phenomenon.
Nurse managers are integral to organizational success. As linchpins, it is imperative that onboarding for new nurse managers be viewed by all leaders in the organization as important as the onboarding of new graduate nurses. The blueprint for successful nurse manager role transition begins with organizational policies that promote nurse manager competence when assuming the role. A supportive transition period includes coaching of novice nurse managers in the application of knowledge learned thorough didactic education to clinical practice experiences. With sustainability in mind, nurse executive leaders need to conduct rigorous program evaluation that includes a determination of the return on investment. The success of our nurse manager workforce depends on successful role transition.
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