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Developing Leadership Competencies in Midlevel Nurse Leaders

An Innovative Approach

Nghe, Megan MSN, RN; Hart, Jennifer MSN, RNC-NIC, CBC, NEA-BC; Ferry, Susan RRT-NPS, CCRC, CPHQ; Hutchins, Larissa MSN, RN, CCRN-K, CCNS, NEA-BC; Lebet, Ruth PhD, RN, CCNS-P

Author Information
JONA: The Journal of Nursing Administration: September 2020 - Volume 50 - Issue 9 - p 481-488
doi: 10.1097/NNA.0000000000000920
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The aim of the program described here was to create a comprehensive leadership development program for midlevel nurse leaders at a large teaching hospital. Program content was based on organizational values and standards, particularly as they related to new leaders, and utilized the American Organization of Nurse Leaders (AONL) Competencies, with a focus on Leadership Skills, Relationship Management and Influencing Behaviors (with a focus on communication), Financial Management, Personal and Professional Accountability, and Strategic Management.1 This novel program was designed to be standardized across platforms within the organization and to be sensitive to the need for individual development across clinical areas and roles. The curriculum design was the result of collaboration among nursing directors, nursing professional development specialists, nurse managers (NMs), safety and quality specialists, and human resources specialists from multiple units and departments. Although implemented in a pediatric hospital, this structure is applicable to any hospital with a large contingent of midlevel nurse leaders. The literature suggests that conflict exists when clinicians assume management roles without appropriate training, support, or instruction, and that in terms of leadership, leaders find that their unit-based goals may be compromised or limited by overarching management or organizational aspirations or targets.2-4 This issue is not unique to any single organization.


Hospitals, nationwide, are challenged with nursing leadership turnover. Organizations struggle to create and implement ongoing nursing professional development and provide thoughtful succession planning to ensure that there is a pool of unit-based nurse leaders well prepared to move into an NM position.3 Ongoing professional training and preparation targeted to unit-based nurse leaders are necessary for the future of healthcare and to positively influence nursing leadership across an organization.4 Nursing leaders must take strategic action to prepare nurses to assume key leadership roles. A primed pipeline of competent nurses prepared to step into leadership roles will reduce recruiting expenses, increase leadership continuity, and decrease role-transition stress. Failing to develop this talent results in a lost opportunity.5

Several changes in our organization led to the need for an increase in midlevel nurse leaders. An increase in inpatient census and inpatient acuity required a significant increase in the number of clinical nurses employed by the organization. To ensure NM effectiveness, senior nurse leaders made intentional adjustments in span of control of midlevel nurse leaders (NM, clinical supervisors [CSs], and clinical nurse experts [CEs]), creating a need for additional unit-based midlevel nurse leaders. Table 1 describes these roles. These positions were typically filled with individuals having limited or no leadership experience. In response to the lack of leadership experience, senior nurse leaders identified a need to develop and implement a leadership onboarding and professional development program aligned with the organization's values and standards, specifically targeted to this group (nurses with supervisory or coaching responsibilities who report to a NM), which addressed group members' varying levels of managerial knowledge and experience. The 2 target groups of midlevel nurse leaders that were the focus of this work were CSs and CEs reporting to the NM. The CS role is an operational lead, responsible for direct supervision of staff, overseeing 30 to 35 full-time equivalents. The CE provides leadership, clinical expertise, mentoring, education, and quality improvement; however, CEs do not have direct supervision responsibilities. This project was specific to our organization. All activities reported here, including the online survey and focus group participation, were voluntary. We report all results as percentages for the categories measured.

Table 1
Table 1:
Midlevel Nurse Leader Roles

Although there are some commercially available training programs that focus on the emerging leader, there is still a strong need for the growth of the next generation of leaders “in-house.”3 Research related to clinical leadership with a range of health professionals showed that most were poorly trained in leadership and even fewer were instructed in formal management skills.6 The creation of a leadership development workgroup led to the recognition that midlevel leader professional development and education needed to be standardized across platforms, while remaining sensitive to the needs of the specific clinical unit. The roles focused on for this program were nurse leaders with supervisory and operational responsibilities.

Literature indicates that most employees possess an intermediate amount of power and must repeatedly alternate between interacting with higher- and lower-power colleagues. This experience is particularly evident among middle managers, a group who are defined by their intermediate power levels within an organization, receiving strategy prescriptions from their bosses above and having to implement those strategies with the people they supervise.7 As Greenfield notes, middle managers are not receiving the leadership development training they need to be successful. This suggests the need for a specific and deliberate learning strategy to enable middle managers to fill the gaps in their management and leadership toolkit.8 Often, the norms and expectations associated with being a leader (e.g., assertiveness) are incompatible with those of a subordinate (e.g., deference). These micro-role transitions are required frequently by middle managers and can become problematic, as humans are inefficient at such task-switching.8

The leadership development workgroup, charged with constructing a leadership development program for new midlevel nurse leaders, did an extensive literature review and selected the AONL NM Competencies1 as the framework for this program. These competencies include the Art: Leading the People; the Science: Managing the Business; and the Leader Within: Creating the Leader in Yourself.1 Utilization of these competencies directly tied the responsibilities of midlevel nurse leaders to the broader organizational mission, helping them to reframe their self-identity from “sometimes a supervisor and sometimes a subordinate” to “a middle manager who is important to this company.”7 The AONL NM Competencies, based on the Nurse Manager Learning Domain Framework, capture the skills, knowledge, and abilities that guide the practice of these nurse leaders. The successful nurse leader must gain expertise in all 3 domains.1 The AONL NM competencies are applicable to this group of novice nurse leaders not only because in their roles they would be implementing many aspects of the NM role, but also because the competencies would provide some consistency in how the role is implemented across the organization. Finally, we chose these competencies because they provide a structure to develop individuals in these roles so that they would be well prepared to move into an NM role.


Assessment of Current State

To ensure successful outcomes of the leadership development program, the group identified and included all key stakeholders (nursing directors, NMs, CEs, CSs, human resources staff, and nursing professional development) in a needs assessment and program planning. Elements of the needs assessment included surveys, focus groups, and group feedback. As this was an improvement project specific to our organization, participation in all needs assessment activities was voluntary, and all results are presented as aggregate data.

To identify competencies and professional development needs, the workgroup performed a needs assessment, collecting quantitative and qualitative feedback from midlevel nurse leaders. The Association for Nursing Professional Development (ANPD) describes a needs assessment as “consisting of several steps that incorporate planning, implementation, evaluation and dissemination.”9 The needs assessment conducted for this initiative was an iterative process that facilitated collection, analysis, and interpretation of the data. The workgroup used these data to set priorities and create objectives for the program. Primary assessment was based on the expressed needs of a group of midlevel nurse leaders, representing a cross-section of midlevel nurse leaders in the organization. The workgroup also reviewed the AONL standards, which defined presumed needs across these leadership roles, and worked with organizational leaders and educational experts to prioritize specific requirements.

The directors for the department of nursing and clinical care services created a set of open-ended questions to be used in several NM forums. At these forums, NMs participated in an interactive exercise, providing their expert opinions on the competencies and skills needed by CSs and CEs. Eighty NMs provided feedback, identifying providing feedback, conflict management, and strong communication as the 3 most necessary skills/attributes. Other frequently mentioned attributes included being an influencer, coach, relationship builder, and leader, possessing emotional intelligence and strong teamwork.

Next, the workgroup assembled stakeholders from the director, NM, and quality improvement groups and created a learner needs assessment using a web-based survey tool. The survey assessed the experience of orientation and ongoing professional development from the perspective of the CS/CE. Questions highlighting the competencies and skills previously identified by the NM group were created, along with questions regarding the orientation and onboarding experience of CSs and CEs, as well as their current professional development activities and support. Respondents were also asked to identify other potential areas of development for those in the role. The survey was sent via e-mail to 163 CSs/CEs in inpatient, procedural, and ambulatory roles. Fifty-seven CSs/CEs (35%), representing a variety of areas, completed the survey. Figure 1 summarizes the results. Respondents identified 4 additional areas for development: providing constructive feedback, self as leader, conflict resolution, and leading difficult conversations. The CSs also included an additional area for development, conducting performance reviews.

Figure 1
Figure 1:
Learner needs assessment data.

The ANPD Learning Needs Assessment Guide describes different categories of needs, such as education needs, environmental needs (systems/setting/processes), or compliance issues.9 During data analysis, the workgroup sorted the needs identified by respondents into these categories. For example, the frequently identified need for a class assisting leaders in managing crucial conversations was classified as an educational need. The identified need for a structured orientation process for new leaders was labeled an environmental need. A consistent structure to support the transfer of knowledge from education to practice (an environmental need) was identified as an opportunity that should be addressed. Written guidelines for managers and orientees, check-in meetings, and a formal mentor program were identified as environmental needs. Table 2 provides survey results obtained before program development in the “Pre” section. An educational summit was developed with content designed to address the findings of the needs assessment.

Table 2
Table 2:
Participant Self-assessment Presummit and Postsummit Attendance

After collecting survey data, the workgroup attended the organization's CS and CE monthly meetings to hold focused conversations using more open-ended questions. The responses were similar to the needs assessment findings, with additional requests for content on peer-to-peer coaching and training to develop skills needed to utilize existing computerized systems for personnel organization and data management. The workgroup also attended a nursing and clinical care services department shared governance meeting to get feedback on frontline staff's perceptions of the CE/CS roles and areas for development. The feedback from shared governance aligned with the feedback from the managers and CS/CE groups, with an additional focus on clarifying the CS and CE roles. After analyzing all the data and identifying the types of needs, the workgroup set priorities for the work, created working subgroups, and identified outcome measures.

Underpinnings of Summit Content

Nursing leaders are increasingly challenged by an ever-changing healthcare environment. According to the American Nurses Association,10 leaders must demonstrate transformational leadership skills and be able to maximize structures and processes to drive excellence. The influence and success of a nurse leader, especially a novice one, depend upon the ability to effectively conduct thoughtful conversations during conflict.11 When emotions and stakes are high, NMs can risk losing a valued employee if they fail to successfully navigate a challenging conversation.12 Although the role of the NM is not an easy one, it is recognized as a high-stakes one. The relationship of the manager to the employee leads to turnover.13 According to Anicich and Hirsh,7 middle managers are increasingly challenged by crucial conversations through the context of their interpersonal relationships. As previously discussed, they are constantly interacting with superiors and subordinates, while adjusting their approach to conform to role expectations. This pull exposes them to many interactions for which they must be prepared, highlighting how vital it is to prepare middle managers not only for competence in their role and future positions but also for their impact on the retention of nursing staff.

Based on the above information, as well as the data gathered, the workgroup put together 2 days of professional development content, divided into to “summit 1” and “summit 2,” that incorporated key topics identified through the data gathering process. Many of the topics lent themselves to interactive learning workshops. The agenda was constructed to incorporate as much interactive learning as possible. In addition, for each issue identified, participants were assigned relevant readings to be completed prior to attending the summits. During the summits, each issue was presented as a short didactic session, followed by activities (Figure 2).

Figure 2
Figure 2:
Summit agendas.

Summit 1

The 1st leadership professional development summit utilized the AONL framework and addressed identified areas of opportunity. The summit planning group opened with a welcome that set expectations. As this was the 1st time many midlevel leaders were in the same room together, there was also an icebreaker exercise. After reviewing the organization's core values, the planning group asked leaders to share experiences that exemplified these values. Human resources also led participants through an activity, “We are___ therefore we will ___,” which allowed individuals to get to know each other and set personal expectations for the day. The icebreaker was followed by a keynote address from the chief nursing officer.

The planning group utilized the core set of NM competency domains as a structure for the initial presentation. The after-lunch session used a flexible model adapted from World Café to adjust seats of the participants and promote dialogue.14 At their new table assignments, participants viewed presentations related to change management, initiating corrective action, accountability, and crucial conversations. After each presentation, attendees completed interactive table activities to help internalize lessons learned. Participants also used content from preassigned readings and information learned throughout the day to role-play real-life situations presenting leadership challenges. At the end of the day, participants shared their observations from activities with the larger group.

An environment of trust allowed participants to acknowledge their own opportunities for improvement as well as learn from each other's strengths. Participants were engaged and asked questions of senior leaders, resulting in robust, productive conversation and thoughtful reflection. Most participants expressed satisfaction in learning not only from the lectures and role-playing but from their tablemates as well. One participant, when asked “What did you like most about today's summit?” responded: “The discussion and application (of) ‘real-life scenarios’ and hot topics that have been going through the hospital.” At the conclusion of summit 1, participants reported through formal feedback that they felt more prepared and had an increased confidence level because of the preassigned readings, presentations, and time dedicated to role-playing (Figure 3).

Figure 3
Figure 3:
Summit 1 participant feedback.

Summit 2

Summit 2 continued to build on AONL nurse manager competencies and incorporated the organization's core values and service standards. Content for summit 2 focused heavily on “The Leader Within.” According to Ingersoll et al15:

An organization's mission, vision, and values statements are the guiding forces behind the institution's administrative strategic planning and performance assessment activities. Linking nursing professional practice model components and performance evaluation criteria with each of these foundational documents assures that their values, beliefs, and intentions are evident in daily work life.

As with the 1st summit, participants were assigned readings to be completed beforehand, related to themes of the summit. The readings covered developing an individual brand, emotional intelligence, and the value of being an authentic leader. Summit 2 started with a bingo icebreaker, requiring participants to move around the room to find individuals meeting each bingo box. A presentation related to personal resilience through the practice of mindfulness was next, followed by a keynote address from the chief nursing officer. Participants then attended sessions focusing on emotional intelligence, the basics of career management, and resources for setting developmental goals and action planning. Program education included core values of the organization and how they relate to real-life leadership scenarios and the intrinsic value of each leader. Themes throughout the day concentrated on the self-driven accountability of the individual: know yourself, explore our organization, get focused, take action.

Participants were challenged to begin a personal development plan that included writing down their goals in a clear, achievable form, as guided by the recommendations of Locke et al.16 Three questions are used to frame out the development plan. How can a personal brand improve your effectiveness at work? How can a personal brand contribute to career opportunities and growth? What are some strategies for bringing your brand to life?

The presenter for this session asked the group to really challenge themselves in terms of creating goals for their individual development plans that encouraged them to stretch and explore their organization for opportunities outside their usual practice setting, allowing them to sharpen their leadership skills and abilities. These individual development plans are meant to be self-initiated and self-driven. Direct managers can view goals but not edit them. In support of summit goals, managers committed to support their developing leaders in completing an individual development plan that fiscal year.


After summit attendance, learners identified solving challenging situations around accountability, differentiating between leadership and management, influencing behavior, change management, and communication as areas of increased confidence (Table 2). In particular, the workgroup saw higher confidence for the 3 focus areas: crucial conversations, initiating corrective actions, and acting as a change agent (Figure 1). The number of staff rating themselves as “very comfortable” in each of these areas increased postsummit attendance. For example, before the summit, 33% of participants stated that they were very comfortable participating in critical conversations. Postsummit, this number increased to 43%. We saw similar increases in initiating corrective action and acting as a change agent. Participants also reported benefiting from focused networking with peers from other units. This networking helped to facilitate the sharing of information, teamwork, and influence among units. At the completion of the summits, most leaders reported that networking was one of the most unexpected wins of the day.

Responses related to networking stated:

These summits were a great opportunity to meet other leaders, make connections, and enhance knowledge.

I left valued as part of the leadership team by having a place for CE/CS to talk about professional development. It was a great opportunity to network and meet individuals in similar roles and through the hospital that I did not know before. This opens up for more collaboration between units and people across the organization.


According to Systems Theory, the way leaders across domains interact allows individuals and groups to achieve positive results when implementing change.17 Hospitals, nationwide, are facing nursing leadership turnover, threatening organizations with diminished support, management, and leadership in hospital units. Ongoing training and preparation targeted to this group are necessary for the future of healthcare and the nursing profession. Organizations struggle to create and implement ongoing nursing professional development and provide thoughtful succession planning.3 We used a structured process to develop a comprehensive needs assessment that identified professional development needs.

The program developed utilized the AONL NM Competencies.1 The AONL standards defined presumed needs across these leadership roles. The leadership development workgroup polled senior leaders and educational experts within the organization to prioritize specific requirements. The impact of this professional development work was beneficial not only to the individuals in these leadership roles but also to the role hospital-wide and was imperative to support organizational succession planning.

The organization's internal methodology related to structure, process, and outcomes was applied when creating these summits. As a result, summit content was created based upon feedback and the needs of the cohorts and aligned with the AONL NM Competencies. The summits led to multilevel learning across leadership, with networking as an incidental benefit. Orientation and mentoring programs for the CS/CE group were transitioned to the nursing professional development department to be sustained. Semiannual summit development will continue to be informed by feedback.

After attending each summit, participants were asked for feedback via anonymous surveys. Participants reported being able to differentiate between leadership and management behaviors in their role with more confidence, as well as feeling more able to demonstrate organizational values in their leadership practice. Many reported that they would apply what they learned to solve challenging behaviors around accountability, influencing behavior, change management, and communication in their leadership practice.

The process and structure utilized by the workgroup were effective in designing and implementing a comprehensive leadership development program for midlevel NMs. Using the AONL NM competencies1 as a framework and incorporating the organization's values and standards resulted in a program that presented both universal leadership skills and concepts specifically situated in the organization's culture. This process, which supports succession planning, is easily replicated and would be useful to any organization striving to improve the leadership abilities of mid-level nurse leaders.


The authors acknowledge Paula M. Agosto, MHA, RN, senior vice president and chief nursing officer, for her direction and support of this program. The authors also acknowledge the support of Caryn E. Douma, MS, RN, in program development.


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