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Building nurse executives

Abraham, Pauline J. DNP, RN-BC

doi: 10.1097/01.NUMA.0000432224.94381.5b
Feature: Executive Extra

Review recommendations for creating and implementing a leadership development program tailored to top-level administrators.

Pauline J. Abraham is a nursing education specialist, Department of Nursing, at the Mayo Clinic in Rochester, Minn.

The author has disclosed that she has no financial relationships related to this article.

Historically, the nursing profession has been slightly behind other professions in creating leadership development programs for the purpose of succession planning. There's substantial need for leadership development due to the tremendous demands on nurse leaders to be skillful in numerous aspects of healthcare policy, human resource management, finance, and enhancement of quality patient care outcomes. Additionally, nurse leaders are expected to be proficient in developing relationships, navigating the organizational system, remaining competent in patient care issues, and supporting healthcare initiatives. Considerable knowledge of external forces and issues likely to influence and direct how various patient populations will be cared for in the future is also needed.

With these issues in mind, one study found that a staggering number of nurse executives plan to leave their positions in the near future.1 Of the 622 nurse executives who responded to the study, 62% planned to leave their position within 5 years. Providing leadership development at critical points over the nurse leader's career may better prepare him or her to accept the challenges the profession faces when influencing quality healthcare in the future.

At our large, academic medical center in the Midwest, a leadership development program is being planned. Nurse leaders who are interested in expanding their knowledge of leadership beyond their individual work units and wish to gain a much broader perspective of the organization's initiatives are the target participants. The organization has recently experienced incremental growth in nursing administrative positions, as well as retirement turnover that has led to a number of nurse administrator vacancies. Creating a leadership development program to elevate the knowledge, skills, and abilities of current nurse mangers can contribute to succession planning.



First, leadership competencies must be identified. Then the essential elements of a leadership development program and major design aspects must be determined to lead to successful outcomes.

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Essential competencies

The American Organization of Nurse Executives (AONE) recognizes the tremendous need for leadership development among nurse executives and has contributed to identifying skills common to nurses in executive roles.2 The five AONE core nurse executive competencies are: communication and relationship building, knowledge of the healthcare environment, leadership, professionalism, and business skills.3 The AONE emphasizes nurse leaders' responsibility to promote, nurture, and sustain interdisciplinary collaborative relationships.4 It's essential that the nurse leader is proficient in communication, leadership, and problem solving with a keen ability to foster interdisciplinary team culture. The AONE suggests that organizations create and support a “just and fair” environment and foster collegial relationships through cross-discipline job discovery and patient-focused care.4 Nurse leaders are vital in setting expectations and creating a culture in which interdisciplinary collaboration is successful.

The Robert Wood Johnson Foundation Executive Nurse Fellows program also offers five core competencies: self-knowledge, strategic vision, risk taking and creativity, interpersonal communication, and inspiring and leading change.5

Much of the literature regarding nurse executive competencies demonstrates the need for building on skills that allow the nurse leader to excel in a former role as a nurse manager or supervisor.69 It's also necessary for nurse leaders in executive roles to enhance their leadership competencies that were successful in the nurse manager role, with the caveat that their scope is broader and far-reaching. More important, the nurse executive must acquire new skills related to broad development of interdisciplinary networks and committee work at the organizational and national healthcare levels. In addition, emphasis must be placed on relationship building with healthcare and professional communities, internal and external to the organization.10

One study discusses the need for nurse executives to master the language of other disciplines to more effectively convey the position of nursing in various decision-making arenas and healthcare environments.11 The rapid increase in the number of articles being published about leadership development in recent years suggests a keen understanding among the nursing profession that leadership development is extremely necessary to prepare leaders within organizations to accept the challenge of shaping our healthcare for tomorrow.

Overall, most studies related to nurse leader competencies describe skills and attributes that share similarities and complement one another; however, it's important to determine what leadership competencies are meaningful and essential for the organization and incorporate them into the framework of a leadership development program. Moreover, it's advantageous to augment the nurse leader's attributes and skills with broader levels of understanding and organizational application of knowledge to elevate decision-making effectiveness and the ability to advance broad initiatives.

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Program design

One approach to leadership development design is to utilize a multifaceted curriculum of didactic, experiential learning; project development; and mentoring.12 Qualitative findings support that participants in this type of program possessed new understanding of the attributes and skills of exceptional leaders and greater insight into their own leadership abilities following the program.12

Which methods of learning are most effective related to leadership development? Several studies have identified key didactic education important to a leadership development program, including acquiring business acumen specifically in finance, workforce management, change management, patient safety, and quality improvement.8,13 One study considered formal didactic education in a structured format versus nonformal methods, including coaching; conferences; and experiential learning, such as shadowing, action learning, 360-degree feedback, and action assignments.14 Nonformal methods were considered highly productive because sharing good practices between participants reduced the time for the learner to acquire competence, resulting in the ability to apply learning to his or her current practice sooner. The findings also supported that the clear choice of learners is a blended approach, combining classroom, electronic on-demand learning, and timely or immediate access to a mentor who could provide support and answer questions.14

Mentoring and coaching by the nurse administrator has been identified as a key success factor.15 Mentoring through shadowing and debriefing of critical situations and sharing insight into the organization's culture helps ground the new nurse leader in the mission and values of the organization.15 Mentoring is intended to provide participants with the opportunity to gain insight in strategic visioning, risk-taking, interpersonal effectiveness, and inspiring and guiding change in the mentor's own leadership environment.16

The mentor should possess extensive leadership experience, be willing to share his or her knowledge and experience, and commit time and attention to mentor individuals for a defined period.16 Additionally, the mentor selected must be appropriate for the participant's leadership development goals. Successful mentor relationships are a result of a clear commitment to the program by the participant and mentor, initiating and supporting a positive interpersonal relationship, and being clear about communication expectations and goals. Finally, mentors who convey learning through sharing real-life stories of their leadership journey are most effective.16

The current literature underscores the fact that a multifaceted approach to leadership development is preferred and desired by contemporary learners. Programs need to provide a variety of educational vehicles, building on basic concepts and leading to practical application. Leadership skill acquisition requires a combination of didactic and experiential learning, followed up by 360-degree feedback by mentors and coaches committed to the developmental success of the participants. In addition, an individualized program plan is preferable to large-scale formal education methods that treat all learners the same. Be clear about the purpose of the program; establish a core curriculum; provide direction to participants on how to create, implement, and evaluate a project; and provide the opportunity to apply new skills on the work unit.17

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Future implications

Several elements essential for nurse executive leadership development have been identified, emphasizing the need for individualized development plans. (See Table 1.) The literature shows that leadership development is multifaceted and the acquisition of leadership skills is a journey. One doesn't simply arrive at a point and declare him- or herself an exceptional leader. Leadership program designers will need to consider future challenges and growing performance demands at the nurse executive level to determine future learning needs. Understanding and incorporating these learning needs into new educational and teaching strategies will assist in narrowing the knowledge gap for nurse leaders.

Table 1

Table 1

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