The nursing landscape has changed dramatically in the past few decades. Today, the best and brightest clinical nurses are often promoted to nurse manager roles with little or no leadership preparation.1,2 There's also a gap in the literature on nurse manager leadership development. The literature does address several major themes, including the projected clinical nurse and nurse leader shortages, the lack of agreement on how to best develop nurse leaders, and the variety of resources and attention directed toward these issues.3-16
To shed new light on this problem, the researcher conducted a qualitative study, which included semistructured interviews with 19 nurse managers at two larger metropolitan hospital systems between 2013 and 2014. Participant responses shaped the qualitative grounded theory that resulted from this study of how clinical nurses transition to being nurse managers.
From the interviews, the researcher identified four main themes that contribute to nurse manager leadership development. The themes discussed are examples from the nurse managers' actual interviews. The quotes expand on the various themes and subthemes in Figure 1.
Identity and purpose. Nurses expressed a deep connection to patients and a patient focus. Participant quotes included:
- “I'm a nurse first. I need to be connected with patients. That's where I get my joy.”
- “Nurse first—then leader.”
- “My purpose as a leader is to make sure the staff have what they need to take care of the patients.”
- “Nursing has provided me with some of the most profound experiences professionally and personally.”
Emotional intelligence. Daniel Goleman argues that emotional intelligence can matter more than IQ.17,18 Common elements of the emotionally intelligent leader include knowing and managing the self, building relationships, and fostering teamwork. One participant said, “I think my social personality warms people up. I'm approachable and it's helped me be successful.” Another described herself as willing to take on new things, saying, “I'll try anything! I'm the type who would rather ask for forgiveness than permission. I'll just try it and if it doesn't work well, then try something else.”
The nurse managers stated that building trust and relationships, connecting with people, having empathy, and knowing staff members on a personal level were keys to a high-performing and happy staff. One reflected, “Honestly, what I learned from my military experience is that you can't advance a group or get the best performance from people without establishing trust. I believe relationship-based leadership is the way to go.”
Building teams also emerged as a major subtheme of emotional intelligence. One participant described how she fosters teamwork among her staff: “I have a goal to be present on my off-shifts. I've come in and made breakfast for the nurses and held a potluck for the night shift, and they loved it.”
Mental models of lifelong learning. In all 19 interviews, participants discussed different aspects of learning. They expressed getting value from their formal education and embraced experiential learning. In addition, they saw their role as helping others learn and developing others as leaders. Seventeen nurse managers affirmed that their formal education was foundational and essential to their leadership development. What the nurse managers highlighted as valuable was more about working in groups—the reflection, professional dialogue, and appreciation of the bigger picture. One participant shared, “I learned about healthcare as a business and to think of business models. We had one instructor who gave us an exercise where we had to take care of a hospital and figure out how to run it and solve the problems. She really challenged us. The answer to problems had to be more than just adding staff.”
Another subtheme was learning from experience, or learning by doing, which involves taking risks and stepping out of one's comfort zone. One participant advised new nurse managers to be bold: “Put yourself out there and accept the challenges. You don't know what you don't know. Try new things, even though it might be scary!”
Another significant finding was helping others learn or developing others. One participant shared, “I have the answer in here (pointing to her chest), but now my role is helping the other person find the answer. I have to let them try things out themselves because the solutions are more self-sustaining when they come from the staff.”
Nurturing community. There's power in knowing others who've walked this way before who are willing to share their experience. One participant explained that she has names to describe her role models and mentors. One is the “master diplomat.” She described the second mentor she utilizes to figure things out when confronted with challenging situations: “I call her my ‘muddy questions go-to girl.’ She always answers my questions by posing more questions, and I always think of things I hadn't before. She takes me down new roads of thinking and learning.”
Three themes emerged within leadership development challenges, which are listed in Figure 2.
Transition into leadership. One participant discerned a transition from a change, which he said is something that happens to people. A transition, on the other hand, is an internal process that happens in people's minds as they experience and go through change.19 Others described the transition as a huge learning curve. One participant said, “It was a complete blur!” Another stated, “I missed my work and my patients so much! I actually went through my own grieving process when I left the bedside.”
Dealing with adversity. We asked what experiences came to mind that were helpful in shaping the interviewees as leaders. The responses to this question were mostly about a challenge when facing some type of adversity; nurse managers described learning from mistakes and difficulties. One recalled, “Mostly, difficult experiences have shaped me. For example, having to work through a corrective action plan with someone.”
Eleven nurse managers responded that they must have the courage to stay the course during the dark times. One said, “It's so important to have a mentor who isn't your boss to use as a sounding board. Then nurse managers don't feel like they're the captain of the Titanic. There are others who are in the same boat with you in the hard times!”
Adversity, resistance, negativity, and making unpopular decisions are all part of leadership development. One participant said, “You have to take on the tough challenges. Don't beat up on yourself when things go wrong. Learn from your mistakes.” Participants also identified that being the manager is often the loneliest job and nurse managers can feel very isolated: “You're the middle person, trying to support the staff as well as your director but with really no level of authority.”
Large scope and relentless pace of change. More than half of the nurse managers interviewed stated that there was a continual need to adapt and be a facilitator of change. Moreover, many nurse managers highlighted their large scope and 24-hour accountability coupled with the rapid pace of change as the greatest challenge. Managers in the role for more than 5 years advised new managers to take time to know the role. One advised, “Sit back and take it in. Don't be a bull in a china closet and try to change everything all at once. Listen to those around you and then slowly try to suggest a change.”
Emerging grounded theory
Through the analysis process, a grounded theory of nurse manager leadership development emerged. The study findings affirmed that leadership development is an ongoing process—not a destination. The leadership development of nurse managers is a transaction between the individual nurse manager and his or her environment.20
The emerging theory has four key facets: 1) the hazardous terrain, 2) the tranquil waters, 3) these dimensions as symbiotic forces, and 4) the reframing and ongoing growth that occurs over time through the experience of these forces.
First, the contributors and challenges were reframed as experiences that were either hazardous or nurturing aspects of role development. The hazardous and unpredictable experiences promote adaptive capacity and occur on the frontline. Through the experience of challenges, adversity, crisis, and the unexpected, the nurse managers described how they gained an increase in confidence, tolerance of ambiguity, and comfort with not knowing all of the answers. In addition, with each new situation, they were learning and gaining confidence in their ability to be dynamically adaptive. As indicated in the findings, wisdom comes from experiencing hazards and adversity.
Likewise, the calm and restorative aspects of leadership development allowed for reflection and provocative introspection. The nurse managers got support from mentors and colleagues as they worked through multiple issues. Reflecting on these experiences helped nurse managers gain confidence for the next time they had to deal with a similar situation. In the “tranquil waters,” nurse managers discussed how they increased their self-awareness through self-assessments, reflection, and working with mentors and other colleagues.
Another element of the theory is the notion that these two forces—the hazardous/unpredictable and the tranquil/predictable—are symbiotic. (See Figure 3.) Through the nurse managers' voices, the researcher determined that these two forces were interrelated, complementary, and synergistic, and at work together as nurses develop into leaders.
Growth comes over time. The combination of these two forces leads to a continual reframing and reinventing of the nurse manager and his or her leadership practice in the context of the patient care unit and the organization. The symbiotic forces move the leader forward as a person with new consciousness, harmony, and purpose in the rapidly changing environment.21
Implications and conclusions
Overall, the study findings confirm that the nurse manager role is complex and demanding, yet the leaders who participated in the study were patient-centered, hopeful, and optimistic. This study has implications for individual nurse managers and organizations.
Individual nurse managers can reflect on the theory and its components by using the following questions to examine their own situation. What are the current hazards that I'm experiencing? What changes are currently happening? What risks am I taking? In terms of the tranquil waters, nurse managers can ask other questions. What supports do I have in my role? Who are my mentors and role models? What am I learning, and how do I incorporate new learning into my practice?
Additionally, the study findings confirm that organizational context matters. Providing support for nurse managers through informal learning opportunities can be valuable to their ongoing leadership development. Researchers recommend incorporating opportunities for experience-based learning and strongly support experiential learning, with the goal to unite individual and organizational learning.22
The study findings provide specific examples of informal learning structures that can support nurse managers' leadership development. First, organizations can offer mentoring programs for nurse managers. Second, organizations can provide support for the transition to leadership, such as residency programs and succession planning. Organizations can foster “learning by doing” by rewarding risk-taking and supporting trial-and-error. Moreover, organizations must allow more time with patients and families to encourage the learning that occurs from these interactions. Finally, organizations should create time and space for all of these activities, including time for reflection. Developing future nurse leaders is a long-term goal that requires understanding, planning, and strategic action.
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