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Where we've been, where we are, and where we're going

Sherrod, Dennis EdD, RN; Holland, Cecil EdD, PhD, RN; Chappel-Aiken, Lolita EdD, RN

Author Information
Nursing Management (Springhouse): September 2019 - Volume 50 - Issue 9 - p 1-3
doi: 10.1097/01.NUMA.0000585320.91285.dc
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In the early 1970s, hospital leadership was a top-down autocratic approach with conformity and seniority at its core. Nurse leaders role-modeled the job by working long hours; focusing expertise on specific clinical challenges; and ensuring that nurses followed physician orders, hospital policy, and agency guidelines. The primary focus was on patient recovery, with patients being hospitalized for weeks and even months at the time.

Healthcare has certainly changed in the last 50 years. Change itself occurs more rapidly, and patients enter the acute care setting sicker and leave quicker. Whereas nurse leaders once managed one unit in a hospital, we now head-up multiple units in complex healthcare systems. The healthcare workforce is better educated and includes multiple generations of workers, and employees, as well as patients, have higher expectations. With patient safety, quality care, and evidence-based practice serving as our drivers, honing best practices is an ongoing process. Expectations of today's nurse leaders are as vast as the people we serve, and the scope of responsibility, knowledge, skills, and attitudes required for effective leadership continues to shift and increase.1


Through the 1970s to today, acknowledgement of civil, women's, LGBTQ, and nurses' rights has placed emphasis on equal employment policies and increasing diversity in the healthcare workforce.2 The American Nurses Association (ANA) recently released a revised position statement encouraging nurses to take an active role in abolishing discrimination and creating inclusive strategies in practice settings, policy, and advocacy.3 This requires understanding implicit bias, which can be a barrier to the discussions, decisions, and processes necessary for employee engagement.

Direct and transparent communication remains central to effective leadership; however, active listening can be difficult in today's world of multitasking and complex organizations. An effective listener is aware of issues and distractions competing for attention but is present in the moment, as well as listening to the tone, speed, and volume of the sender along with the intended message.4 For this reason, emotional intelligence, comprised of self-awareness, social awareness, self-management, and relationship management, is a quality linked with successful leaders.4

Nurse leaders are asked to coach and mentor others; innovate faster; serve as a team leader to equip and inspire staff members to rapidly address challenges; staff units appropriately; review unit metrics to ensure the accomplishment of benchmarks; and make sure budgets remain balanced. This requires the ability to interpret and integrate data and information into everyday practices, as well as demonstrate proficiency in the field of informatics. In addition, leaders are expected to examine their leadership style and use self-reflection to correct perceived deficits. Today's nurse leaders understand the importance of fit between their personal leadership core values and the values, mission, and vision of their organization.

Nurse leaders also understand that healthcare is a business and financial management is a necessary skill. Leaders must recognize parameters that are fiscally responsible, as well as those that can harm the bottom line. Knowledge of budget, income, and cost statements is imperative and helps the leader make sound economic decisions.5


Trends in business and healthcare warrant further expansion of forward-thinking nurse leader competencies. The following developments are expected to influence nurse leaders through the next 5 to 10 years.

Adaptability. Flexibility and adaptability are core competencies for nurse leaders as we function in ever-changing, value-added workplaces. These skills become even more important as we accommodate cultural and technologic changes.

Diversity. By 2020, the non-White working-age portion of the workforce is projected to reach 37%, whereas the White population is projected to decline to 63%.6 We can also expect larger numbers of women in health system leadership and CEO positions, and healthcare workplaces will include a wider variety of employees with different cultural perspectives. Although recognizing implicit bias will remain important, leaders should consider moving diversity programs from bias recognition to inclusiveness strategies to establish a work culture that readily welcomes diverse thinking and problem-solving.

Innovation. Quality improvement (QI) has become a primary and daily focus of healthcare systems. Implementing and leading data-driven QI processes improves patient care and keeps organizations relevant. Nurse leaders can support innovation cultures by providing on-time information sharing, building formal and informal team networks, and creating a shared vision.7 Porter-O'Grady and Malloch identify innovation as a vital nurse leader competency, ranging from knowledge creation to transforming healthcare.8

Patient-centered care. Digital and robust patient feedback mechanisms and reporting are expected to continue to assist nurse leaders in fashioning delivery systems that meet the preferences, needs, and values of our patients.9 A primary focus for nurse leaders will be to keep people (patients and employees) at the core of the organization's mission and vision.10

Interdisciplinary teams. Leadership development is expanding to groups and teams rather than individuals. Leadership models are expected to move outside and beyond customary boundaries to focus on accountability.11 In healthcare, this means leading individuals from multiple disciplines and engaging in interdisciplinary problem-solving to incorporate highly collaborative and broad-based approaches to achieve solutions.

Generation management. As millennials move into nurse leader and executive roles, workplaces will become more highly collaborative.10 Healthcare systems will need to cultivate strategies that address the qualities of collaborative teamwork, high achievement, and technologic innovation.

Work-life balance. Although healthcare is a 24/7 endeavor, talented nurses are looking for jobs and schedules that balance their work and home lives to decrease burnout and increase output. Flexible schedules and self-scheduling are becoming more important.10

Regional and global perspectives. As healthcare systems continue to expand, nurse leaders will need a greater understanding of regional and globalized healthcare markets. Some business leaders predict that understanding what goes on outside one's organization will be as important or even more important than understanding how things work within one's organization.11

Leadership education. Formal leadership development programs will need to include real-world nurse leader experiences and make them available in short-term formats that are easily available to working professionals. Leadership development will need to be more virtual and interdisciplinary to reflect the realities of healthcare.11 Online problem-solving case studies and scenarios can provide accessible, just-in-time learning experiences that meet the career goals and personal needs of working nurses focusing on leadership development.12

And beyond

To navigate the changes ahead, maturing clinical nurses as leaders and preparing current nurse leaders to address evolving leadership challenges are paramount. As the nursing workforce continues to age, development of nurse leader competencies becomes more critical. In less than a year, it's anticipated that over half of all practicing RNs will reach retirement age.13 To be ready for the exodus of experienced nurse leaders, we must identify and grow nurse leader talent that will sustain the profession.

As you interact with nurses on your unit, look for qualities of self-awareness, self-regulation, empathy, and inclusiveness.14 Evidence suggests that leaders who have good social skills manage conflict effectively, and a fundamental aspect of relationships and the social work environment is respect.15,16 Recognizing and cultivating these qualities in emerging leaders are keys to future success.

Once you've identified up-and-coming leaders, determine what motivates them. A motivated leader inspires others, encourages transformation, and has a vision that he or she shares with others. Look for leadership behaviors such as fostering trust, facilitating change, innovating and influencing, driving results, engaging in high-impact communication, resolving conflict, team building, and problem-solving.17,18 Identiying these types of behaviors in your nurses can assist you to recognize leadership talent and allows you to explore their interest in nurse leader development.

Encourage nurses interested in leadership development to visit the American Organization for Nursing Leadership's website ( and review nurse manager and nurse executive competencies, which provide an excellent guide for self-assessment.19 Promote continuous learning, whether online or face-to-face, through graduate education and specialty certification.20,21 Equipping nurses with the leadership knowledge, skills, and competencies essential for providing quality, accessible, and cost-effective care is a requisite for sustained success.

In position

Nursing leadership has vastly evolved in the last 50 years. As healthcare environments change, 21st-century nurse leaders are positioned to influence systems and guide the nursing profession, developing new leaders who will transform patient care and the healthcare landscape of the future.


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