Leveraging the emeritus nurse expertise and experience when orienting new nurse managers

In Brief

A program that capitalizes on the nurse emeritus experience and expertise can support a new nurse manager's transition and, at the same time, extend the nurse emeritus career.

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Nurse managers are often chosen based on expertise and experience as a clinical nurse, and, in most cases, are oriented through lectures or self-led learning modules. Orienting new nurse managers to the role could make a huge difference in their leadership success and retention. The authors' organization ventured into a program that capitalized on the emeritus nurse manager's skills to orient new nurse managers. This program helps accomplish two critical organizational goals: preparing the new nurse managers to be successful in their role and retaining valued and prized expertise and experience by extending the emeritus nurse career.

Background

The American Organization for Nursing Leadership (AONL) reported nurse manager vacancy rates as high as 8.3% nationwide, higher than senior nurse managers, CNOs, and hospital administrators.¹ The cost of replacing nurse managers is estimated at 75% to 125% of their annual salary, which is approximately $124,040 to $144,637 total losses; those costs don't include the organizational experience lost with turnover.² The Bureau of Labor Statistics also predicted a 32% increase in the demand for nurse managers between 2020 and 2030.³ The challenge is further compounded by an influx of nurses retiring and leaving the profession.

Nurse managers play a vital role in the success of an organization. To contribute to the achievement of the organization's vision and efficiently manage their unit's operations, patient outcomes, and staff, they need to acquire the competencies to perform their roles. Several nursing leadership organizations have identified these core competencies. A scoping review of 76 studies in 15 countries, including the US, identified six competency dimensions: management, communication, technology, leadership and teamwork, knowledge of the healthcare system, nursing knowledge, and personality.⁴ The role is extensive and complex. This demanding role often creates an increased workload and becomes a significant source of job stress.

A cross-sectional study revealed that almost every nurse manager surveyed experienced high stress from workload, resulting in higher overall job stress.⁵ High stress levels are often tied to a lack of knowledge because of insufficient training, unknown expectations, work overload, conflict, and responsibility for other workers. Intent to quit and mental health symptoms were the most significant outcomes of stress.⁶ Higher overall job stress is associated with higher intention to leave the organization, lower job satisfaction overall, and a more negative perception of the practice environment.⁵ This is why the nurse manager's position is among the most difficult to recruit and retain.

With most orientation programs geared toward providing lectures, online modules, and shadowing, this preparation for a dynamic and complex nurse manager role isn't enough. It leaves the new nurse manager overwhelmed and confused, unsure of what to do next, and having difficulty with their transition from peer to leader. One qualitative descriptive study compared this experience to learning how to “swim” or else you'll “sink.” The same descriptive study discussed the nurse manager's feeling of “never-ending” tasks and accountability, their need for senior leadership support, and lack of work-life balance.¹

In the authors' organization, the CNO advocated for a position to support, mentor, and assist with the orientation of nurse managers. The role of nurse manager consultant was created with the support of local and network leadership, approving per diem positions for this purpose. The organization leveraged and transitioned an emeritus (retired) nurse leader to develop the program encompassing this role. The goal is for the nurse manager consultant to provide nurse managers with systematized, well-developed orientation and training during their transition period.

The emeritus nurse supplements the organization's new hire's orientation lectures, online modules, and meetings with experts with weekly one-to-one meetings with each mentee. Depending on the mentee's progress and needs, the emeritus nurse supplements learned concepts with practical tips for application, scenarios, and examples. If the emeritus nurse feels additional education is needed to help enhance learning, this person coordinates follow-up meetings and shadowing of resource people. The emeritus nurse also offers continued support and mentoring, even after the mentees' orientation period. The emeritus nurse served as the new manager's coach, advocate, and resource person.

Knowing nurse managers have a person they can go to for questions and clarification is important and helpful, especially during their transition period. One study implemented a nurse manager orientation program that showed an increase in skill level for the AONL nurse manager' competencies and psychological empowerment.⁷ Another study used a web-based modular approach, combined with engaged nursing executive mentorship, significantly increasing the perceived competence of developing nurse leaders.⁸

Cultivating transformational leaders

Being a designated Magnet^® organization, the vision is to cultivate the development of transformational leaders who will lead the team to where they need to be to meet the demands of the future and the ever-changing healthcare landscape.⁹ Transformational leaders develop their leadership skills when inspiring others to achieve extraordinary outcomes. It supports practices and behaviors that improve job satisfaction, productivity, turnover, and organizational commitment.¹⁰

Transformational leaders work through empowerment, motivation, consideration, and influence. They listen, affirm, communicate, and exercise creativity in approaching obstacles and challenges. Transformational leaders exemplify six behaviors: articulate a vision, set a positive example, communicate high-performance expectations, show sensitivity to individual followers/needs, encourage a team attitude, and provide intellectual stimulation.⁹

Leaders don't end up in leadership roles by chance; they're recognized for influencing others or for being great and effective charge nurses or direct care nurses. It's important to enhance those potential skills so nurse managers successfully navigate and cope as they assume a role with multiple demands, stakeholders, and initiatives. One of the most effective ways to navigate through day-to-day demands and controlled chaos is to have a list of priorities to keep you on track and create an effective routine.

Brainstorming with another leader, the emeritus nurse developed the Nurse Leader's Resource Binder/Checklist. The checklist is beneficial, especially in guiding the discussion in the meetings with the new nurse managers. Competencies and available resources are reviewed, and their understanding of their new roles and the leader's expectations are assessed. Thought-provoking questions to gain deeper insights include: “What's their most important priority that they'd like to accomplish first in this role?”, “Does it support the organization's mission and vision?”, and “What could be incorporated into their daily routine and workflow that can consistently support the organization's mission and vision?”

One example of daily routine and workflow is the safety huddle. Daily safety huddles can provide opportunities to update the staff about what's going on, discuss any challenges and facilitate timely resolution, and plan and prioritize daily tasks. This approach helps the staff understand how they can contribute to attaining the organization's mission and goals and the efficient operations of their unit.

Focusing on the organization's goals as a framework and developing consistency in the approach is critical to success. An important concept to close the communication loop and build trust is the trust-tell-do approach (tell the leader what you're going to do, do it, and tell them you did it). Being fair but firm and consistent is vital. Building resiliency to adapt to changes and cope with pressure is a quality that makes a difference in the leader's success.

The mentoring/orientation program

The AONL developed the Nurse Manager Competencies based on the Nurse Manager Learning Domain Framework. In this framework, nurse leaders must gain expertise in three domains: 1) The Science: Managing the Business; 2) The Art: Leading the People; and 3) The Leader Within: Creating the Leader in Yourself.

Competencies under The Science domain involve financial management, human resource management, performance improvement, and foundational thinking skills.¹¹ These are usually covered through classes, online modules, and one-on-one sessions with experts or resource persons and are usually the emphasis of the orientation. The emeritus nurse leader goes through in-depth staffing needs, talent recruitment and retention, the scope of practice and role definitions, labor laws, and union contracts. Also included in the discussion are budgeting, revenue, the impact of reimbursement, data metrics such as nurse-sensitive indicators and patient satisfaction, survey and regulatory readiness, and workplace safety.

A review of information technology and business tools such as business intelligence, strategic planning and project management, clinical practice guidelines, and evidence-based practice are discussed. The emeritus nurse leader's one-to-one session with the new nurse manager allows simplification of the concepts, opportunities for clarification and questions, identification of specific examples, “how to” demonstrations, and application of learned concepts (see Figure 1).

Figure 1:: Nurse manager orientation competencies¹¹

Figure 1:: Nurse manager orientation competencies¹¹ (continued)

The Art competencies involve human resource leadership skills, relationship management, and influencing behaviors and diversity.¹¹ These are usually covered in orientation classes; however, the emeritus leader uses practical tips and scenarios to simplify and explain the concepts. The discussion usually starts with reviewing the professional chain of command and escalation policy, guidelines for cooperation and discipline, and absenteeism and lateness.

They're followed by scenarios that require “difficult conversations,” such as discussing performance when the employee isn't meeting expectations and guiding them in developing action plans for improvement, initiating corrective and disciplinary actions, or terminating an employee. Other scenarios and examples include: conflict management; dealing with an employee expressing dissatisfaction, frustration, or disagreement with the policies, guidelines, or the leader's directive; or when comments or actions aren't culturally sensitive.

Principles for dealing with these scenarios may be discussed and covered in classes or online modules but applying those principles is usually challenging. Tips, scenarios, and conversations with the emeritus leader come in handy when considering emotions, personal reactions, and face-to-face interactions. At times, encountering the actual situation and having someone to discuss it with, allowing objective analysis of “what ifs” and expression of how they felt as a leader, is also beneficial (see Figure 1).

Lastly, The Leader Within competencies include personal and professional accountability, personal journey, succession planning, and career planning sessions.¹¹ The emeritus leader can factor in personal goals, plans, and timelines when discussing growth and development, such as advancing academic degrees and obtaining specialty certification or future career path and reflective practice on leadership behaviors. The emeritus nurse shares with the new nurse manager information on organizational resources and opportunities, such as tuition reimbursement, scholarships and grants, certification exam fee reimbursement, review classes, leader fellowship, and the organization's sponsored MBA/DNP (master of business administration/doctor of nursing practice) program cohort. Nurse managers are encouraged to use these resources.

One of the new nurse leaders who applied to the organization-sponsored DNP program was accepted and is now pursuing her DNP degree. A committee on advancing scholarly work was also put together to support any nurse's desire to do quality improvement projects, research, conference presentations, and publishing. Several new nurse managers attended the education offered by the committee on these topics. One of the nurse managers successfully presented a poster at a national conference on a performance improvement project that she led. Another nurse manager is assembling a team to start researching the effect of teatime on their staff's well-being and mood (see Figure 1).

A total of 10 new nurse managers participated in the program. Six have already completed their orientation period, and four are still in orientation. The six who completed the program have successfully assimilated their roles and responsibilities and are thriving well. The emeritus nurse continued to meet with them on an as-needed basis and provided feedback to the nurse directors who oversee these nurse managers for ongoing support. The retention rate for the program participants is 100%.

Relationship with mentor

Our organization uses the Organization of Nurse Leaders of New Jersey (ONL-NJ) took kit for mentoring. Assessment surveys are part of the tool kit. Completion of the surveys implied consent to participate. We used the survey to assess the relationship with the mentor/nurse manager consultant (see Table 1).¹² The surveys were completed by the mentees. Overall assessments of the relationship with the mentor were very positive. Participants rated 19 out of 20 items 4 (quite a bit) or 5 (very much) on a 1 to 5 Likert-type scale.

Table 1: - Satisfaction with the mentor relationship

Relationship with mentor	Somewhat (%)	Quite a bit (%)	Very much (%)	N/A (%)
Been available to talk/meet you when you wanted to talk/meet	0	0	100	0
Talked with you about your professional development	0	33	67	0
Helped you strategize activities to meet your professional goals	0	0	100	0
Assisted with introductions to people who could help you professionally	0	17	83	0
Assisted you with long-range career planning	17	33	33	17
Guided you in assessing your future potential	0	33	67	0
Been nonjudgmental when listening to you	0	0	100	0
Expressed confidence in you and your abilities	0	0	100	0
Fostered your independence	0	0	100	0
Discussed with you ways to handle challenging situations	0	0	100	0
Encouraged you to act as an advocate	0	17	83	0
Given you feedback	0	17	83	0
Guided you in assessing your immediate learning needs	0	17	83	0
Discussed understanding of various regulatory agencies	0	0	100	0
Allowed you to openly express your feelings	0	0	100	0
Demonstrated that she/he cared about you	0	0	100	0
Communicated in such a way as to enhance your self-esteem	0	0	100	0
Gave insight with interpersonal relationships and relationship-building	0	0	100	0
Been a role model for you	0	17	83	0
Been supportive of you overall	0	0	100	0
Engaged in the mentor-mentee relationship	0	0	100	0
Comments: “She is a great mentor.” “Meeting with her helped me gain more confidence & become an effective leader.” “I look forward to our weekly meeting.”

High-scoring areas included: the availability of the mentor, discussions about professional development, the mentor being nonjudgmental when listening to mentees, encouragement of the mentee to act as an advocate, effective communication in such a way to enhance the mentees' self-esteem, giving insight with interpersonal relationships, and discussions about regulatory compliance, to name a few. The mentor supported the new nurse managers and allowed them to openly express their feelings and concerns, which the mentees found beneficial.

One area that didn't score as high for some was assisting with long-term career planning; 17% of participants rated it a 3 (somewhat) and another 17% thought it wasn't applicable. Long-term career planning wasn't a priority for the emeritus nurse as the mentees are new nurse leaders who are still learning their new roles. The feedback was provided to the mentor and was well accepted. This feedback can enhance the program, especially on future offerings.

Mentoring program survey

The second survey completed by the mentees was to assess the overall mentoring Program (see Table 2). Again, the ONL-NJ form was used to complete the survey. The survey rated specific components on a scale of 1 to 5. Eight out of nine items scored 5, with 17% to 33% of the mentees scoring some items beyond the 5 scale (“much”).

Table 2: - Satisfaction with the mentorship program

	Rating on a 1-5 scale (%)
Survey question	4	5
To what degree has this program assisted you in developing supportive relationships?	0	100
To what degree has this program contributed to your professional growth?	0	100
To what degree has this program contributed to your personal growth?	0	100
To what degree has this program enhanced your ability to communicate with your colleagues?	0	100
To what degree has this program enhanced your ability to problem-solve work-related issues?	33	67
How satisfied were you with the communication with your mentor?	0	100
How satisfied were you with the discussions at your meetings with your mentor?	0	100
To what degree do you think this program has been helpful?	0	100
Overall, how satisfied were you with this program?	0	100
Comments: “Coaching is essential for new leaders within an organization.” “The mentorship program is extremely helpful.” “Great program, especially for new leaders. She provided excellent support & clarification.” “The mentorship program was extremely helpful in navigating me to a new organization. Communication with other leaders and how team member roles applied.”

One area that didn't score as high for some was the program enhancing their ability to problem-solve work-related issues. Problem-solving involves familiarity with the resources, workflow, and team. Learning to problem-solve takes time, and the scenarios and examples provided to mentees, in addition to their own experiences, will help them develop the problem-solving skill in due time.

The mentees felt that the program assisted them in developing supportive relationships, contributed to professional and personal growth, and enhanced their communication with their colleagues. They were extremely satisfied with the communication with their mentor and looked forward to their meetings and discussions with her. One mentee stated, “Coaching is essential for new leaders within an organization.” This statement supports the study results that nurse managers gained increased resilience, confidence, and better coping mechanisms following coaching. Findings also supported that coaching led to improved team management and cohesion and appeared to lead to a better quality of care for patients.¹³ Coaching was considered a vital leadership development strategy and a valuable investment for the long-term success of healthcare managers.¹⁴

The meeting sessions with their mentor have helped them gain confidence in becoming an effective leader and helped the new nurse leaders navigate as they learn their new roles with many competing priorities. This program has given them direction and support as they come to understand and cope with the expectations of a nurse leader. Mentorship is vital to the new leader's success. The nurse managers were fortunate to have additional support from this program.

Next steps

The orientation program continues to evolve. Three more per diem emerita nurses were hired to support the program. A formalized self-assessment checklist was developed to identify individualized learning needs. Given the success of having the supportive presence of the emeritus nurse and the coordination of the orientation programs and topics, the CNO plans to extend this support to other nurse leaders regardless of their tenure and experience. Future research and projects can include expanded roles for the emeritus nurse and the effects on outcomes such as nurse-sensitive indicators and patient satisfaction.

Supporting leader success

With the ever-changing healthcare landscape, we need to provide nurse leaders with the education, support, and framework needed for their success. This is the only way we can ensure new nurse leaders are equipped to handle the expectations and challenges that accompany their roles. A program that tapped into the emeritus nurse leader's experience and knowledge has given the nurse leaders the education and support they critically need. The results showed that the mentees valued what they had learned about strategizing and dealing with challenging situations and regulatory agencies.

More important, they appreciated having someone who cared, listened to them, and allowed them to express their feelings. The mentees felt that the emeritus nurse as their mentor helped their personal and professional growth, enhanced their communication skills, and built supportive relationships with their teams and patients. This program has been highly successful at our organization, and nurse leaders have grown and developed as a result.