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Nurse Leadership Development Programs

The United States health system is in a constant state of flux. The implementation of innovative methods such as IPC, the Patient Centered Home Model, and other programs to improve patient care and satisfaction have been introduced to improve patient care and organizational performance. As a result, the healthcare system often appears chaotic and ineffective. Over the last two decades, healthcare’s quality-safety-performance-improvement structure has burgeoned but providing quality and safe care for patients and families remains challenging (Reid & Dennison, 2011). Patient and employee satisfaction scores suggest that there is a disconnect between leadership and patient care.  Nurses inundated with the task of caring for patients and meeting quotas often feel that their desire to help and their ability to provide quality care is constantly challenged and as a result tend to leave the profession. Menzies Lyth study of nurses revealed that the stresses of nursing and the intimate relationship it demanded with patients,  made an impact on the organization of care, leaving those closest to patients exposed to emotional pressures (Campling, 2015). High turnover rates in nursing is not a thing of the past and is definitely making its impact known on the current state of nursing. Past leadership strategies have not solved the professions problems; continuing the same approaches will lead only to the same unsatisfactory results (Sherwood, 2003). According to Kotter, “vision plays a key role in producing useful change by helping to direct, align, and inspire actions on the part of huge numbers of people (Kotter, 2012). If an organization is not able to envision its future and instill that into its leadership, an inefficient system may result. Without a clear vision of nursing and its unique role in healthcare, the nurse administrator is unable to effectively articulate nursing and to advocate for nursing; inability to communicate that vision may inadvertently contribute to a diminished quality of nursing service within the organization (Boykin & Schoenhofer, 2001). Nurse leaders serve as a link between the executive board and the patient. Per Anne Herleth, nurse leaders are the connection between strategic priorities and front-line implementation (Infantino, 2016). Per Fuller, nurse leaders, whether commissioners or providers of acute, community, primary care or mental health services must support frontline staff in working with patients, careers, and service users to improve health and wellbeing (Fuller, 2014). However, nurse leaders often find themselves ill-equipped to take on the enormous task of communicating the vision and inspiring staff to deliver the vision through care.

Leadership development programs

This section of the literature review provides background information on leadership development programs. This section examines the unique role of the nurse managers and the need to create a leadership development program that is complementary to the nurse managers skills and abilities. Leadership programs are designed to improve a manager’s leadership capabilities and skills. There are leadership programs that have been implemented with great success. However, most leadership programs do not address the challenges of nurse managers. According to the Department of Health, developing effective leadership at all levels of service is crucial for successful modernization (Gillian, 2008). Most leadership development programs are generic and can be ineffective for the nurse manager who is responsible for the lives of patients, the safety of staff, and the success of the health care organization.

Nurses who have risen to executive positions are able to provide insight into direct patient care activities to include the possibilities and limitations of short staffing, lack of needed equipment and resources, and inefficient electronic medical record systems. Per Larson, “our goal is to address every risk proactively, and nurses know where these risks are. They have a vantage point that health care leadership needs” (Larson, 2017). These nurse managers, however, must understand the essential characteristics and realities of creating structures to facilitate and drive change in health care organizations. A nurse must be committed to their passion and purpose and have the type of commitment that turns into perseverance (Guyton, 2012). Nurse managers who promote communication between nursing staff and other disciplines can set the stage for a collaborative culture (Carlson, 2016). A collaborative culture that includes principles of nursing such as caring and compassion may have a positive impact on an organization’s performance.

The principles of nursing include care, compassion, commitment, communication, courage, and competence (Royal College of Nursing, 2016). Moreover, the principles of nursing can be used to drive quality improvement, continuing professional development (CPD) and sharing between disciplines, patients, and their families (Royal College of Nursing, 2016). Along with nursing principles are nursing theories. Nursing theory aims to describe, predict, and explain the phenomenon of nursing  (Lee, 2014). Unfortunately, many nurses have not had the training or experience to deal with the abstract concepts presented by nursing theory (Lee, 2014). When nurses use theory and theory-based evidence to structure their practice, it improves the quality of care (Ahtisham & Jacoline, 2015). As a result, translating the value of the development of nurses to senior leaders is a challenge for nurse executives. Failing to provide substantive information only supports the ambiguous nature of nursing.

The role of the nurse manager1

Nurses constitutes the largest proportion (23%) of the health care workforce with approximately 2.5 million Registered Nurses (Barton, 2018). The profession of nursing is defined by the American Nurses Association as “the protection, promotion, and optimization of health and abilities, prevention of illness and injury, facilitation of healing, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, groups, communities, and populations (Barton, 2018). Thus, the unique role of the nurse manager derives from the principles of nursing and that is providing care to those in need. This concept changes the role of the nurse manager; nurses have great potential to lead innovative strategies to improve the health care system (Institute of Medicine, 2011). Consideration to the patient’s well-being and their outcomes emulates the care that nurses provide, it is evident from the literature that patients welcome compassionate care and it influences their perception of the quality of care provided (Adamson, King, Moody, & Waugh, 2009). Not only is caring an essential component  of nursing but it is an integral part of care as perceived by patients receiving care. Nurse leaders are called to infuse the organization with an understanding of what it means to “live caring” (Boykin & Schoenhofer, 2001). However, the concept of dignity, like compassion, is abstract and difficult to measure (Davison & Williams, Compassion in nursing 1: defining, identifying and measuring this essential quality, 2009). Providing supportive and caring environments for staff and patients continues to be the greatest challenge for nurse leaders.

Moreover, “it is not unusual for nurses who are effective in direct patient care to be promoted to positions of nursing leadership without any formal advanced preparation for this role (Boykin & Schoenhofer, 2001). Most nurse leaders have little formal leadership education and have learned on the job mostly through trial and error (Sherman, Bishop, Eggenberger, & Karden, 2007). And, although it is mostly agreed upon that there should be a formalized nurse leadership development program, health care organizations remain reluctant to implement these programs. Several reasons organizations fail to invest in leader programs include limited resources, a failure to understand the benefits of competent nursing leaders at every level (or what competencies clinical leaders need), and a lack of awareness of the costs incurred when clinical leaders are not developed (Sanford, 2011).

Nurse managers play an integral and indispensable role in contributing to quality patient care, patient safety, nurse satisfaction, nurse recruitment and retention (Sullivan, Bretschneider, & McCausland, 2003). This role is often confused by a lack of understanding and knowledge as to what a nurse does and what a nurse manager should be responsible for. Without a clear vision of nursing and its unique role in health care, the nursing administrator is unable to effectively articulate nursing and to advocate for nursing. The lack of vision and the inability to communicate that vision can inadvertently lead to diminished quality of nursing service (Boykin & Schoenhofer, 2001).

In several studies, there are recommendations for a nurse manager leadership development program. Fennimore and Wolf noted that, Chief Nursing Officers (CNOs) describe communication, conflict resolution, role transitioning, scheduling, budgetary and payroll management, performance evaluation, and staff counseling as the primary developmental needs for nurse managers (Fennimore & Wolf, 2011). Other recommendations for leadership training include: the business of healthcare with financing and budgeting, leadership practices, behaviors, and skills; use of self in communcation skills and personal effectiveness (Sherman, et al, 2007). These varying perspectives have an impact on how senior leadership groups would think about leadership development for nurses (O’Neal, Morjikian, Cherner, Hirschkorn, & West, 2008).

The caring role of nurses1

It is not known why society expects nurses to be compassionate and caring. Historically, this may be related to the profession’s religious origins and the fact that most care was provided by family of friends with whom we have emotional attachments (Davison & Williams, Compassion in nursing 2: factors that influence compassionate care in clinical practice, 2009). The general public and patients assume that nurses will provide compassionate care. However, attempts by nurses to overtly display caring and compassion, may lead to institutionalized behaviors, lacking any real feeling and ultimately worth less (Davison & Williams, Compassion in nursing 2: factors that influence compassionate care in clinical practice, 2009). One of the challenges of care theories is the individual perspective of what care and compassion means, what people don’t understand is caring for others may have a personal cost to the nurse providing care and that the effects of helping or wanting to help others who have been traumatized or suffering can result in compassion fatigue (Davison & Williams, Compassion in nursing 2: factors that influence compassionate care in clinical practice, 2009). Compassion requires that staff give something of themselves. Work fatigue, personal factors, and organizational circumstances conspire to create workplace stress, it becomes more difficult for staff to feel and show compassion, creating a gap between their intentions and their capabilities (Cornwell & Goodrich, 2009). To embrace this concept of compassionate care, nurse leaders must demonstrate resilience in responding to change and supporting others to embrace this in a positive way (Frankel, 2018). The leadership challenge proposed by Kouzes and Posner and Models of Caring Leadership by Jean Watson have shed light on the importance of instilling certain principles of practice into the development of nurse managers. Watson feels that in the current environment of the healthcare system: the person is split apart, and the soul is replaced with narcissism of self or denied all together. The human soul is further destroyed with a depersonalized, manufactured environment, advanced technology, and robot treatment for cure, delivered by strangers in a strange environment (Ryan, 2005). The leadership challenge model of Kouzes and Posner speaks to modelling the way, inspiring shared vision, challenging processes, enabling others to act, and encouraging the heart (McDowell & Charlescraft, 2014). Jean Watson’s Care Leadership Model is based on core values that include leading with kindness, generating hope, innovation, protected spaces, and embodying an environment of care (McDowell & Charlescraft, 2014). Both of these models have been used to create the Caring Leadership Model. The Royal College of Nursing recommended the 6Cs as principles of nursing practice. The 6Cs include care, compassion, commitment, communication, courage, and competence (Royal College of Nursing, 2016). If a leadership development program for nurse managers considered these six areas, the results could prove to be beneficial to the nurse managers ability to lead and direct their teams. Moreover, if a leadership development program directed at nurse managers does not address real-world issues, the program will be a waste of time for the nurse manager. In spite of these realities, health care organizations fail to understand the impact of poor leadership and its effect on employee retention, patient satisfaction, and organizational performance. Therefore, can caring based leadership programs be the best option for nurse managers? Without taking consideration of the role of the nurse manager, leadership styles, the culture of the organization, relationships, and communication, this question cannot truly be answered. And thus, examining the role of the nurse manager becomes imperative.

The nurse manager as the crucial link

Leadership development programs are often focused on managers in traditional business structures and covers all levels of leadership. The special role of the nurse manager needs to be redefined and considered. Nurses, because of their involvement with patients and families, serve as a direct link between the customer and the executive board. Nurse managers complete this link by serving as the bridge between the nursing staff and the executive board. Because of their special role in healthcare, nurse managers have the ability to move change through a complex health care organization (Hanley, 2013). Moreover, the nurse leader is able to move between the roles of change agent and change coach to transform the health care environment and how care is delivered (Stefancyk, Hancock, & Meadows, 2013). Although there are leadership courses in most nursing school curricula, they do not adequately address the realities of the complexities of the healthcare system, idiosyncrasies of health policy as it unfolds in the clinical setting, or challenges of technology – this leaves the organizations with the tasks of educating and grooming future nurse leaders (Schmidt, 2013). And, in spite of the evidence that supports the value of nurse leadership development programs, healthcare organizations continue to report barriers in developing these programs. Seven barriers that have been identified by O’Neil and colleagues include lack of interest in leadership, lack of program availability, poor program fit, dissatisfaction with existing programs, lack of executive support, and budget and release time (Ramseur & Fuchs, 2018). The challenge for health care organizations will be incorporating a leadership development program with a focus on nursing and nursing care; and to know how to structure the knowledge, skills, and abilities of nurses so they are positioned to step into roles that are needed for both present and future job opportunities (Joseph & Huber, 2015). Leadership development programs for nurses should consider the complex role of the nurse manager and the everyday challenges that they fact. Healthcare organizations must be cognizant of the link between nurse leadership, employee satisfaction, and how this relationship impacts patient care and organizational performance.

Preparation for leadership – nurse managers

Although, nurse leaders are an essential part of the healthcare puzzle, nurse leaders often find themselves ill-equipped and lacking support. Although nurse managers are responsible for the operation of business units, nurse mangers are often less well prepared to manage the business activities than clinical activities (Kleinman, 2003). As a result, employees are affected by poor management. A survey of 1,780 registered nurses revealed that supervisor support and quality of supervision was lowest for nurse managers; with 509 nurses commenting that the problems with management include inadequate leadership and frequent turnover of nurse managers, insufficient physical presence on units, failure to address problems, and a modest awareness of staff issues (Jennings, 2008). The harsh reality is the nurse leaders time is often filled with a long list of responsibilities and other activities that take them away from their units. Nurse managers are expected to manage day-to-day operations, empower staff, build productive work teams, maintain quality, and satisfy customers (Kleinman, 2003). Nurse managers find themselves overwhelmed by their responsibilities. Nurse managers find themselves spending more time on ‘back office’ work, which limits the amount of face-to-face time they have on their units and reduces meaningful rounding time with patients and staff (Infantino, 2016). Moreover, management is responsible for decisions related to how hospital customers will be reached, how to optimize the services the board wants to offer; how to make the hospital efficient; what actions the hospital should take to achieve the boards goal; and who should work for the hospital (Dahl, 2017). The nurse manager must serve as an agent of change to improve the role of nursing The nurse manager must be a skillful negotiator to impart ideas, portray the value of emotional energy, increase balance within the organization, increase communication and educational knowledge, and provide input toward clinical and administrative decision making (Maragh, 2011). However, the fact remains that most nurse managers are poorly prepared for this role. The development of a nurse leadership development program may serve as a possible solution.

The purpose of nurse leadership development programs

The purpose of leadership programs is to develop the leader’s skills which will enable them to achieve organizational goals, improve individual performance, and organizational consistency (Studer, 2003). To better develop a nurse leadership development program, it is imperative that executive leadership understand the role of the nurse manager in relation to the goals of the health care organization. Executive leaders must determine the direction or vision that they have for the organization and then define how nursing will play a role in the success of the organization. Moreover, it is important that the perspective of the ‘nurse’ be represented at the highest levels of hospital leadership and integrated into hospital decision making (Needleman & Hassmiller, 2009). Organizations that fail to invest in their leaders risk the high cost related to employee turnover and decreased patient satisfaction scores. Moreover, service effectiveness is determined by evaluating achievement of specific targets and measurable outcomes, and this emphasis on outcomes can also be seen in the context of education, with an expectation that high quality education will have direct benefits on care (Draper, Clark, & Rogers, 2016). A leadership development program directed at nurse managers should provide provisions for integration throughout the organization. For example, leadership activities should be integrated into job descriptions, performance evaluations, professional models of care, professional advancement programs and the philosophy or culture of the organization (Hanley, 2013). “In order for an organization to be great, it has to have great leaders; in order to have great leaders, the organization has to invest in them” (Studer, 2003).

The importance of a nurse leadership development program

The harsh reality is the nurse managers time if often filled with a growing list of responsibilities that they are not prepared for and no support or direction from the nurse executive. The disconnect between the executive office, the nurse executive, and the nurse manager lends itself to a chaotic health care system where employees report dissatisfaction with care. Staffing shortages, increasing workloads, inefficient work and technology processes, and the absence of effective pathways for nurses to propose and implement improvements all have a negative impact on job satisfaction and contribute to the decision to leave (Institute of Medicine, 2011). According to Fahad Al-Mailam, “quality leadership in health care organizations fosters an environment that provides quality care which is linked with patient satisfaction” (Peltier & Dahl, 2009). When people think of a nurse, they think of that person who empties bed pans. Darbyshire noted that people see nurses a s heroines, hookers, handmaidens or harridans, and certainly older nurses will remember that discipline, menial tasks such as cleaning, and tidiness of the wards were once regarded as more important by nursing’s leaders in some regimes than caring (Shields, 2014). The reality is that every day that a nurse steps into a clinic, hospital, or any health care environment, they are bound by their profession to save the lives of those in their care. Every day nurses make decisions based on what they assess, diagnose, plan, implement, and evaluate; ADPIE is an extension of the nursing process acronym, APIE (assessment, planning, implementation, and evaluation) to include diagnosis (Shuey & Hoaks, 1989). Every piece of data that they receive either by observation or actual contact is used to determine the best course of action to bring patients comfort, healing, and empathetic care. This fact does not exclude nurse managers. Nurse managers are in a position where they are aware of the daily risk to patients and nursing staff. Based on the uniqueness of the nurse managers role, leadership styles that support the philosophy of nursing should be in line with the nurse managers role, values, and beliefs.

The benefits of a nurse leadership development program