Strategies for cultivating nursing leadership

Stephanie Conners, BSN, MBA, Rosemary Dunn, RN, MSN, CRNP, MBA, Kevin Devine, RN, MSN, CRNP, CEN, and Cindy Osterman, RN, MSN

n nursing management, competent front-line leaders are essential to driving excellence in an organization, but they tend to be the most difficult to recruit. How do we identify and cultivate nursing leaders? Senior nursing leaders must use creative approaches to draw on the talent of potential leaders who otherwise may go unnoticed. As many are aware, a strong clinical nurse does not necessarily make an effective nursing leader. This article examines traits and qualities of nurse leaders, relates two personal stories of nursing leadership, and describes the development of a leadership program called “Staff-nurses Transitioning to Administration Review” (STAR) at Hahnemann University Hospital. Much has been written about the current nursing shortage and the challenges faced by the profession in both recruiting and retaining nurses. One need only conduct an internet search on “nursing shortage” and hundreds, if not thousands, of popular and scholarly responses will be retrieved. Much also has been written on what characteristics make a good nurse leader.1-3 However, material addressing the identification and cultivation of nursing leaders is less plentiful. Literature searches in medical, nursing, and allied health databases, such as Medline and CINAHL, show that much less attention has been paid to identifying nurses in an organization who may have the potential to become future leaders. Searches performed using terms or phrases such as “growing nurse leaders,” “developing nurse leaders,” and “succession planning” did retrieve some relevant information. Articles have been published that examine generational issues affecting younger nurses entering nurse leader positions4 and also discuss formal programs with structured curriculums developed to prepare nurses

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to make the transition into leadership positions.5,6 Several authors have discussed general approaches to the concept of succession planning,7-11 but many lament that it is not a priority in today’s nursing culture. The Advisory Board Company agrees that, unlike many other industries, nursing and health care have been slow to develop strategies for identification of future leaders.12 With a dynamic health care environment and the current nursing shortage predicted to continue, it is more important than ever to identify nursing leaders early in their careers.

fence, they can be easily persuaded to move to the wrong side of the fence. We, as senior nursing leaders, must identify and develop the quiet, positive, visionary leaders among us.

THE DRIVER

We have an imbalance in health care. We attempt to drive results but do not always evaluate whether the appropriate talent is in the driver’s seat. Choosing people who have the energy and willingness to solve problems can literally change a culture in a very positive way. In today’s health care environment, certain measures and THE FENCE standards dictate success. A strong foundation of leaderIn all organizations, there are three types of people: ship can be the difference between perceived excellence those on the right side of the fence, those on the left, and recognized success. and those sitting on it. The key to a successful organizaHow do you establish a strong foundation? First, you tion is ensuring that people on the “right” side of the must connect emotionally with the team, a process somefence are in leadership positions. Those on the right side times referred to as building a strong emotional bank acof the fence innately demonstrate qualities of leadership count. An early emotional investment in your team such as drive, energy, determination, vision, self-disciallows you to draw from that account in challenging pline, and flexibility. times, which in turn, helps the team stay focused and A true leader not only needs to be on the right side of keeps it on track. Second, you must create a branding strategy, which the fence with the aforementioned qualities but also must can be as simple as creating a shared vision, a descripbe able to assemble a team. Innately strong leaders have tion of the business as you want it to be. Webster’s Dica clear vision of what they want, take definitive steps to tionary defines vision as “imaginative insight or achieve it, and motivate others to join that vision. Howevforesight.” Imagine your ideal health er, many of these best performers are care environment and then envision not recognized as leaders, and as a reA true leader not only what is needed to realize that ideal. sult, others fail to learn from them. As This vision will help you set boundnursing leaders, we must strive to idenneeds to be on the right tify this informal “cream of the crop” side of the fence with the aries and provide a guideline as to what can become reality. and help them develop so that others aforementioned qualities As a senior nursing leader, it is escan discover their leadership strengths. Unfortunately, every fence has two but also must be able to sential that you inspire people to sides, and on its left side is the loud work toward this shared vision. You assemble a team. and negative staff member who somecontinually need to focus and bring times has more influence on a team clarity to the desired goal, and most than the quiet, positive leader. Negative informal leadimportantly, you need to guide people in their decision ers demonstrate none of the traits found in positive making as they reach for this future. In the environment leaders, and instead tend to have a negative influence in which we approached this process, a simple internal on a team. They are indecisive, disorganized, and inbranding strategy, “Believe and Achieve,” was created. If consistent, with little follow-through. Moreover, they you sincerely believe in the vision of the organization, tend to be vocal and, as a result, may create their own you can achieve anything. group of followers. With a solid foundation established, you then must To avoid building an organization rampant with these focus on developing management skills and identifying types of false leaders, it is essential to have a mentorship leadership qualities. In assessing managers for leadership program to help identify potential leaders. It is easy to potential, how do you identify the best candidates? Manassume your best clinician will be your best leader, but agers execute and put processes in place to accomplish a that is not always the case. In fact, if that same clinician task, while leaders imagine the desired future and direct does not have innate leadership qualities, you may be the efforts of a team. Management decides how to supsetting up this person to fail. ply appropriate resources to obtain the maximum return. An organization that fails to develop its quiet leadA leader champions change by inspiring and developing ers is apt to be left with negative informal leaders, individuals to perform at maximum levels. A manager who, while vocal, produce little. Without an environdrives a team to work harder, while a leader ultimately ment that fosters internal growth, the best talent may focuses its direction. be virtually unnoticed or go elsewhere. And, since the It is essential for organizations to have both strong majority in any organization generally sits on the managers and leaders. Ultimately, the goal is to identify October 2007

Nurse Leader 27

thoracic surgery, and asked me to help support the potential leaders and mentor and groom them to be not unit during a transitional period. I accepted but was only strong leaders but also successful managers. You not committed. I insisted that this “fix” would be can teach a nurse any technical skill necessary to be suctemporary and encouraged her to begin a search for cessful at the bedside, but you cannot always train somea permanent manager. I did not realize it at the time, one to be a successful leader. If the critical innate traits but this abrupt change in my career path led to my of drive, energy, determination, vision, self-discipline, personal leadership awakening. and flexibility are identified, the management skills can As a novice manager, I pursued be learned. all of the expected management Once the right leader is selected for If the critical innate competencies: unit organization and the driver’s seat and provided training structure, policy development, staff in the appropriate management skills, traits of drive, energy, competency and education, unit metrics to measure success must be determination, vision, environmental improvements, quality established. These criteria should be in self-discipline, and assurance projects, budgetary developline with the organization’s vision, and ment, and staff payroll. I also enrolled the entire team must be aware of the flexibility are identified, in an MBA leadership program to criteria and how they can achieve posithe management skills guide my management competency tive results. Once those measurements can be learned. development. As I grew in my role have been established, consider how and became proficient at basic manato sustain success and make it part of gerial skills, I realized that being a the culture. leader was very different from being a manager. I also Sometimes we know exactly where we want to go realized that I had been preparing for a leadership role and how to get there. But often we have an idea of what throughout my nursing career. we would like but not exactly how to get there. Here are Even as a young nurse at the bedside, I watched and personal stories of two people who began their careers learned from those bedside nurses who made a differas front-line nurses and eventually moved up through the ence. They were nurses who unknowingly set the unit ranks to become senior directors of nursing. expectation for patient care excellence. Their inherent leadership abilities influenced the cohesiveness of the deEXPERT CLINICIAN TO NOVICE LEADER partment and shaped the action of others to perform at Although today I’m in a nursing leadership position, as the set standard. I reflect on more than 30 years in the profession, I know Today, I consider these nurses to be my initial role modthat I did not enter the field of nursing to pursue a manels in leadership. I have kept track of their career paths, and agement position. In fact, I do not recall any of my colas expected, many of them have moved on to advanced leagues in those early years ever discussing a desire to clinical practice or to hold other leadership positions. manage, nor was there a leadership track built into our However, throughout my career, I also have encounnursing curriculum. At that time, we focused on developtered the other type of unit leader. These informal negaing the skills required for bedside nursing. It was undertive leaders are often loud and aggressive, and their stood that if you excelled as a clinician, you might issues—whether personal or work-related—tend to bequalify for a management position as a charge nurse. At come the unit’s issues. Too often, they ultimately can be that point in my career, a leadership position beyond that mistaken as unit leaders because they influence and level did not matter because I took pride in being an exshape the actions of others, albeit through poor behavior. pert clinician, which was my initial and ultimate goal. Left unmanaged in an environment lacking strong posiMy clinical career as a bedside practitioner extended tive forces, these informal negative leaders can destroy over 2 decades. As I mastered one skill set, I desired to the cohesiveness of the work team. learn another. As a result, my rewarding clinical path inAs a bedside nurse, I had no tolerance for these cluded medical/surgical, emergency, and intensive care unchecked behaviors, and later as a unit leader I worked nursing, as well as specialty care experience in radiation quickly to identify and minimize their negative behaviors. oncology, cardiac catheterization, and cardiothoracic surAs I moved into a leadership role as unit director, I once gery. I continued to pursue clinical excellence, joined proagain became acutely aware of the positive influence my fessional organizations, and obtained critical care and leadership mentors had on my success as a unit leader. emergency nursing certifications. As a novice nurse, I reThe transition to a new leadership role is difficult regardturned to school to earn my BSN and eventually obtained less of what level is involved. Once basic management a master’s degree as an acute-care nurse practitioner. skills are established, many leaders are often confused Shortly thereafter, my clinical course took an abrupt about their true purpose. change, and I entered management, albeit unwillingly. I was aware that others who had come before me had More than 10 years later, I smile as I recall how one of established a plan. However, it was only after I matured my mentors in leadership approached me during a weak in my role that I realized the plan was actually a vision moment, tugged at my vulnerable heartstrings for cardio28 Nurse Leader

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and that its creation is what distinguishes a true leader from a manager. It was during a time of chaos and change that I began to fully understand my new responsibilities to own the unit’s vision, create a plan for action, and share leadership on all levels to empower staff members to act. The organization had just declared bankruptcy, and nobody anticipated the resulting fallout. There were daily crises of a lack of supplies, linen, and staff. Managers and senior leaders resigned on a daily basis, and services were curtailed as physicians departed. The fear of not knowing what the future would bring permeated the facility, creating an atmosphere of despair. As a leader, I was fully aware of what the facility and others were experiencing, and while I could empathize, I could not relate fully because the experience in my unit was totally different. The atmosphere in my unit was business as usual: OR cases continued, staffing remained constant, leadership remained steady, and the internal structure of the unit managed cleaning and stocking of supplies and linen. Work life continued at a normal, steady pace. It was in this moment of utter chaos and crises that I truly grasped the essential nature of leadership and how it should prevail. I remained a unit director for many more years, for I embraced my role as a leader. Being a respected leader became my passion. As had those leaders who came before me, I found that my greatest rewards came in developing and guiding a staff to fulfill their goals. The emotional connection I enjoyed with my staff was my ultimate high and made every day as a leader worthwhile! Leadership is a rewarding career path and provides an opportunity and responsibility to identify and nurture future nurse leaders. I advise new leaders to take their time as they begin their leadership roles, and remind them to view today’s crisis as an opportunity to learn and grow. Most importantly, I tell them to listen to their heart and discover their passion. Those who dare to make a difference will succeed!

THE ACCIDENTAL DIRECTOR My nursing career began in 1978 as a licensed practical nurse. As time progressed, so did I in my profession. As rumors circulated surrounding the fate of LPNs, I quickly obtained my associate’s degree and eventually earned my master’s degree in leadership and management in 2005. During the first 21 years of my career, I worked in a hospital at the bedside. In those early years, I never realized that I was a leader or wanted to be in a position of authority. Instead, I was encouraged by my nursing director to become her assistant. She saw leadership ability in me that I could not see. The initial skill sets that I developed revolved around organizational ability. Fortunately, I was already enrolled in a computer class, and my new skills were essential. I was able to create an Excel spreadsheet to track everything October 2007

from CPR evaluations and PPD compliance to license renewals. I set my Outlook calendar to remind me of all projects that were due. Since my first days as a nurse in 1978, timeliness was drilled into me. Being on time for a nurse meant arriving to work 15 minutes early and being ready to take report. As a result of my computer skills and my obsession with timeliness, I always met deadlines. Management behaviors consist of care coordination, planning daily operations, staffing, monitoring the quality of staff performance, counseling subordinates, and hiring. Every good leader should always be mentoring her replacement, so as I conquered one skill, my boss added new responsibilities. When my director resigned, and with encouragement from staff members and the leadership of our organization, I applied for her position and was hired. The areas of my responsibility included a 10-bed coronary care unit, a four-bed heart failure intensive care unit, and a 24-bed heart failure telemetry floor. Initially, I aligned the vision for my units with the organizational vision of 100% employee, physician, and patient satisfaction. This goal was accomplished by engaging staff to seek solutions to problems and empowering them to make changes. Employee satisfaction scores were reviewed with the staff and posted in the unit. Staff involvement was a key driver in improving employee satisfaction scores to some of the highest in our organization. Simple solutions provided by staff members included increasing par levels of supplies and the frequency with which supplies were ordered. In addition, hourly patient rounds, rewarding and recognizing outstanding employees, and staff accountability boosted patient satisfaction scores to the highest in our organization. After these changes, I revealed my vision to combine the two ICUs into one unit. These ICUs were located next to each other but were divided by a doorway. The heart failure ICU was staffed with two nurses daily, which posed a problem because it was difficult for nurses to help each other in busy times. The nurses were not comfortable asking for help from the coronary care unit because they were separate units. Some physicians preferred one unit over the other, and the staff’s frequent rearrangement of patients from one ICU to the other caused unnecessary workload. The merger announcement was made during a combined mandatory staff meeting. As expected, several staff members were unhappy. However, with my rationale and the trust they had in me, my staff grew to accept the decision and understand the need. Committees were formed to discuss issues such as staffing, naming the unit, and seniority. While the decision to combine was mine, the success of the combination was theirs. Today, you would never know that this unit once existed as two separate units. This successful initiative was my defining moment as a leader.

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Figure 1. Five Pillars

in an environment of constant flux. With these guidelines in mind, we realized there was already a framework by which to create our program in our organization’s five pillars: People, Cost, Service, Quality, and Growth (Figure 1).

A STAR IS BORN

Leadership is visionary. The leader must be able to chart the course and make difficult and often unpopular decisions to stay the course, basing them on what is best for the whole, not an individual. Effective leaders use empowerment and allow staff to make their own clinical practice decisions. I have transitioned into another leadership role in my organization and have handed my torch to another. In looking back, I realize I was always a leader. Mutual respect, communication, trustworthiness, and vision are leadership characteristics that I have always possessed. I lead from the heart and let my instincts be my guide.

STRUCTURING THE PROCESS We have examined the qualities managers and leaders need to effectively do their jobs and have presented two personal success stories of individuals who transitioned from front-line staff to leadership positions in our organization. How does an organization formalize the process of leadership selection and grooming to become part of its culture? In our organization (Hahnemann Hospital in Philadelphia), we realized a process was needed that could be applied at an individual unit level, would allow unit directors to identify staff suitable for mentorship into management, and would establish a roadmap by which staff could measure themselves in the development of new skills. Because our unit directors are challenged daily to meet organizational goals, we also wanted to provide a structure and tools for the education and guidance of staff members chosen for leadership development. We wanted the program to provide practical skills that could be applied once a staff member had entered management, with enough flexibility to allow unit directors to impart their own personal leadership style and ensure a self-determined learning pace that could function easily 30 Nurse Leader

Mirroring our hospital’s five pillars, the STAR (Staffnurses Transitioning to Administration Review) program is divided into sections, each of which addresses the skills and qualities that managers and leaders need to be successful. Although the program relies on such self-guided learning techniques as reading the current published scholarly literature and computer-based training programs, it also incorporates interaction between student and leader. The reading exercise of the program usually contains a current journal article, which serves not only to introduce the subject to students but also to remind them that a good leader stays in touch with the everevolving trends in the market and considers all points of view. The program also uses a variety of computer education tools that are readily available as part of a large health care system. These computer programs serve to expand the particular topics in a given section and provide structured testing to ensure that the student understands key elements. Finally, the program also contains practical exercises, which are designed to put into practice the lessons studied. Completion of the practical exercises must include an initial discussion of the topic with a current nursing leader. Many of these discussions occur between the student and unit director, but many others involve meeting with senior nursing directors or the chief nursing officer. The unit director’s involvement is crucial in the student’s development of skills, as much of the reading and computer learning is self-guided. It takes the unit director’s expertise and guidance to fine tune those skills and evaluate the student’s progress. The practical exercises are also designed to progress in complexity from the fairly simple (developing and typing an agenda) to the very complex (developing, implementing, and collecting data for a performance improvement project centered on patient satisfaction). Some of the topics covered in the program include agenda development, communication styles, interviewing, conflict resolution, payroll review, financial variance identification, unit budgets, computer programs, performance improvement, developing vision, and employee, patient, and physician satisfaction.

RESULTS Almost anything can be achieved when a team has a clear vision and a common goal around which to work. Leadership is the key factor in the success of any organization, which is why the identification and development of potential leaders is so crucial. October 2007

Figure 2. HUH Evidence-Based Medicine Trends (EBM) 100.0% 87.5%

90.0%

84.6%

85.8%

Q4-05

Q1-06

97%

93.7%

95%

Q3-06

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89.7%

80.0% 70.0%

70.9%

67.6%

60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Q1-05

Q2-05

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Q1-07

Figure 3. Reduced Central Line Infection Rates

C V C a s s o c B S I/1 0 0 0 lin e d a y s

Hospital Wide CVC Associated Bloodstream Infection 2006-2007 16 14 12 10 8 6 4 2 0

13.5 11.3

7.4

6 4.2

4.7

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5.11 5. 1.9

1.1

Jan 2006

Feb

Mar

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In my organization, our leaders, focusing on similar goals, have realized tremendous gains in a variety of areas: 0% turnover in nursing administration for 2005 and 2006, improved evidence-based medicine scores from 86% to more than 95% (Figure 2), reduced central line infection October 2007

Aug

Sept

Oct

1.8

Nov

4.1

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2.6

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3.4

2.9 1.3

Feb

Mar

Apr

rates from 13% to less than 2% (Figure 3), a 2.4% overall RN vacancy rate, and a reduction (over a 2-year period) from $600,000 a month in contract labor to almost 0 (Figure 4). Identifying your up-and-coming leaders will help you achieve and maintain success!

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Figure 4. Contract Labor 2006

$180,000 $160,000 $140,000 $120,000 $100,000 $80,000 $60,000 $40,000 $20,000 $0 Jan

Feb

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References 1.

Scoble K, Russell G. Profile of the future nurse leader. J Nurs Admin 2003;33(6):324-330. 2. Upenieks V. What constitutes effective leadership? J Nurs Admin 2003;33(9):456-467. 3. Arioan J, et al. Developing nurse leaders for today and tomorrow: part 1, foundations of leadership in practice. J Nurs Admin 1996;26(9):18-26. 4. Sherman R. Growing our future nursing leaders. Nurs Admin Q 2005;29(2):125-132. 5. Wolf G, Bradle J, Greenhouse P. Investment in the future. A 3level approach for developing the healthcare leaders of tomorrow. J Nurs Admin 2006;36(6):331-336. 6. Fonville A, Killian F, Tranbarger R. Developing new nurse leaders. Nurs Econ 1998;16(2):83-87. 7. Bonczek M, Woodard E. Who’ll replace you when you’re gone? Nurs Manage 2006;37(8):31-35. 8. Byham W, Nelson G. Rx succession planning. Health Forum J 1999;42(6):19,24-6. 9. Cadmus E. Succession planning, multilevel organizational strategies for the new workforce. J Nurs Admin 2006;36(6):298-303. 10. Redman R. Leadership succession planning, an evidence-based approach for managing the future. J Nurs Admin 2006;36(6):292-297. 11. Smeltzer C. Succession planning. J Nurs Admin 2002;32(12):615.8 12. Nursing Executive Center. Cultivating leadership ambition, building a foundation for effective nursing succession planning. Washington, DC: The Advisory Board Company, 2006: 4-7.

All authors work at Hahnemann University Hospital in Philadelphia, Pa. Stephanie Conners, BSN, MBA, is the chief nursing officer. She can be reached at [email protected]. Rosemary Dunn, RN, MSN, CRNP, MBA, is the senior director of nursing, Kevin Devine, RN, MSN, CRNP, CEN, is presently in the per-diem staffing pool, and Cindy Osterman, RN, MSN, is the senior director of nursing. 1541-4612/2007/ $ See front matter Copyright 2007 by Mosby Inc. All rights reserved. doi:10.1016/j.mnl.2007.07.005

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