How to Succeed in Nursing Management

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Changes in the healthcare system, such as value-based payment models which favor outcomes over volumes, along with increasing technological, quality, and patient demands, require a clinically expert nurse leader. To retain and recruit nurses in a diminishing workforce, and achieve the outcomes expected in today’s healthcare environment, a transformational leadership approach is recommended as a solution. Nurse managers will experience multiple challenges and will need to employ continuous education as well as obtain multiple venues of support to be successful. 

Introduction 

“Leadership is helping believe in a better tomorrow or a better outcome than you have today.”  

-Marissa Mayer, Former CEO of Yahoo 

Some people were born knowing that they wanted to be leaders, and some stumble into it. No matter how you get there, you can be a great leader, particularly with the proper support and preparation. There are many leadership roles, including nursing management, supervisory, chief officers, etc. I choose not to define the differences between nursing management and leadership because all leadership levels contribute to ensuring a high-functioning healthcare environment. Oftentimes, nursing management is the first of many steppingstones in healthcare leadership; therefore, that will be the focus of education.  

As a nurse manager, you will likely be required or have already achieved an advanced degree, at least at the master’s level. Continuous learning and availing yourself of new leadership tools and concepts are required to solve complex and morphing issues that arise with new technology, a developing workforce, and societal changes that impact the health environment.  

A Need for Quality Nursing Management and Leadership 

The nursing profession is experiencing a crisis of low morale and increasing technological, financial, quality, and human demands. One of the most impactful changes for the nurse’s role is moving from volume-based payments to a value-based payment model, which places a higher emphasis on clinical outcomes. Nurse-sensitive quality measures, such as infections, pressure-associated wounds, and falls, require specific and time-sensitive care; when these needs are not met, it results in poor outcomes that negatively affect the patient, family, and the organization. While these outcomes have always been nursing’s responsibility, the visibility is now raised to a detectable level. Today, nursing management must not only be prepared to lead, but they must also have the clinical expertise to ensure evidence-based practices are used for problem-solving and achieve positive outcomes (15). 

When combining the elevated responsibilities of today’s nurse (whose average age is 50 years), along with the high turnover rates among new nurses, it paints a grim future for the industry that those in nursing management and leadership will have to diligently work to resolve (1).  The American Association of Critical Care Nurses predicts a 15% growth in the need for nurses by 2026 (1). In comparison, for the same period, the National Board of Labor expects the demand for healthcare leaders to increase by 20%.  

The current vacancy rate for nursing management is 8.3%; since a 2010 American Organization of Nurse Executives (AONE) report, not much has changed. While there is great demand for more nursing management and leadership overall, there is a stronger need for those currently in these positions to possess the quality characteristics and competencies to succeed. 

Competencies of Successful Nursing Management 

Once you become a nurse manager, your focus turns from supervising yourself and working as part of a team, to influencing a group of independent and interdependent professionals to accomplish the required outcomes. While clinical expertise is essential for a nurse manager, other vital characteristics pave the path into successful leadership. These are:   

1. Ability to collaborate with a team and build relationships 
2. A desire for continuous learning 
3. Effective two-way communication- listening, body language, and interaction with diverse individuals both professionally and personally 
4. Ability to prioritize and organization skills 

These characteristics facilitate nursing management and leadership’s required competencies, which are gained over time through experience and continuous learning. The American Organization for Nurse Leadership (AONL) identified five core competencies of nursing leaders (2):  

In today’s environment, one can argue that communication and relationship building are the most essential characteristics in nursing management and one of the most crucial competencies to develop. A growing body of evidence shows that nursing leadership, particularly relational leadership, directly correlates with patient outcomes, work environments, and retention (15). A nurse manager’s challenges are frequently mired in emotion that innately comes with being, and working with, humans who are unique, passionate, and have needs. Ahead are some challenges of nursing management and leadership.  

Challenges of Nursing Management and Leadership 

Managerial Blues

Managerial blues are a phenomenon in which managers feel like their supervisory role is less meaningful than their position as bedside nurses. This could be particularly true for nurses moving into management after being at the bedside during the COVID-19 pandemic. Frequently, a confident nurse has a lot of autonomy during a crisis and achieves a sense of meaning with the accomplishments (19).  The managerial blues are common in many industries outside of nursing, and there are reasons beyond this that managers may become unsatisfied in their roles.   

Thinking back, have you known a nurse leader who left the role because they felt it was less meaningful than bedside nursing?   

What do you think would have made a difference for the manager to be retained?  

Lack of Job Satisfaction

With vacancy rates of both nurses and nurse managers being above 7%, additional responsibilities become necessary, including managing more than one unit and possibly providing patient care. Add that with 24-hour responsibility and the growing concern of appropriate staffing resources, stress begins to mount. The main reason nurse managers leave is due to burnout; this is consistent with bedside nurse turnover as well.  

Regardless of today’s nurse manager’s immense responsibilities, surveys reported that 68% were satisfied with their roles; content nurse managers cited positive relationships with their colleagues as being fundamental to their satisfaction (12). 

Although both nurses and their nurse managers may face familiar stressors, concerns about job satisfaction are not limiting factors in the decision to pursue a leadership position or not. For those motivated by the desire to improve their working environment, change can be energizing even with a surplus of responsibilities. Having an encouraging and supportive supervisor can also impart energy to balance the demands of a high-pressure role.  

How does taking on different responsibilities affect your energy level? 

How does your relationship with your immediate manager affect your job satisfaction?  

Interpersonal Conflicts

Interpersonal conflicts, such as incivility, vertical aggression, bullying, and passive-aggressive behavior, are some of the most challenging issues to confront and manage. However, nothing is more likely to take the joy out of nursing and negatively affect quality outcomes than not dealing with interpersonal conflicts (4). 

The most effective means for dealing with interpersonal conflicts is to understand the negative impact they can have on the team. Until you gain experience managing interpersonal conflict, employ resources such as your immediate supervisor, more experienced nurse manager colleagues, as well as human resources to assist in these matters. In all situations, confidentiality, showing respect, seeking to understand, and leaving people with their dignity will help you manage with confidence.  

How are interpersonal conflicts handled on your unit?  

Thinking back on an interpersonal conflict you resolved, are there additional measures you would employ today?  

Recruitment and Retention

The biggest challenge facing nursing management and leadership in 2021 is recruiting and retaining nurses. As noted, positive relationships are imperative for a high functioning work environment, for both the retention of current employees as well as the recruitment of new nurses; more so than money, workload, or other factors. A social media thread from Reddit highlights the importance of meaningful nursing management and leadership and the outcomes it can have on the working environment, take a look:  

She is the type of manager who reads off the policy, neglects to address any concerns we voice, and abandons any role in advocating for us even if our concerns are valid. Despite these being trying times in the healthcare setting as a whole, her demeanor and attitude combined with passive-aggressive remarks make morning huddles and day shifts absolutely awful. It’s to the point where nurses who float to our unit ask if this is how it goes every day… and the unfortunate answer is yes. 

I didn’t realize the extreme difference until I floated a few months ago to another unit and was so refreshed by the overall work environment. It was actually a busier floor and assignment overall but the change in management style completely reversed the expectations I had for the day (9). 

One form of leadership that has been shown to positively impact clinical outcomes, nurse retention, and the working environment is transformational. Let’s dive in! 

Transformational Leadership 

Transformational leadership is a relational, evidence-based management practice cited by the AONL as one of the critical factors in improving mortality rates, hospital acquired infections, and medication errors (15). In addition, the transformational leadership style improves retention by creating positive work environments.  

Transformational leadership is defined as addressing one’s higher-order needs by developing long-term solutions in place of reward and punishment-based actions, also known as a transactional leadership style. Transformational leadership promotes self-actualization and self-esteem by inspiring employees and building self-confidence. Transformational leaders set clear goals, encourage, recognize, and reward staff members with the goal of building future leaders.  

To be successful in nursing management, it is essential to know your leadership style and to recognize your natural responses as opposed to needed responses that are often learned and practiced.  

Below are the characteristics and behaviors of a transformational leader (6):  

Making the Transition 

Nursing management transitions can be difficult, and success requires accepting that roughly 80% of your role requires a communication transaction (6). In, Insights on becoming a first-time manager, Nancy Anderson, RN, provides great advice based on her own mistakes assuming the new role (3):  

1. No one expects you to know everything, but they do expect you to ask and to listen. Leadership = less talking and more listening.  
2. Interruptions to your day and your to-do list will be the norm. Plan a specific time to get work done and communicate that, but otherwise, accept that this is likely the most crucial part of your role.  
3. Shifting from co-worker to boss feels uncomfortable. Focus on treating everyone equally and setting boundaries.  
4. Leading people is not a necessary evil as part of the nurse manager role. It is the job.  
5. Round early and regularly with your staff and hold one-to-one meetings to get to know their strengths and weaknesses.  

Below is an additional Reddit post from a nursing-related thread, echoing the importance of availing yourself as a leader, to your staff: 

Excellent attention to detail, terrible communication skills, poor people skills, and frankly a bully all around. It doesn’t matter how on the ball you are, if you can’t deal with people and realize half of your job is dealing with your staff, you shouldn’t be in management (8). 

If you are curious as to what else you should not do when assuming a new nursing management position, check out this Reddit post: 

My new manager has worked in her position for 6 months now and has yet to formally introduce herself to me. The only thing I get from her is passive-aggressive emails about what we’re doing wrong and how we need to get off her bad list for not getting our little managerial tasks done a month ahead of time (11).  

When Should I See Results? 

A new nurse manager’s ideal time to feel fully competent in their role and achieve positive results as a relational leader is five years (16). This timeframe is based on the time it takes to fully develop meaningful relationships. According to a consulting company, Healthcare Source, the average number of people for a nurse manager to be responsible for is about 50 (13). That span of control, or number of people under your responsibility may be higher depending on your organization’s ideal staffing model as well as recruitment and retention strategies. The higher the number of individuals under your leadership, the harder it is to tend to individual support and development needs while managing numerous regulatory and quality commitments. However, there are many successful nurse managers, and here are some recommendations to get the support you need to thrive.  

• Seek the counsel of other nurse managers, whether new or experienced, to offer and get support. Having friendships among co-workers is a key factor in achieving work-life satisfaction. Getting practical advice to solve issues or to validate that you are not alone provides reassurance and builds confidence.  
• Set boundaries. Not only boundaries between your work and home life, but limitations on your relationships with your responsible staff members.  
• Be participatory. You are not required to solve all the problems or know all the answers. Engage the team in problem-solving.  
• Seek the support of human resources. Understanding how and when the human resource team can intervene for support and assistance should be an early task in your orientation. The HR team will be one you will engage with frequently before implementing changes, dealing with interpersonal conflicts, and recruitment and retention.  
• Be a continuous learner. Subscribe to relevant journals, continuing education, and stay up to date on evidence-based processes.  
• Determine the specific help that you need and ask for it regularly.  
• Avail yourself of your organization’s resources, including education, development, mentors, and support services.  
• Become a member of professional organizations focused on nurse leaders such as the American Organization for Nursing Leadership and pursue certification once you have the required years of experience.  

Tools for Continued Support and Development 

No matter the nurse manager’s experience, there is always the opportunity for the unexpected, whether that be among the workforce or health related. Side-by-side support is not a realistic expectation over the 24 hours in a day. Do not wait until you are experiencing a crisis to find resources, and instead, stay ahead of current trends and the struggles of other nurse managers. There are multiple resources to support you now, whether you seek to be a nurse manager or are currently in the role. Here are a few of my go-to support and education forums:  

Journals 

Nursing Management: The Journal of Excellence in Nursing Leadership   

Published monthly. Provides strategic professional information nurses need to excel as healthcare leaders. Places special emphasis on the challenges you face and skills you need to succeed in today’s fast-paced nursing leadership environment. An independent platform for the expression of various opinions and views, the publication targets leadership concerns, including recruitment and retention, reimbursement issues, legal considerations, regulatory compliance, and professional development. 

Professional Organizations 

American Nurses Association (ANA) or your state nursing association 

ANA recommends standards for clinical practice as well as safe practice environments and advocates for healthcare issues for nurses and the public. There are also leadership opportunities within this and other professional associations.  

American Organization for Nursing Leadership 

Known as the voice of nursing leadership. AONL changed its name from the American Organization of Nurse Executives (AONE) in 2019. AONL also offers Nurse leadership certification review courses as well as competency checklists and assessments.   

Blogs 

Emergingrnleader.com: A Blog for Nursing Leadership Skills and Career Strategies.  

By Rose O. Sherman, EdD, RN, NEA-BC, FAAN. This is a helpful blog for leading in today’s health care environment with bite-size pieces of information and resources to learn more.

Podcasts 

Today in Nursing Leadership from the AONL 

Most podcasts are under 10 minutes, and many are interviews with current nurse leaders and specific to recent research on leadership tactics such as “Reducing documentation burden to return joy to nursing” January 18, 2021 

Nurse Leader Network with Chris Recinos  

A good balance of education, career development, and self-care. Here is the description of the podcast:  

What happens when you provide nurse leaders with tools to learn, share and connect? You get the Nurse Leader Network! A podcast dedicated to building your career, helping you find your work-life balance, and creating a lasting social community (network) with other nurse leaders. 

Conclusion 

The nursing profession is faced with a crisis of low morale, complex clinical needs, increasing responsibility for improved outcomes, and a diminishing workforce. The current environment requires expert nurses who are effective in leadership roles.  

Since retention and clinical outcomes are positively affected by relational style leadership, it is imperative that nurses recognize their leadership style and seek the necessary education and support to become transformational leaders of the future.  

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