Presentation/Article Critique: Presentation Selected journal article (2010-2022) related to administration, management, or leadership in public health. After a brief introduction,

JONA Volume 41, Number 5, pp 204-210 Copyright B 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

T H E J O U R N A L O F N U R S I N G A D M I N I S T R A T I O N

Nurse Manager Leadership Development Leveraging the Evidence and System-Level Support

Laura Fennimore, DNP, RN

Gail Wolf, PhD, RN, FAAN

The complexities of healthcare demand new leader- ship approaches to achieve organizational goals while developing and sustaining healthy work environ- ments. The nurse manager is the defining role, cru- cial to achievement of workplace outcomes. Preparing nurses for this dynamic, complex role is often depen- dent on didactic education or on-the-job training that falls short of true leadership development. The authors describe an innovative approach to the development of successful nursing leaders across an integrated healthcare system.

Changing patterns in healthcare, including changes in patients and providers, medical advances, information technology, and reimbursement, create enormous challenges for nursing leaders.1 Managing these changes and driving strategic execution of goals re- quire strong leadership that begins with adequate preparation. However, studies indicate that frontline managers are often the least prepared to handle these challenges. Leadership development for nurse man- agers is often loosely structured and fails to offer experiences and mentors that assist nurse managers to develop the competencies of successful leaders.2

Nurse managers are often selected for their positions based on their clinical expertise, but they lack confidence in topics ranging from human resource management, preparing and monitoring budgets, managing upward to senior colleagues, and using

technology in everyday practice.3-5 Being a successful leader on the front lines requires not only clinical expertise, but also the effective use of emotional and cultural intelligence as well as energy management skills.6 Chief nursing officers (CNOs) and other nursing leaders in acute care hospitals describe com- munication, conflict resolution, role transitioning, scheduling, budgetary and payroll management, per- formance evaluation, and staff counseling as the pri- mary developmental needs for nurse managers.3

Establishment of a high-performing culture is the critical element that distinguishes units where pa- tients receive high-quality care from units where pa- tient care is poor and unacceptable. Nurse managers are Bchief culture builders[ who lead professionals rather than just manage workers. They must be competent in establishing healthy work environ- ments through development of staff, effective dele- gation, trust, and mentorship.7-9 Nursing leadership is linked with the national patient safety agenda through interventions targeted at preventing pres- sure ulcers, reducing the incidence of central line infections, and effective discharge planning to pre- vent hospital readmissions within 30 days of patient discharge. The attainment of these and other quality outcomes requires sophisticated leadership skills to engage staff that embrace change and systematically evaluate care practices.10

Building the Case for Leadership Development

The University of Pittsburgh Medical Center (UPMC) is a fully integrated academic health center with 20 hospitals and healthcare facilities employing more than 10,000 nurses. In 2006, under the direction of a new system-wide CNO, UPMC identified the need to refocus leadership development across all leadership

204 JONA � Vol. 41, No. 5 � May 2011

Author Affiliations: Director of Clinical Programs, Medic- aid, Medicare Special Needs Plan, and Children’s Insurance Plan (Dr Fennimore), University of Pittsburgh Medical Center Health Plan; Professor (Dr Wolf), University of Pittsburgh School of Nursing, Pennsylvania.

Correspondence: Dr Fennimore, UPMC Health Plan, 112 Washington Place, Pittsburgh, PA 15219 ([email protected] upmc.edu).

DOI: 10.1097/NNA.0b013e3182171aff

Copyright @ 201 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.1

levels including the role of the nurse manager. The current leadership development program was offered for leaders throughout the hospital administration but was not specific to nurse managers. The program was provided in collaboration with a leadership development consulting firm at a high cost to the institution (approximately $100,000 per year). In addition to direct cost savings that would result by offering this course as an internal program, there was an interest to design a program that would address the unique needs of nurse managers and subsequently impact quality and cost measures influenced by this level of leadership. In particular, there was a system priority to reduce nurse turnover, especially among new graduates. In 2006, the average RN turnover rate across UPMC for inpatient units, emergency rooms, and surgical services was 10.07%. Turnover among newly hired nurses and new graduates within their first 6 to 12 months of employment was 17%. To address these issues, a multidisciplinary task force of executive leaders from nursing and human resources examined the preparation of its nurse managers across a multihospital system and studied best in class programs based on contemporary research in both the nursing and business literature.

Evidence-Based Framework

The Leadership Development Task Force completed a comprehensive review of the nursing and contempo- rary business literature that revealed multiple leader- ship and management competencies essential for nurse managers (Table 1). Key knowledge, skills, and at- tributes emerged as critical to developing nurse leaders including knowledge of complex systems and health- care financing; interpersonal skills and supportive behaviors including caring, conflict resolution skills,

the ability to motivate others; and personal qualities such as risk taking, confidence, and creativity.8,12,14

Four transformational roles for meeting future busi- ness challenges include the ability to be a master strategist, change maker, relationship/network builder, and talent developer.13 Studies conducted by the Center for Creative Leadership on successful leaders noted that the most important leadership skills include (1) leading employees, (2) strategic planning, (3) inspiring commitment, (4) managing change, (5) re- sourcefulness, (6) being a quick learner, and (7) doing whatever it takes.15

Similar competencies form the basis of a specific framework for nurse manager leadership development developed by the American Organization of Nurse Executives (AONE), the AACN, and the Association of Perioperative Registered Nurses (AORN). The Nurse Manager Leadership Collaborative (NMLC) model encompasses 3 domains including The science of managing the business, the art of leading people, and the leader within: creating the leader in yourself (Figure 1).16

Effective nursing leadership is soundly correlated with retention of staff and a healthy workforce. De- cisions made by managers affect turnover costs and thus significantly contribute to increased cost. The average nurse turnover in 2007 for hospitals in the United States was estimated at 8.4%, with an aver- age voluntary turnover rate for first-year nurses at 27.1%.17 Turnover for new nurses was reported as significantly higher than this rate in a study of 352

Table 1. Nurse Manager and Leadership Competencies7,11-13

& Personal mastery & Leading employees & Financial

management & Strategic planning

& Human resource management

& Inspiring commitment

& Caring & Managing change & Systems thinking & Resourcefulness & Staffing and

scheduling & Being a quick learner

& Risk management & Doing whatever it takes & Interpersonal skills & Building effective teams & Setting the vision & Translating vision and

strategy & Conflict resolution & Maintaining focus on patient

and customer

Figure 1. Nurse Manager Leadership Collaborative Learn- ing Domain Framework. The NMLC is a cooperative project of the AONE, the AACN, and the AORN. Used with permission.

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nurses in Nevada with 30% of nurses leaving their first job within 1 year of employment and 57% of new nurses leaving within 2 years in their first job. Although patient care issues were cited as the pri- mary reason for leaving, concerns about the work environment including management issues, lack of support and guidance, and being given too much re- sponsibility were noted as the second highest cat- egory of reasons for departure from the first job.18

The PricewaterhouseCoopers’ Health Research Institute estimates that every 1% increase in turnover costs an average hospital an additional $300,000 annually.17 Calculations of turnover costs include expenses related to prehire costs associated with re- cruitment, vacancy replacement fees including salary increases due to overtime and the use of temporary or agency staff, and posthire costs associated with orientation and reduced productivity due to new nurse prolonged learning curves. Turnover cost estimates vary with the size of the institution, service mix, and the availability of hospital systems to sup- port new nurses. In 2007, the average RN turnover costs were estimated to be between $82,000 and $88,000, depending on the experience of the newly hired nurse.17 Indirect costs associated with RN turn- over (eg, increased hospital length of stay, complica- tions related to missed care, and inefficient discharge planning) are difficult to measure but may represent the mostly costly expenses to the healthcare system.19

Successful organizations value the investment in lead- ership development activities and balance program ex- pense against these key cost drivers.13,20

Methods

The UPMC Leadership Development for Nursing Middle Managers program was designed within the following instructional conceptual framework fo- cused on (1) contemporary issues in healthcare, (2) evidence-based content, (3) links to recommendations from professional organizations, and (4) knowledge of self through assessment. The program provided real-time dialogue with peers, nursing and human re- source executives, and academic faculty. The program was offered in five 8-hour sessions offered every other week over a 2-month period. This schedule was se- lected to minimize the impact of taking the nurse man- ager away from his/her unit for extended periods.

Twenty-five nurse managers participated in the initial pilot program. The program has continued with more than 100 nurse leaders completing the course in 4 separate sessions offered in the past 2 years. Al- though targeted to nurse managers with limited ex- perience in the role, participants in this program included individuals with a broad range of experience

in nursing, management positions, and educational backgrounds. Demographics for the pilot group in- dicated that 68% had been in nursing for 16 or more years; 60% had been in the role for 2 years or more; 60% had a BSN and 36% had a master’s degree or PhD; 72% identified their role as nurse manager or unit director, with the remaining 28% identified as clinicians or clinical supervisors.

Nursing executives from the academic health sys- tem, as well as faculty from the University of Pittsburgh School of Nursing, and graduate-levelYprepared hu- man resource specialists presented the leadership sessions. Course participants earned a total of 27.2 contact hours for this offering. The course curricu- lum including the program goal and objectives is outlined in Table 2. Learning activities included as- signed readings from key leadership texts and ar- ticles, lecture, discussion, self-assessment tools, and Bhomework assignments,[ such as preparation of a business case to support an increase in budgeted direct patient care hours, designed to encourage participants to apply content presented during class (Table 3).

Evaluation

Participants completed an evaluation for each session as well as a summative course evaluation. Content that was viewed as being the most valuable included fi- nance and budgeting techniques, conflict management skills, application of emotional intelligence, and staff motivation strategies. Content that was used the most by course participants 1 month following the course included financial accountability, managing conflict and confrontation, performance accountability, and in- terviewing and communicating with staff. Participants described extensive benefit gleaned from group inter- actions and the opportunity to share their own growth experiences in the role in a low-risk discussion forum.

Additional feedback indicated that nurse manag- ers appreciated obtaining tools that they could use for themselves and with their staff including specific tools to identify turnover trends, conduct behavioral inter- views, and conduct team assessments regarding work style and personality preferences. Course participants provided multiple positive comments regarding their experience: BI wanted to tell you how much I have appreciated these classes. I will be able to take so much information to help me make things even better on my unit. I also have so much to share with my peers![ BThis course answered so many questions that I’ve had, and I know that it will only enhance my knowledge and skills. Even though I had recently completed an MSN program, I found the information useful for day-to-day job functions.[ BThe whole series was wonderful with thought-provoking and

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insightful presentations offered by experienced speakers.[

In addition, course participants completed a self- assessment tool rating their leadership skills on a 5-point scale from novice to expert using an adapta- tion of the Nurse Manager Inventory Tool developed by the Nurse Manager Leadership Partnership.21

Pilot participants completed the tool prior to the first course session and 6 months following course com- pletion. Composite precourse and postcourse scores for key competency areas are listed in Table 4. Group means were compared across 15 competency areas.

Managers reported an average raw score improve- ment of 0.68 for all competency areas 6 months following the completion of the course. Participants’ self-perception of their competency 6 months follow- ing the course improved in each of the domains identified within the NMLC model. There was an average increase of 26.7% in the domain of the sci- ence of managing people, an increase of 20.9% in the art of leading people, and an increase of 27.0% in creating the leader within.

Competencies identified as having the greatest improvement were (1) Bpersonal journey disciplines[

Table 2. Nurse Manager Leadership Development Course Curriculum

Course Purpose

& This course is designed to strengthen the leadership of nurses in leadership roles at the department or unit level. The course focuses on helping nurses understand their preferential leadership styles, strengths, and opportunities for further development. The course provides specific didactic and experiential content related to the art of leading others and to the science of leadership in terms of finance and human resource principles.

Course Curriculum

Session 1. Understanding the leader within: challenges in healthcare, relationship management, and using assessment tools & Explore the impact of changes in healthcare systems upon the role of the nurse manager including changes in patients,

providers, technology, medical advances and reimbursement, and regulatory requirements & Identify reflective learning techniques that may be useful for nurse managers in daily practice & Discuss relationship management techniques & Complete the Myers Briggs Personality Assessment Tool & Identify opportunities to integrate personality assessments in working with other members of the healthcare team

Session 2. The art of nursing managementVskills for leading people: key leadership tools: responsibility/accountability, problem solving, decision making, and using influence

& Identify problem-solving skills through recognition of differences between responsibility (process, task, function, effort) and accountability (result, sustainable impact, outcome)

& Discuss essential components to create a culture of accountability & Differentiate between leadership and staff skill sets needed for effective decision making & Identify opportunities for application of shared decision making at the departmental level & Describe key steps in conducting crucial conversations and coaching tips and tools & Explore theoretical principles related to power, persuasion, and influence & Identify opportunities to apply personal, social, and structural sources of influence in practice and leadership roles

Session 3. The art of nursing management: current issues & Describe nursing workforce trends and the implications of generational differences in the workplace & Identify the significance of use of emotional intelligence and cultural competency as key leadership skills of the nurse

manager & Discuss the phenomena of horizontal violence among nurses & Develop an action plan to address bullying by nurses & Identify tools to engage employees in shared governance and professional practice & Discuss factors that contribute to healthy work environments and the impact of the work environment upon nurses’ health & Identify sources of nurse turnover and opportunities to minimize turnover through engagement and team-building activities

Session 4. The science of nursing management: financial management for nurse managers & Identify key financial concepts associated with development of a budget for a nursing department or unit including direct

and indirect costs, variable and fixed costs, productivity and performance measurement, and key volume indicators & Describe the use of a financial monitoring system to evaluate financial performance at the department or unit level & Discuss the link between quality and finances & Using available historical data and developing a personnel and operating expense budget

Session 5. The science of nursing management: human resource issues and strategies for nurse managers & Describe the purpose and mechanics of the behavioral-based interview process & Evaluate a pool of interview questions that can/cannot be asked of job applicants & Identify best practices related to orienting new staff including the identification of standard metrics for evaluating the

effectiveness of orientation and development initiatives & Describe coaching opportunities that include the establishment of performance expectations and counseling techniques to

ensure that performance remains at or above expectation & Identify common unfair labor practices and how the nurse manager can avoid these errors

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(knowledge/skill in managing councils that promote shared leadership, use of action learning to solve problems, use of a reflection as a leadership be- havior); (2) Bfoundational thinking skills[ (use of systems thinking, complex adaptive systems, orga- nization behaviors, decision-making skills, and problem-solving skills); (3) Bhuman resource man- agement[ (recruitment interviewing techniques, un- derstanding of hiring policies and labor laws, and orientation of new employees); and (4) Bshared de- cision making[ (understanding the structure and processes of shared governance and implementing shared decision making at the unit level). The com- petency with the least amount of change was Bappro- priate clinical practice knowledge.[ This particular finding reflects the perception that most managers

described themselves as clinically proficient prior to and following this course.

System-wide UPMC nurse turnover improved during the period following the implementation of this program. Although the overall system hospital RN turnover for inpatient units, emergency rooms, and surgical services showed a slight improvement (10.07% in 2006 vs 9.2% in 2009), new nurse and new graduate turnover significantly declined for nurses employed 6 to 12 months (17%in 2006 vs 11% in 2009). Multiple factors may have influenced this improvement, including a significant change in the economic environment following the recession of 2008; however, enhanced leadership skills of the nurse managers that attended this program may have contributed to meeting this important outcome.

Table 4. Nurse Manager Inventory Tool Resultsa

Precourse Assessment, Mean (n= 22)

6 mo Postcourse Assessment, Mean (n = 21) Change

The science: managing the people 1. Financial management 1.77 2.48 0.71 2. Human resource management 2.66 3.47 0.81 3. Performance improvement 2.66 3.38 0.72 4. Foundational thinking skills 2.45 3.33 0.88 5. Technology 2.95 3.58 0.63 6. Strategic management 2.25 2.99 0.74 7. Appropriate clinical practice knowledge 3.32 3.65 0.33

The art: leading the people 1. Human resource leadership skills 2.92 3.55 0.63 2. Relationship management and

influencing behaviors 3.02 3.47 0.45

3. Diversity 3.03 3.62 0.59 4. Shared decision making 2.78 3.57 0.79

The leader within: creating the leader in yourself 1. Personal and professional accountability 2.86 3.45 0.59 2. Career planning 2.96 3.52 0.56 3. Personal journey disciplines 2.05 3.17 1.12 4. Reflective practice 2.94 3.59 0.65

aScale: novice = 1 to expert = 5.

Table 3. Sample Assignments

Influence concepts Develop a 2-minute Belevator speech[ designed to influence a key stakeholder in your clinical practice using the principles of influence

Crucial conversations Describe a recent Bcrucial conversation[ that you have had with an employee or your supervisor. Describe why the discussion might be identified as crucial, your feelings and reactions during the conversation, how you responded, and what you might have done differently given the content presented in class

Team management Describe a patient care issue or outcome in your department and how principles of team management supported the effective resolution of this issue. If the situation remains unresolved, describe strategies that the team might consider based on content presented in class or in the course readings

Finance Prepare a business case for your supervisor that will win his/her support for an increase in direct patient care hours for your unit

Behavioral interviewing Prepare a list of behavioral interview questions to share in class

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Limitations

Limitations of this program included a minimal op- portunity to measure the longitudinal impact of the program. Although 92% of the pilot program par- ticipants have remained within their nurse manager positions since the initial course offering 2 years ago, this program did not attempt to measure the nurse turnover ratios on these manager’s units, which would have contributed to a cost-benefit analysis for the program. Additional comparison metrics that could be evaluated precourse-postcourse might include staff satisfaction through engagement surveys and clinical quality outcomes including patient satisfaction. Ob- taining direct performance feedback from attendees’ supervisors would also add to the strength of the pro- gram evaluation by examining how the nurse manager applied the leadership skills presented during the program. This analysis would be useful to others who may wish to replicate a similar program.

Future Considerations

As leadership continues to evolve and challenges in healthcare become more complex, there is a need for increased emphasis on manager engagement, flexibil- ity, collaboration, crossing boundaries, and collective leadership.22 Classroom training, however, is only 1 component of a comprehensive leadership development program and may represent only 10% of the solution. Future initiatives should incorporate growth opportu- nities embedded in formal education and ongoing work assignments with guidance by seasoned mentors.

The UPMC Leadership Task Force instituted changes for future iterations of this program based on group evaluations. Identification of appropriate course applicants was identified as an opportunity to facilitate better discussions. For example, the course was not designed to serve as a remediation opportu- nity for nurse managers exhibiting performance issues. Future program offerings included an application and approval process that included review by the CNO. This process facilitated selection of a more appropriate target audience. This approach is consistent with rec- ommendations that leadership curriculum be designed around levels of experience from novice to expert.23

Conclusion

Effective leadership of nurse managers is essential for successful hospital outcomes. Chief nursing officers are

challenged to prepare nursing leaders for this role using best practices and an evidence-based approach. The primary role of the CNO is to develop leadership ca- pacity and create cultures of excellence through inno- vation, collaboration, workplace engagement, and active involvement in the development of nurse man- agers. Effective leadership preparation and commitment of the nurse manager can lead to enhanced staff nurse retention, reduced turnover costs, and improved quality and financial outcomes for healthcare institutions.24

This program offered evidence-based leadership content within a contemporary context to nurse man- agers and provided an opportunity for nurse execu- tives to use a common language to share their values, expectations, and expertise on key organizational ob- jectives influenced by nurse managers. The concep- tual framework of the program leveraged the strength of the evidence and system-level support. Customiz- ing the program to the unique needs and environment of the system provided a distinct advantage over stan- dardized educational programs available from pro- fessional organizations or training offered from human resource departments. For example, content related to financial competencies was based on the institutional financial management system providing practical information for immediate application. The description of the course curriculum and sample assignments may be useful to educators and admin- istrators seeking to customize programs unique to their own institutions. In addition, the Nurse Man- ager Inventory Tool may serve as valuable tool to assess increasing levels of competence across a career pathway and identify ongoing opportunities to seek additional learning opportunities.

Acknowledgments

The authors thank UPMC and the University of Pittsburgh School of Nursing for their support of this initiative in nursing leadership development and to the nurse managers who have completed this course. Special thanks are offered to Pamela Klauer Triolo, PhD, RN, FAAN, for her leadership in shaping this program as the former UPMC system-level CNO and for her contributions to this article. Additional thanks are offered to Holly Lorenz, MSN, RN, UPMC chief nursing executive, and Drs Susan Albrecht and Lisa Bernardo, University of Pittsburgh School of Nursing, for their review of this article.

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