JONA Volume 37, Number 2, pp 85-94 Copyright B 2007 Wolters Kluwer Health | Lippincott Williams & Wilkins
THE JOURNAL OF NURSING ADMINISTRATION
Development of a Leadership Competency Model Rose O. Sherman, EdD, RN, CNAA Mary Bishop, MSN, RN, CNAA, CHE
Terry Eggenberger, MSN, RN Ruth Karden, MSN, RN, BC
Background: Although research findings support that the nurse manager has a pivotal role in influencing all aspects of the nursing environment, recruiting talented staff into these nursing leadership positions has become increasingly more difficult. There is a need to better understand the competencies needed by contemporary nurse managers and the challenges in the role. Objective: The purpose of this research was to explore the viewpoints of 120 nurse manager study participants on the contemporary nurse manager role and to gain perspective on the critical leadership skills and competencies to build a nursing leadership competency model. Design: A grounded theory methodology was used in this study to capture the perspectives of the nurse managers interviewed about their role. Results: Six competency categories emerged from the research findings to form a nursing leadership competency model. Two major themes identified from the data included the nurse manager role as a career choice and the stressors and challenges in the role. Conclusion: The results of this study led to the design of a nursing leadership competency model and confirmed that there is a need to formally develop and mentor our next generation of nurse leaders.
involve the retention of staff, concerns about patient safety, meeting the budget, or complying with regulatory rules, more demands are being made of professionals in nursing leadership positions. This is especially true for nurse managers and other nurse leaders in frontline manager roles. Although research findings support the pivotal role of the nurse manager in influencing all aspects of the nursing environment, recruitment of talented staff into these leadership positions has become increasingly more difficult.1-3 In 2002, the Nursing Leadership Institute at the Christine E. Lynn College of Nursing at Florida Atlantic University was funded by a grant from Palm Healthcare, a community foundation, to provide continuing education programs for nurse managers. As an initial step to planning what competencies would be emphasized, a qualitative research study was designed. Face-to-face interviews were conducted with 120 nursing leaders in 23 healthcare agencies in South Florida and the Treasure Coast. These nursing leaders had frontline leadership responsibilities, and most had the title of nurse manager. In this study, the term ‘‘nurse manager’’ was used to encompass leaders in frontline leadership roles. The purpose of this research was to explore the viewpoints of study participants on the contemporary nurse manager role and gain perspective on the leadership skills and competencies needed by nurse managers. When we asked our first question about why the managers had chosen nursing leadership as a career path, we were interested to learn how few of the nurse leaders interviewed had actively sought out and applied for their current positions. Many described themselves as having ‘‘fallen into the position through assuming it as an
Healthcare environments today challenge the skills of even the best nursing leaders. Whether the issues Authors’ affiliations: Director, Nursing Leadership Institute (Dr Sherman); Instructor, Casual Learning Center (Ms Eggenberger); Graduate Student (Ms Karden), Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, Fla; Chief Nursing Officer (Ms Bishop), Jupiter Medical Center, Jupiter, Fla. Corresponding author: Dr Sherman, Christine E. Lynn College of Nursing, Florida Atlantic University, 777 Glades Road, PO Box 3091, Boca Raton, FL 33431 (
[email protected]).
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interim assignment’’ or ‘‘ were asked to apply for the position’’ by chief nursing officers (CNOs), their supervisors, or the staff they worked with. This and other insights shared by the nurse leaders who were interviewed for the study led to the development of a nursing leadership competency model and has provided guidance for academic and continuing education planning for nurse managers. This article presents the findings from this research and implications for nursing leaders.
Perspectives on the Nurse Manager Role Rising healthcare costs and concern about the recruitment and retention of the nursing workforce has intensified the spotlight on the nurse manager role. The pivotal role that nurse managers play in their environments has been addressed in the nursing literature. The work of Sullivan et al,4 Tourangeau,5 and Upenieks6 validated the significant role that nurse managers have on the individual morale and job satisfaction of the nurses that they supervise. Although nurse researchers have looked at educational and developmental needs from the perspective of the nurse managers, many of the studies that have been conducted have been limited in scope because of small sample size and convenience samples.6-9 Parsons and Stonestreet10 limited their study to nurse managers with a minimum of 2 years of experience. Russell and Scoble9 and Kleinman11 had a higher proportion of nursing directors and executive respondents than actual nurse managers. Anthony et al12 focused on the characteristics needed to promote retention. Upenieks6 compared Magnet and non-Magnet facilities, and Wilson13 focused on long-term care facilities. Building on these and other studies, the current nursing leadership literature contains recommendations regarding areas for competency development for nurse managers. Tourangeau,5 Noyes,14 and Scoble and Russell15 recommended that leadership training for nurse managers should be formalized. They each independently noted some common areas that call for competency development: the business of healthcare with financing and budgeting; leadership practices, behaviors, and skills; and the use of self in communication skills and personal effectiveness. The American Organization of Nurse Executives16 has published a nurse manager leadership collaborative learning domain and a nurse manager inventory tool to help nurse managers assess their learning needs. More recently, Porter-O’Grady17,18 focused attention on the significance of emotional intelligence in nursing leadership roles and a need to
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maintain a caring connection to communicate effectively. Considerate, fair, and trustworthy leaders motivate staff to clinical excellence.19 Force20 supports charismatic, optimistic nurse managers as having the most effective interpersonal skills for the position. Cardin and McNeese-Smith21 developed a nursing leadership curriculum on the 5 practices of exemplary leadership as described by Kouzes and Posner22 that includes a need to encourage the heart of followers. The authors of this study interviewed nurse managers working in a wide range of specialty areas. These nurse managers practiced across a broad range of healthcare organizations in a geographic region. Using a large sample size, the focus of this research was to obtain their perspectives on the challenges and critical competencies needed for the nurse manager role. The ultimate goal was to build a competency model that could be used as a framework to design programs and nursing curriculum to meet the educational needs of nurse managers. Strong nursing leadership begins with adequate preparation.
Research Methods and Analysis Study Design A grounded theory methodology as described by Strauss and Corbin23 was used to capture the perspectives of the nurse managers interviewed about their role. The themes and concepts that emerged from the data were coded into competency categories that formed a framework for the development of a competency model. A structured face-to-face interview that consisted of 26 openended questions (Figure 1) was used by the investigators. The questions used in the study were developed by the investigators, with input from nurse leaders on the advisory board of the Nursing Leadership Institute. Institutional review board approval was obtained from Florida Atlantic University and from two of the healthcare agencies that required agency review of the study. Sample Forty CNOs in hospitals and public health agencies throughout South Florida and the Treasure Coast of Florida were invited by letter to select nurse managers to participate in this study. Two groups of nurse manager candidates were sought for this study. The first group consisted of nurse managers with more than 2 years’ experience in a nurse manager role who were performing well from the perspective of their CNO. The second group consisted
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Figure 1. Interview questions.
of nurse managers with less than 2 years’ experience in a nurse manager role. Of the 40 CNOs contacted, 23 expressed interest in having their nurse managers participate in the study, for a response rate of 57%. Agency types included for profit, nonprofit, and governmental. All but 3 agencies were acute care facilities. Administrative support staff in the offices of the CNOs in the healthcare agencies assisted the investigators in scheduling onsite interviews. It was the goal of the investigators to interview equal numbers of experienced and inexperienced nurse managers, but many of the agencies who participated in the study had either very few or no nurse managers with less than 2 years’ experience in the nurse manager role. Ninety-eight experienced nurse managers and 22 inexperienced nurse managers were interviewed by the investigators. Demographic information on the study participants is presented in Table 1. Of the sample interviewed, 88% were women, with an average age of 46 years. They managed a broad range of specialty areas. The experienced nurse managers who were interviewed had been in their current leadership positions for an average of 10 years and had 16 years of experience in nursing. Inexperienced nurse managers had been in their positions for 16 months and had an average of 17 years’ experience in
nursing. Although most managers interviewed had a baccalaureate degree or higher in nursing, 43% of experienced nurse managers and 45% of inexperienced nurse managers had either an associate degree or a diploma degree as their highest level of nursing education. Experienced nurse managers supervised an average of 67 full-time equivalents (FTEs), whereas inexperienced nurse managers supervised an average of 54 FTEs. Few nurse managers in this study managed multiple units. Data Collection and Analysis Interviews with the nurse managers were conducted onsite at their facilities, in their offices or facility conference rooms, by the investigators. One hour was scheduled for each interview. Although the investigators were initially concerned about whether nurse managers could or would take this time from their busy schedules, very few cancelled once the appointments were scheduled. The nurse managers were engaged once the interviews began, and many indicated that this was the first time that they had ever discussed their thoughts about their role with anyone. Twenty-six open-ended questions developed by the investigators and reviewed by a panel of CNOs on the Nursing Leadership Institute Advisory Board were asked. Answers from the managers were
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Table 1. Demographics of the Sample Experienced Managers Highest nursing educational level Diploma 16 Associate degree 26 Baccalaureate 40 Master’s 16 Age range 31-40 y 9 41-50 y 50 Older than 50 y 39 Average number of 67 FTEs supervised Time in the nurse manger role Average time 10 y Median time 12 y Range 2-31 y Type of nursing unit Ambulatory care/ 6 outpatient Cardiac Cath Lab 2 or Interventional Cardiology Lab Critical care 15 Emergency 10 department Education 2 Extended care 3 Medical-Surgical 19 OB/GYN 5 Post Anesthesia Recovery/ 4 Pain management Pediatrics 1 Psychiatry 2 Rehabilitation 3 Surgical services 10 Telemetry 10 Home care 3 Night supervisor 3 Total 98
Inexperienced Managers 1 9 11 1 5 10 7 54 16 mo 8 mo 2 wk-2 y 2
5 2
8 1
2 2 22
validate the themes that emerged from the study, presentations of the data were held onsite at 17 of the 23 healthcare agencies, and participants in the study were present for the discussion.
Study Findings Six competency categories emerged from the research findings to form a nursing leadership competency model (Figure 2). These included personal mastery, interpersonal effectiveness, financial management, human resource management, caring, and systems thinking. Two major themes identified from the data included the nurse manager role as a career choice and the stressors and challenges in the role. The Nurse Manager Role as a Career Choice New nurse managers and many experienced nurse managers reported that the decision to accept a nurse manager role was not a career choice that they had planned. Some experienced nurse managers with many years of longevity acknowledged that at one point in time, there were no nursing career ladders and moving into leadership roles was the only way to advance in nursing, and that is why they took the position. Most managers in this study reported that they had received little or no orientation to their role, with new nurse managers more likely to report this. Orientation was found to be facility dependent, and some institutions did receive high marks for their orientation, although nurse managers reported that it often occurred several months after they assumed the role.
FTE indicates full-time equivalent; OB/GYN, obstetrics/ gynecology.
transcribed verbatim by the investigators and read back to the participants to insure accuracy. A grounded theory method of coding and content analysis as outlined by Strauss and Corbin23 was used by the investigators to analyze the field notes from the interviews. Field notes were read and coded by the investigators immediately after each interview. Data from the field notes were categorized as level I, level II, or level III. Using a constant comparative technique, participants in subsequent interviews validated the emerging themes and provided additional data. Verbatim quotes from the interviews were categorized as level I and then condensed into thematic content categories (level II). An analysis of the level I and II codes by the investigators resulted in the generation of level III category constructs. To further
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Figure 2. Nursing leadership competency model. Copyright 2003, Rose O. Sherman.
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Experienced nurse managers expressed satisfaction with their nurse manager role. We often heard from them during the interview that ‘‘I know it seems that I have been complaining, but I love what I do.’’ This was less true with new nurse managers, who acknowledged feeling overwhelmed and questioned their ability to effectively manage the role. Connectedness with staff and seeing them develop were the key satisfiers in the role for both experienced and inexperienced nurse managers. Experienced nurse managers also frequently mentioned that making a difference in the big picture of patient outcomes and having more control over their time than they had in a staff position were role satisfiers. Going back to school for more education was a short-term goal mentioned by both groups, although attending school while in the position was seen as a challenge. Retirement was the most frequently stated long-term goal. Many managers in this study indicated that they would be looking at retirement in the next 5 years. They expressed concern about who would assume their leadership roles when they retire. They reported a lack of interest among younger nurses in leadership roles, and many commented about their inability to ‘‘even find charge nurses despite the differentials we offer.’’ Role Components, Challenges, and Stressors Nurse managers reported that the recruitment and retention of staff were both a major challenge and key role responsibility in today’s healthcare environment. Budgeting and staffing consume much of their day and also present challenges. Communicating with patients, physicians, and staff and managing conflict were cited by both experienced and new nurse managers as significant parts of their role. New nurse managers were much more likely in their interviews to discuss direct patient care as part of their role than were experienced managers, whose primary focus was on their staff. Both groups of managers see patient safety and quality initiatives as part of the nurse manager’s role. The ability to personally deal with change and to coach staff to deal with change was seen as a major role responsibility. When asked about what competencies they would look for if they were assigned to be part of a nurse manager competencyYbased panel interview, nurse managers cited interpersonal and communication skills as critical skills. As one manager expressed, ‘‘If you lack good communication and interpersonal skills and the ability to be flexibleyou will not succeed in this role.’’ Project management skills, the ability to manage a budget, and evidence that the candidate will have a caring
approach with patients and staff are other strengths that the nurse managers interviewed frequently cited. According to the participants in this study, workload and time management pose major challenges for nurse managers, especially for those new to the role. Experienced nurse managers reported that finding competent staff, dealing with the rising patient acuity levels, and generational issues in the workforce are all challenges they are confronting. Medical-Surgical nurse managers expressed concern about their ability to recruit new graduates as more nurses now begin their careers in specialty areas. Both groups reported that recruitment/ retention and staffing issues will become even more difficult as the nursing shortage intensifies. They discussed a need to change the current models of nursing care delivery but were not sure when and how this will happen. Frustrations expressed about the role included lack of clerical support, staff attitudes, the disengagement of professional nurses from participation on unit issues, union activity, ongoing justification of budget variances, and disciplinary problems. ‘‘Being all things to all people’’ was cited as a major stressor in the nurse manager role. Staying within budget and dealing with increasing numbers of regulatory issues were also cited as stressors. Personal wellness and self-care are major challenges for the nurse managers, particularly new managers. Many of the new nurse managers reported that they had completely shut down their private lives and worked long hours. The most seasoned nurse managers discussed the ability to draw the line on how long they stayed at work as being a key survival skill. Few of the nurse managers from either group exercised on a regular basis, but most wished for better work-life balance.
Critical Competencies for Nurse Managers Today The investigators used the framework developed by Lucia and Lepsinger24 to guide the development of the competency model and the identification of competency behaviors (Figures 3Y8) from the data collected. Their framework describes competency models as descriptive tools that identify the skills, knowledge, personal characteristics, and behaviors needed to effectively perform a role in an organization.24 Knowledge, skills, attitudes, and behaviors are clustered into competency categories that are the building blocks of the model. Competency model development should include information about the experiences and ideas of significant numbers of individuals who work in the role. The
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mistakes, acknowledge them, and learn from them. There is nothing that staff appreciates more than a leader who is able to say ‘‘I was wrong.’’ Interpersonal Effectiveness Interpersonal effectiveness was felt by the managers in our study to be a key factor for role success. From their perspective, this skill includes the ability not only to communicate, listen, and facilitate conflict but also to ‘‘be a visible presence for staff.’’ Nurse managers emphasized that nursing staff today want face-to-face contact with their leaders. E-mail is simply not enough. Staff want to know that they can talk with their managers and feel that they are really being heard and known as individuals. This is a challenge, they observed, because the average number of staff supervised by an experienced manager in our study was 67 FTEs. Human Resource Management The healthcare job market today is a very competitive one. Nursing leaders reported that their
Figure 3. Personal mastery.
model should be validated with those in the role and their supervisors and tested over time. Once developed, the competency model was presented onsite to the nursing leadership teams of 17 healthcare agencies who participated in this study. These presentations generated interesting discussions about the nurse manager role. The 6 key competencies and competency behaviors that emerged from the study were further validated in these follow-up discussions. Personal Mastery Nurse managers reported that true leadership begins with understanding one’s self. From their leadership lens, personal mastery is a critical component of leadership success. Outstanding leaders, they observed, demonstrate self-confidence and are able to trust and empower others. They know how their communication and actions impact others and are sensitive to watching the cues in an environment when things are not going well. Nurse managers told us that to be a great leader, your staff needs to have confidence that you are trustworthy and treat everyone fairly. Leaders make mistakes, but having personal mastery is being able to look at your
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Figure 4. Interpersonal effectiveness.
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justify the nursing staffing budget, which is a critical part of any hospital’s operating budget. Managers are aware that there is now good research to support that higher registered nurse staffing ratios result in better patient outcomes. To improve staffing, they observed, proposals that clearly outline the financial benefits of registered nurse staffing models will need to be constructed to make the arguments clear to chief financial officers. The costs of turnover and unfilled beds because of staffing issues need to be quantified. The nursing leaders we interviewed recognized a need to have confidence in presenting financial information.
Figure 5. Human resource management.
Caring for Staff, Patients, and Self Of all the competencies discussed, the managers we interviewed were most passionate about the need to demonstrate that as a leader, you care. The ability to maintain a connectedness to staff was a recurring theme. Whether it means bringing in food or celebrating successes, a great leader cares for his or her staff. Even with 67 FTEs, our managers felt that they needed to learn about each of their staff and their families. Most told us that they try their best to accommodate the needs of staff for time off or shift schedules. Despite the demands of the nursing leadership role, it is important not to become disconnected from the patients that you care for. Our nurse managers told us that it was important for their staff to see them making rounds on patients. Caring for staff or patients begins with selfcare. This seemed to be a problem area for all but the very seasoned nurse managers that we interviewed. Most of the nursing leaders we interviewed
ability to do a good job of managing the human resources that they are given has never been more critical. Retention begins with a sound selection and orientation process. The needs and desires of nursing staff in various age groups are often very different, and nurse managers reported that generational issues are challenging for them. Identifying what motivates and keeps staff was identified an important part of their job. Nurse Managers in our study told us that it was important to keep an open mind about scheduling, developing and rewarding staff. Financial Management Nursing leaders in this study recognized that they will not survive in their roles if they are not savvy about financial management. Most nursing leaders in our study cited this as their weakest area. They acknowledged that there is constant pressure to
Figure 6. Financial management.
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our study told us that the most effective nursing leaders are ‘‘big-picture thinkers.’’ They make it a point to try to develop a good understanding of how the area that they lead fits into the whole of the organization and to respect the perspective of other disciplines. They are proactive in looking at new initiatives, such as changes in Medicare reimbursement, patient safety standards, or information security expectations, and in assessing what their impact will be on their work units. They look at health policy initiatives and educate their staff, patients, and colleagues about the implications of what is being proposed.
Limitations and Findings Although the sample size in this study is large and includes participants from a broad range of healthcare agencies and specialty areas, the study was limited to 1 geographic area. Perceptions about the nurse manager role could be different in other geographic areas. The competency model developed as an outcome of this research has been used for educational program planning but has not been tested. The findings of this study support work done by other researchers who have studied the nurse manager role. Manion25 and Connelly et al26 found in their work with nurse managers that affiliation, appreciation, and recognition by leadership were key components to nurse retention. Nurse managers in this study concurred with these factors. Mathena8 reported that nurse managers in her research ranked communication as the most important variable to success in the role and financial management skills as their greatest learning need. These findings were
Figure 7. Caring for self, staff, and patients.
work very long hours and feel a responsibility to be a resource for their staff at all times. The ability to remain optimistic and resilient during times of turbulence and change is a key ingredient to leadership success. Systems Thinking The final competency identified by the nursing leaders in this study is the ability to be a systems thinker. No nursing unit, profession, hospital, healthcare agency, or healthcare network can function in isolation. The healthcare system is interconnected, and the challenges confronting the system impact every part. The nurse managers in
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Figure 8. Systems thinking.
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supported in this study. Parsons and Stonestreet10 found in their research that nurse managers felt that successful practices for life-work balance would be a significant factor to their retention in the role. Nurse managers in this study reported the same concerns. The research findings of Sullivan et al4 indicated that nurse staffing presented the greatest challenge for nurse managers. Nurse managers in this study also agreed that staffing presented their greatest single challenge. Several significant findings that warrant future study did emerge from the research. These include the lack of career planning to become a nurse manager, a need for formal orientation and mentorship early in the transition to the role, self-care strategies to promote retention, and a need for succession planning for the nurse manager role.
Implications for Nursing Educators Most nurse leaders have little formal leadership education and have learned on the job mostly through trial and error. The career potential and significance of the nurse manager’s role needs to receive the same attention from academic institutions that advance practice roles receive. Academic organizations should create and test competencybased curriculums for nursing leadership on a national level. Educational programs should use research findings to develop curriculums responsive to the needs of both novice and expert nurse managers. Flexible academic options must be available to encourage nurse managers to seek higher education. The findings of this study confirm that there is a need to formally develop and mentor our next generation of nurse leaders.
Implications for Nursing Leaders Over the last several years, much attention has been placed on the current and impending nurse shortages. Little attention has been placed on the present and future shortage of nurse leaders. This study showed that the trajectory for the retirement of large numbers of very experienced nurse managers could begin within the next 3 to 5 years. Excellent nursing leadership is vital to manage the increasingly complex healthcare environment. Frontline managers are pivotal to linking the organizational vision and strategic plan with the clinical practice at the unit level. Supporting, strengthening, and nurturing the leadership skills of the nurse manager will improve both professional and patient outcomes. Nurse executives have a responsibility to assess current leadership talent, define needs for the future, and develop strategies for succession planning. Kouzes and Posner22 suggest that the true legacy of leaders is to create institutions and develop people who will adapt, grow, and change over time. This is especially true in today’s complex healthcare. Developing a formalized career path for aspiring nurse leaders to assume nurse manager positions demonstrates professional commitment, ensures continuity of leadership when vacancies occur, and makes good business sense.
Acknowledgment The authors thank the Palm Healthcare Foundation in Palm Beach County, Florida, for its grant support of this research and the support of the CNOs of 23 healthcare agencies who participated in this research.
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