Leadership Development Recommendations for Clinical Nurse Managers to Bolster the Postpandemic Workforce

Abstract

The postpandemic atmosphere has created a perfect storm that has necessitated a renewed prioritization to bolster support for the role of the clinical nurse manager. Role transition, competencies, mentorship, and ongoing development for the clinical nurse manager have been solidly supported in nursing leadership literature for decades. Preparing competent, ready-to-respond, people-oriented, transformational nurse leaders for these positions is essential to survival of our health care workforce. This article includes a summative review of comprehensive published findings related to nurse manager competency, development, and support. Findings have been correlated with one health system's postpandemic internal surveys, focus groups, reaction panels, and gap analysis to validate historic recommendations and prepare for program development. The purpose of this project was to endorse manager support and development recommendations and implement an evidence-based program to better prepare clinical nurse managers in today's health care leadership reality.

FRONTLINE CLINICAL NURSE MANAGERS (CNMs) are vital to operations, safe patient care delivery, and clinical effectiveness in health systems. Historically, clinical knowledge and experience have been adopted as primary preparation for these mid-level manager roles. Over the last 10 years, patient acuity and complexity have caused the health care environment to become increasingly challenging. This paired with uncertainties related to workforce changes and the recent global pandemic have magnified the level of required knowledge, skills, and abilities for the CNM. Health care systems have an imperative to elevate preparation, training, and support for nursing leaders for sustainability. With the current average CNM tenure of 2 to 3 years,1 the task of maintaining a cadre that is prepared for the future appears daunting. This project was designed to validate prepandemic best practices for nursing leader development and describes one health care system's design, development, and implementation plan for nu-rse manager postpandemic support including

• American Organization for Nursing Leadership (AONL)–based competency tool and transition pathway;

• structured, guided, and accountable mentorship;

• evergreen leadership development sessions focused on experiential, application, and reflective learning; and

• recommendation for a foundational vendor-led workshop for novice nurse managers.

LITERATURE REVIEW

A systematic, critical literature review was performed to assess pertinent competency and transition support recommendations. Inclusion criteria were peer-reviewed publications in the last 5 years. Electronic databases of PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Google Scholar, and Cochran were searched. Ancestry search was also conducted to resource additional, relevant publications. Search terms included “clinical nurse manager,” “nursing leader,” “nurse leader orientation,” “nurse leader competencies,” and “transition to role.”

CNM competencies and development program content

The AONL program and competencies were most frequently referenced and supported in the literature.1–5 Most development programs focused on goals and desired outcomes to drive content and competencies. More specifically, staff engagement, patient experience, and excellence in nursing were noted to be important to most health systems.3 Decision making, communication, and relationship building were the most reported stand-alone competencies.6 In reviewing literature for personal leader benefits, Warshawsky and Cramer1 correlate confidence in role to competency procurement. McGairty et al7 further underscore the importance of defined competencies and implications on confidence, ability, and culture when building development programs around core competencies.

CNM program design

Program designs varied in all studies. Most averaged 1 year of targeted support time with a recommendation to then transition to an ongoing structured leadership or mentorship program. McBride et al6 provide specific details on the design and varying pathways of mentorship as part of a support program. Warshawsky et al8 recommend simulation as an added strategy to practice response skills that are required for success in the role. Bryant et al9 describe the effectiveness of experiential learning and project work used in the Robert Wood Johnson Executive Nurse Fellows Program to provide opportunities for real-time application. Experiential, hands-on learning program designs were the most reported learning strategies for optimal outcomes.

Transition to practice support and timing recommendations

Several programs included elements of ongoing development and mentorship to support transition to practice. Pedersen et al10 describe leader retention and enculturation as benefits of a full immersion pipeline program and underscore the importance of succession planning and mentorship. Recommendations about when nurse leaders should complete a structured competency-based transition to practice program ranged from starting development in preleadership informal leader roles to continuing focused support for CNMs with less than 3 years of experience (novice) in the role.1,3,5,8,10 Literature suggests that it takes a CNM 5 years to achieve competency and 7 years to become proficient in leadership operations.1 Building a structured, comprehensive program to guide nurse leaders as they make the role transition from clinical expert to leadership novice is essential to strengthening the nurse leader's future and current workforce.

Summary of literature review

Improved engagement scores, higher leader retention rates, improvements in patient measures and outcomes, and confidence as a leader were among the most frequently reported positive outcomes of CNM development and support programs.3,4,10 The literature review yielded recommendations for a structured transition to practice program with defined AONL-driven competencies as outcomes for ongoing learning. Program length and design varied across all studies, signaling that there is not a one-size-fits-all solution for leadership development training. Program benefits and positive outcome data were reported in all studies. A majority of the CNM competency areas highlighted relational skills. Clinical nurse managers who are “competent in relationship building are better prepared to develop strong cohesive teams who deliver high-quality care.”7^(p281) Several studies recommended that competency definition was pivotal to building confidence and success in frontline nursing leaders.1,3,4,11 Most programs provided elements of transition to practice support through development pathways leading up to CNM roles, navigation through the onboarding period, defined competencies, and guided ongoing mentorship.3,6,8,11 A comprehensive program that includes competency and mentorship and is focused on support and relational skills for CNMs is recommended.

DESIGN

To validate the summative literature and recommendations for postpandemic validation, this multihospital mid-Atlantic health care system conducted surveys, focus groups, and reaction panels. Project sponsors reviewed human resources systems data and cross-walked internal and external nurse leader development programs and competencies. The health care system prioritized support of the CNM role as 1 of 4 nursing strategic imperatives for 2022. This allowed laser focus and resourcing to arrive at program recommendations and a plan for implementation.

Nurse manager composite

A composite of the health care system's CNM was pulled from the internal human resources information system. The data sample included hospital-based CNMs in March 2022 (n = 196). The average nursing experience of CNMs was 13.9 years. Average CNM tenure was 3.6 years with a range spanning novice (0.2 years) to experienced leader (20.7 years). The sample and inclusion in the survey, focus groups, and reaction panel include all CNM roles within 12 acute care inpatient hospitals and 3 free-standing emergency departments. These data follow prepandemic literature trends, which describe nurse managers as experienced clinical experts who are promoted into leadership based on success in direct care nursing roles.

Survey of Strengths, Weaknesses, Opportunities, and Threats

A survey of all current CNMs was conducted across the health care system and results were organized into a Strengths, Weaknesses, Opportunities, and Threats (SWOT) format. The survey response rate was 32% (n = 63). All 12 hospitals across the health care system were represented in the survey data. Clinical nurse managers from all unit types except behavioral health and pediatrics responded. A slight majority of CNMs (55.6%) reported having less than 15 years total nursing experience before stepping into the CNM role. The average tenure in the CNM position was 3.6 years with 76.5% of CNMs reporting less than 5 years' experience in nursing leadership. Perception of lack of training, preparation, and resources available during the transition to the CNM role and challenges identified in the current state SWOT analysis were opportunities identified in this survey. Responses and trends from the survey about leadership preparation and development closely aligned with national status reports (ie, American Nurses Association [ANA], Advisory Board, AONL).

The SWOT analysis survey format included open-ended questions and utilized a Likert scale to provide revealing detail about CNM role preparation, ongoing development needs, and perception of current state of role quality. The Likert scale of 0 (Unprepared) to 5.0 (Fully Prepared) revealed an average rating of 2.5 (Somewhat Prepared) when inquiring about leadership development preparation for the current CNM role. A majority of 87.3% responded that a formal mentoring relationship with structured dialogue would have been helpful when starting the role. Of CNMs surveyed, 65% did not have a defined succession plan. Resource support and leadership development were identified as opportunities in gap analysis questions. Top ranked needs included regulatory navigation, safety, and clinical performance improvement support. The survey also validated Warshawsky and Cramer1 who structured that orientation and mentorship would be valuable best practice for successful role transition.

Focus groups

Focus groups were organized and facilitated to gain additional insight to needs and concerns. Focus group participant CNMs (n = 23) represented all health care system hospitals and a variety of general nursing and specialty areas. The CNM role experience ranged from 4 months to 16 years. The focus groups provided more detailed, personal, and health care system–specific insight, additional current state analysis, and success driver requests than the survey and SWOT. Clinical nurse managers also voiced the need for ongoing learning for continued role development. Items identified for initial orientation were echoed in requests for ongoing professional development.

Themes from the focus groups included the following:

• Orientation and ongoing professional development: Most participants revealed a lack of specific preparation or training before entering the CNM role. This theme aligns with literature indicating that nursing leaders are commonly promoted because of clinical nursing expertise.8 The focus groups confirm a shift from expert back to novice without the support of orientation or transition to role. The sentiment that “I learned by myself day by day” was a common refrain from the groups when recalling formative years in the role. The need for more preparation and training for transition to the role included the following:

• Technical skills: Budget and health care finance, payroll, identification of and access to critical applications, productivity, standardized list of expectations for role clarity, and use of technology applications.

• People-centered soft skills: Employee performance management, feedback, crucial conversations, employee conflict, and prioritization.

Review of internal resources and external programs and competencies

A crosswalk of internal resources and external nurse leadership development programs and competencies was leveraged as a framework for recommendations and program development. Best practice for CNM role transition, development, and competencies were requested via interview from comparable external health systems. Responding systems stated similar perceived or identified gaps for competency, development, and support of the CNM role. Most health systems had some form of checklist or pathway to guide CNM with orientation but did not have a standardized CNM competency tool. Given the solid benefits of competency completion from the literature, competency tool definition and development became a priority gap identified by this project.

Leadership development programs offered by nursing vendors were reviewed and crossed for content, cost, frequency of program sessions, setting of offering (virtual, in-person, asynchronous, etc), and availability of contact hours awarded on completion. At the time of the program crosswalk, a variety of programs were offered through AONL, American Association of Critical-Care Nurses (AACN), ANA, and Lippincott.

DEVELOP

Competency tool development

The literature review, internal surveys, and focus groups identified that CNMs have a very unique set of experiences and challenges to achieving excellence in the role. Although there is a strong presence of leadership development for general manager roles within the health care system, the lack of a comprehensive competency tool specifically for CNMs was a gap. Without support of a role-specific competency tool, CNMs are at risk for uncontrolled scope, undefined expectations, and inability to successfully function. Role clarity and intentional movement toward competency will work toward building confidence and satisfaction in role.1,3

An AONL-based competency tool was developed by the clinical education department team of the health care system. The tool was reviewed by internal CNMs and nurse executive sponsors. The tool was designed to be independently driven with periodic review and validation from a peer or leader. It is organized to identify beginner and advanced competencies to guide leader progression. A transition pathway was developed to complement the competency tool. This pathway takes the CNM through the first week, 30 days, and 90 days to help the leader prioritize, reach milestones, and limit the overwhelming feelings that can come along with learning such an expansive role.

Mentorship program

The most requested item by the CNMs in the health care system was a formal structured mentorship. Correlating studies identify mentorships as a cornerstone for the progression, development, and support of CNMs.8,11 The mentorship program includes a formalized relationship with a matched mentor with scheduled meeting sessions. A mentorship tool kit supports guided dialogue and reflective exercises to enhance the sessions. The program has been designed to include an accountability plan to support sustainability.

Leadership program development

This project verified the continued postpandemic need for CNM competencies, mentorship, and ongoing leadership development to support the role. In-person simulation-based classes were developed to reinforce competencies and provide guided practice. Specific content was selected on the basis of feedback from internal and evidence-based input drivers and focuses on relational, experiential, and application learning. Because the health care system spans the mid-Atlantic region, classes will be offered on a rotating basis in the 2 major geographic regions.

The planned personal connection and networking are intentional and important core characteristics of the development classes. Nawaz,12 in a recent Harvard Business Review article, underscores the value of creating a sense of belonging and facilitating connection in the post-COVID workplace. The classes will help model and support connection as a key attribute of success for CNMs and will allow leaders to connect on a personal level with each other.

Foundational vendor workshop for novice nurse managers

The crosswalk analysis performed as part of the design phase of the comprehensive recommendations revealed several nurse leader or manager programs offered by nursing vendors. The AONL: Transition to Nurse Manager Practice and ANA: New Nurse Manager Basics Workshop programs were selected as preferred programs for novice nurse managers. Enrollment targets CNMs who have less than 3 years' experience in any leadership role. These programs are meant to provide a solid foundation for general people-centered and technical skills required for the role.

IMPLEMENT

Implementation plan

The CNM pathway begins with new to role CNMs and includes a warm welcome from the health care system's clinical education team during the first week to introduce the program, competency tool, internal classes, foundational vendor workshop options, and resources for successful mentor identification and mentorship program introduction. The formalized mentorship program is required for all new CNMs and is fully supported with accountability tracking. Novice CNMs are supported to attend a nurse manager foundational vendor workshop. Existing novice CNMs with less than 3 years' experience are encouraged to attend all internal classes, and current CNMs beyond novice experience are invited to choose and attend any internal classes that support personal and professional development gaps.

Evaluation

Evaluation of program outcomes is measured by direct and indirect methods. Evaluation of content and quality of sessions will be achieved using postsurveys given to program participants. Interim pulse check surveys have been designed to monitor perceived effectiveness, progress, and accountability. Evaluation of direct outcomes is focused on measuring self-confidence. The Van Dyke Nurse Manager Confidence Survey (NMCS) was selected as a valid and reliable tool to assess this outcome data with permission of use from the author received by the health care system. The 15 items in the survey concentrate on manager skills and behaviors that influence confidence. The NMCS is given to the participants before attending their first internal class and is administered again 1 month after completion of the class series. Several indirect data points and trends are included for evaluation within the health care system. Staff turnover; manager retention; staff, manager, and patient satisfaction; safety events; and quality outcome data will be compared between hospital units of CNM program participants and nonparticipants.

Barriers to success and future recommendations

Although the project served to validate and describe effective postpandemic recommendations for development of CNMs, there are some potential barriers to success that should be noted. Warshawsky et al8^(p255) warn, “Despite recognition of the need for more competent nurse managers, nurse leaders cited fiscal constraints and operational demands” continue to present as barriers to implementing sustainable CNM development programs. They add, “The blueprint for successful nurse manager role transition begins with policies that promote nurse manager competency when assuming the role.”8^(p260) Although these are real concerns, health systems will need to prioritize and push through steadfast support for role transition, mentorship, and ongoing leadership development to stabilize the mid-level manager workforce. Including return on investment as part of program evaluation can mitigate historic barriers and influence sustainability.

Another area of concern elevated by the literature and the postpandemic internal snapshot assessment performed for this project was span of control (SOC). Even with intentional transition, mentorship, and development, too wide of a SOC can lead to persistent negative impacts on key performance indicators, staff and manager satisfaction, safety, and engagement.13–21 New-generation CNMs want more than just resources and training. They want work-life balance, flexible scheduling, and administrative support.22 Assessment of SOC and ensuring a balance of work time and time away from work must also be considered and corrected to achieve the level of success that is required in today's increasingly demanding health care environment. Expanded and applied inquiries around the intersection of SOC, work-life balance, and adequate leadership development and training are needed to better understand outcome relationships.