By Jennifer Thew, RN
Originally appeared in HealthLeaders Media
Ronda J. McKay, DNP, RN, CNS, NEA-BC, vice president of patient care services and chief nursing officer at the 458-bed acute care Community Hospital in Munster, Indiana, began her journey into management as most nurse managers typically do.
"How you used to become a manager was, you were one of the best workers on the floor, so they made you a manager. It wasn't so much that you had the leadership capability, but that you were a hard worker," she says.
Nurses with strong clinical skills often find themselves hastily appointed to the role of nurse manager without the proper training and skill development to thrive in the role.
"I was appointed as manager of four units and [the previous manager] left at noon that day," McKay recalls. "I got a phone call from the finance people, and they wanted to know how many FTEs we were going to need for the next fiscal year. I said, 'You know what? I'm going to call you right back.' I called the VP [of nursing] and I said, 'What's an FTE?' "
But as healthcare becomes increasingly complex, healthcare leaders are realizing that nurse managers can play key roles in improving financial, clinical, and quality outcomes.
"[Nurse managers] are critical to the mission of the organization and meeting the strategic initiative at that point-of-care service. We need to make sure that they're competent to do the job that they're put in charge to do," McKay says. "It's really about how we are orchestrating to train these nurses to be agents of administration, to be fiscally responsible, to understand what the strategic mission and values of the organization are, and to follow those."
Fortunately, some organizations across the country are creating well-thought-out, intentionally designed programs to help nurse managers develop the skills they need to succeed in a value-based care environment.
Leadership development is lacking
Developing strong nurse managers is important for many reasons, says Paula McKinney, DNP, RN, NE-BC, vice president of nursing and CNO at Scotland Health Care System in Laurinburg, North Carolina. The healthcare system had 23,244 hospital patient days (all patients) in fiscal year 2016.
"If they don't learn how to be a good leader, and they're just managing the processes, then they [could] set their unit up to create an unhealthy work environment," she says.
Results from the decadelong RN Work Project, a multistate, longitudinal panel study of new nurses' turnover rates and their intentions and attitudes about work, highlight the importance that nurse managers have on the work environment.
According to the study's findings, poor management was one of the top three reasons newly licensed RNs gave for leaving their first jobs, and 17% reported that, because of their supervisor, at least once a month, it was difficult or impossible to do their job.
Lack of proper training affects the longevity of nurse managers as well.
"If you promote someone to nurse manager and [he or she leaves] you within 12 to 18 months, you're losing a great deal of money. It could be up to $100,000," McKinney says. "I think there's some cost savings involved in better preparing them to be leaders and managers instead of letting them be out there on their own to flounder and then they end up leaving the job."
In McKinney's recent study, "Improve Nurse Manager Competency With Experiential Learning," published in the October 2016 issue of Nurse Management, 86% of the respondents said they had no formal leadership development when they first became a nurse manager.
The study, of which McKay is a coauthor, assessed leadership and management competency in three leadership areas—the science (business management), the art (leading people), and the leader within (self-reflection)—as self-reported on the Nurse Manager Skills Inventory by 28 nurse managers at Community Hospital.
"It's a self-reported evaluation that the leader does, and they can see in what areas their deficits are," McKinney says. "Those are the ones they can focus on for professional development or finding a mentor that can help them in that area."
The majority of Community Hospital's nurse managers self-identified as less than competent in the financial management area.
To address this, a targeted experiential education module was developed to give nurse managers a better understanding of financial issues, such as the topics of expense forecasting and cost-benefit analysis.
"They understood the concept, but they had never practiced it themselves," McKinney says. "We did some experiential learning in the classroom setting with them on how to do a cost-benefit analysis—some of them had never done that before and some had—but as a group they were able to sit [together] and figure through some of that."
When the nurse managers retook the skills inventory after going through the module, their scores in the areas of unit department budget, creating a budget, monitoring a budget, and analyzing a budget increased from less than competent to competent.
Scores in the areas of understanding healthcare economics and policy, expense forecasting, concepts of capital budget, and concepts of cost-benefit analysis increased from novice to advanced beginner.
The nurse manager residency
Lancaster General Hospital, a 533-bed nonprofit hospital, part of Lancaster General Health/Penn Medicine in Pennsylvania, has been ahead of the crowd in the way it develops nurse managers.
In 2006, the organization began its nurse manager residency program to better address succession planning and knowledge transfer from seasoned nurse managers to new nurse managers.
"At the time, we had a lot of tenured nurse managers who had been in the roles for I'd say 15–20 years, and they knew that we were going to have turnover," says Valerie Adams, RN, MSN, MBA, CCRN, director of nursing at Lancaster General. "They started seeking out, 'How do we better prepare people for going into the nurse manager role?' "
Kimberly Callahan, RN, BSN, NE-BC, nurse manager for the vascular surgical unit, was one of the first participants in the nurse manager residency when it began over a decade ago.
She says the program was invaluable in helping her develop skills specific to the role.
"I think the first skill is being a visionary and actually sharing that vision so your team has a purpose and they know what they're working toward. That's really important for our goals that we have as a nursing department," she says.
To take part in the program, nurses must have a bachelor's degree and three to four years of bedside nursing experience.
Those interested in becoming nurse manager residents fill out an application for the program after they've shadowed and interviewed three nurse managers, explains Adams.
They then go through an interview process with a team of nurse managers, a human resources representative, and the nursing directors.
Candidates take a personality factors test to identify their strengths and weaknesses to help connect them with the preceptor best suited to their needs.
There are usually one to two cohorts per year consisting of two to three residents.
Each resident is assigned a preceptor. To give them the chance to observe different leadership styles, residents rotate preceptors each quarter over the yearlong program.
They meet monthly with Adams, who oversees the program.
"We talk through different things because I want to be sure they're viewing situations through a leadership level not through the staff nurse level," she says.
Since its inception, 20 nurse manager residents have gone through the program. Two relocated out of state and two were nurse managers for a short time before going back to the bedside.
"Otherwise, everyone else is in a nurse manager role or some other kind of nurse leadership role within the organization," says Adams.