The Apprentices
Training, mentoring and support programs help new or potential nurse leaders polish their skills and ensure a rich future for the profession

By Cathryn Domrose
April 6, 2004

When a staff nurse in an oncology unit at Banner Desert Medical Center in Mesa, Ariz., came to Rhonda Anderson, RN, MPA, with a list of well-researched changes the staff could make to improve patient care, the chief operating officer and chief nurse executive could have seen a troublemaker or an upstart.

Instead, Anderson saw a leader.

Anderson told the nurse she wanted to mentor her, cultivate her skills, see what she wanted out of a career in nursing and to help her to achieve those goals. “You are absolutely a leader of the future of the profession of nursing,” she said she told the nurse. A leader she wanted to keep at Banner.

That’s what all nurse leaders should be doing, Anderson said. “That’s how we can encourage our future leaders, even if they’re not ready right now.”

Although it’s difficult to find surveys or exact statistics that address the issue, many nursing leaders say they wonder who will take their place when they retire.

The nursing shortage, past layoffs of middle managers, cuts in education programs and lack of support in some places for nurse leaders have created what some fear could be a growing leadership deficit unless hospitals and nursing groups take action.

Many nurse leaders say they see the trend changing. More hospitals and nursing organizations are providing training, encouraging further education and offering more support for their nurse leaders.

But much work remains to be done, they add, and in this, the leaders themselves must take lead—by identifying potential new leaders, by mentoring them and giving them resources and by being positive role models that newer nurses will want to emulate.

Growing gap

Statistics from the American Hospital Association show the average vacancy rate for RN managers in 2000 was 6.5 percent, with the highest rates in the Western and Southern regions and in urban hospitals. Compared to an average vacancy rate of 14 percent for critical care nurses, this does not seem like a huge crisis.

But the average age of nurse managers, 46 to 50, puts them closer to retirement than staff nurses, and some nurse leaders say they worry there may not be enough qualified people to fill in behind them.

Judy Sullivan, RN, is practice manager for the Boston office of Hudson Global Resources, a specialty staffing firm based in New York. Right now, she said, she doesn’t have much trouble finding people to fill nursing leadership positions. The tricky part of her job is finding the right leader to match the right culture. But in 15 years, when many current leaders are expected to retire and the pool of qualified nurses is expected to shrink, she said, making those matches may prove far more difficult.

Leadership roles have become increasingly stressful, said Pamela Thompson, RN, MS, chief executive officer of the American Organization of Nurse Executives, and other nurse leaders.

The workload has increased over the years, and nurse leaders feel pressure from demands that sometimes conflict. Young people may overlook the rewards of the job and see only the pressure and time demands, Thompson said. “This is not a highly attractive job because of the stress.”

About 20 years ago, nurse managers had more time to identify and mentor young nurses in part because there were more managers to go around, said Frank Shaffer, RN, EdD, FAAN, president of the education and training division and chief education officer of Cross Country University, which offers “boot camp” training programs for new nurse managers.

Assistant manager positions allowed potential leaders to try out a less stressful management position under the guidance of an experienced manager. “We didn’t call it succession planning then because we didn’t know that’s what it was,” he said.

But in the cost-cutting frenzy of the 1980s and early 1990s, many hospitals eliminated middle management positions and education programs for them, Shaffer said.

At the same time, many nursing schools began switching to advanced degree nurse practitioner programs and eliminating their administrative tracks. The managers who kept their jobs were given more units and more responsibility, including advanced financial planning—something they hadn’t covered in nursing school.

Many became overwhelmed and frustrated, unable to find time to do their own jobs let alone mentor and groom someone else. An advisory board study found that 61 percent of nurse managers considered leaving their roles in the past 12 months and less than one-third reported they were satisfied with their jobs.

Jeanna Bozell, RN, a former nurse recruiter and founder of NurseQuest and the author of A Nurse Leader’s Little Instruction Book, said she recently heard about a staff nurse who had been put in charge of a unit after two weeks’ orientation.

“She just couldn’t handle it,” Bozell said. The nurse returned to being a staff nurse and didn’t go into management again. “I know that happens quite frequently,” said Bozell, who is based in Muncie, Ind. “They’ll take these wonderful shooting stars that are RNs with excellent clinical skills and put them in a leadership role with little or no preparation. They set them up to fail.”

Appetite for learning

Many of those who do manage to stick it out are desperate for education, training and resources, say those who educate and train nurse leaders. Catherine Robinson-Walker, MBA, president of The Leadership Studio in Oakland, Calif., has worked with nurses in leadership development since 1980.

When she offers weeklong or weekend training seminars for nurse leaders, she is always amazed and gratified by the response. “People really love it. It’s so great to teach them, they really are hungry,” she said. “They’ve been trained to be great clinicians, but almost none of them have much leadership training.”

Nursing coalitions and some hospitals and health care organizations are responding to the cry for information and support from nurse leaders. Shaffer’s Nurse Manager Boot Camp, based in Tennessee, is an intensive five-day program that covers staff management, leadership, financial management, culture and organizations, and career and staff development.

About two years ago, the Pacific Northwest Nursing Leadership Institute, sponsored by a number of nursing groups and medical facilities, began offering a leadership program in Seattle. The program consists of a two-day class followed by eight full-day seminars once a month.

Students work on a project with a sponsor from their organization, which they present at the end of the session. Projects included creating a falls prevention program, a process for purchasing surgical supplies and a detailed orientation book for RNs on the orthopedic floor.

All the projects address some challenge the managers are facing in their workplaces, said Sally Watkins, RN, MS, vice president and chief nurse executive for Multicare Health System, administrator for Tacoma General Hospital and president-elect of the Northwest Organization of Nurse Executives.

The students, almost all with less than three years in management, may be capable of doing the projects on their own, but usually don’t know how to get started, Watkins said.

The class helps them focus, and gives them information on subjects such as teamwork and staff development to use in their work.

A number of hospitals are focusing on identifying, educating and training potential leaders, then supporting them throughout their careers.

Rosemary Luquire, RN, PhD, CNAA, senior vice president, patient care and chief quality officer at St. Luke’s Episcopal Health System, a Magnet-designated hospital in Houston, said her organization has found many leaders among through its system of shared governance, which lets nurses take part in making decisions.

“Many times, you’ll see through that mechanism who is strong and who has the ability to influence their peers,” she said.

Katherine Johnson, RN, BS, BSN, nurse manager of transplant acute care at St. Luke’s, said her experience on the staff nurse council as a staff nurse helped her meet people and gave her a taste for leadership.

Lisa Cushman, RN, MS, CNA, nurse manager of the coronary care and cardiac observation units, said when she and other interim nurse managers went to their director and said they wanted to make their jobs permanent, the director interviewed them, then hired them.

A few years later, Cushman said, the hospital offered to pay tuition for nurse managers who wanted to earn their master’s degrees. The nurses also received paid time off for their studies. Most of them put in their regular hours anyway, she said, “but just for [Luquire] to say it’s OK to work on school stuff meant a lot.”

Nurses also received support from supervisors who asked how their classes were going and discussed ways to apply what they were learning. Managers in other departments broke away from their busy schedules to answer their questions.

“This is something I’ve always wanted to do, and I wanted to do it 15 years ago,” Cushman said of her degree. “All I needed was somebody to say, ‘Here is an opportunity. You should take it and run.’ ”

Stretched thin

Much of nurse leadership begins that way, nurse leaders say. Many say they got into leadership because of someone who tapped them on the shoulder and said, “You can do this.” But most nurse managers don’t have time for anything but day-to-day tasks.

“I think people are just so busy,” Watkins said. “We as a profession don’t have a real good history of mentoring each other, coaching each other.”

Because current leaders are stretched so thin, Bozell suggests bringing in retired leaders to mentor for potential or hiring a nurse leadership specialist—a sort of clinical nurse specialist for leadership—who would provide education and training, pair up mentors and research new ideas about leadership and staff development.

Hospitals and other health care facilities need to support the decisions of their nurse executives, Robinson-Walker said, even in the face of opposition from an upset physician. “It needs to be OK for a leader to say something that is different from the way the rest of the group thinks.”

Nurse leaders, with the support of their institutions, should be assessing potential leaders when they begin hiring, then working to develop those leaders throughout their careers.

“We need to think across the lifespan,” said Karen Haase-Herrick, RN, MN, executive director of the Northwest Organization of Nurse Executives in Seattle and president of the American Organization of Nurse Executives. “Not all of them are ready to move to the next level, but they would like to become ready.”

Perhaps the most important thing nurse leaders can do, say those who train them, is to provide them with positive role models and show them how the rewards far outweigh the frustrations of leadership. People go into management because they want to emulate people they like and because they want to make a difference, Shaffer said.

Johnson, who applied for manager jobs with the support of her director three times before she landed her present position, said she came out of school wanting only to do bedside nursing.

But as she grew in her position, she saw and appreciated how her managers supported her, her co-workers and the patients. “The other managers are really good and really strong and the structure is really good,” she said. “They are very positive nurses. I wanted to be like them.”

As a manager, Johnson said, she tries to encourage and help other potential leaders whenever she can. As her own mentors have done, she wants to share her enthusiasm and show her staff she believes in them.

“It really helps to have strong people supporting you,” she said. “It really helps to have them say, ‘I know you can do this.’ ”

Contact Cathryn Domrose at kaguilar@well.com.