Developing new nurse leaders

Health care agencies, especially rural acute care hospitals, have been enmeshed in
revolutionary change. The presidential campaign of 1992 and the Clinton Health Care
Reform efforts that followed have produced a sea change in health care. The Pew Health
Professions Commission has continued the change process with their numerous
recommendations. It has identified needed change for all the major health professions --
medicine, nursing, pharmacy -- as well as suggested changes in health profession
education and regulation. They also have identified workforce reform, especially as it
relates to regulation (The Pew Health Professions Commission, 1994).

Excellent nurse leadership is vital to our surviving and thriving. Excellent leaders
must possess administrative competence, appropriate educational preparation, business
skills, broad clinical expertise, and a thorough understanding of leadership principles. In
particular, first-level nurse managers hold a pivotal role in linking the vision of nursing
administration to the actual clinical practice at the bedside. Pederson (1993) found that
"the leadership abilities of a head nurse can have a profound impact on patient,
professional and organizational outcomes."

Nurse executives have a responsibility to identify and develop dynamic fresh

nurses to manage the complex health care environment of the future. This is especially
challenging in a small rural hospital. The authors describe a leader traineeship program
and process used to meet this challenge which provides a low-cost, low-risk approach
with positive outcomes.

Background

In the spring of 1992, there seemed to be few problems in a 120-bed rural

hospital. There was a stable and experienced nursing staff with low turnover and much
excitement about education and certification.

Yet, little movement among nurse leadership positions meant little opportunity for
dynamic, ambitious nurses to advance. A clinical career ladder provided recognition and
financial reward for nurses at the bedside, but nurses interested in developing
management skills did not have similar opportunities Newly appointed nurse managers
became so overwhelmed with the role responsibilities that they left after less than a year
in the position. The management role was too complex and the transition from the staff
role too great. Once promoted, new nurse managers needed to learn too much, too fast.
Staff were not very patient or tolerant of a "learning" manager. They were less than
understanding about mistakes in payroll or scheduling. With these hurdles, it was not
surprising that staff nurses were reluctant to apply for open management positions and
did not have positive experiences when they did.
The Problem

How to provide a stimulating and supportive learning experience for prospective

nurse leaders, maintain a "flat" organization (not add a layer to the hierarchy), and use the
skills of a group of well-advanced and experienced nurse managers?

The Process (Solution)

Though the title came later, the associate clinical nurse manager (ACNM) was
conceived to solve this problem. The principal feature of this position was its time limit.
The ACNM position is a 12-month appointment (with the opportunity to reapply) for
experienced clinical nurses with an interest in management and a commitment to
continue their education.

During the summer of 1992, the department of nursing was reorganized, the unit
supervisor position was eliminated and all incumbent nurses who had been in leadership
positions were invited to apply for the new position of clinical nurse manager (CNM).
The traineeship position of ACNM was introduced at the same time. All nurses, clinical
and management, were encouraged to examine their career goals and qualifications and
invited to apply for the new positions.

The job requirements for the ACNM specified a registered nurse with 3 years of
clinical experience, entry level leadership skills, and an interest in management. A BSN
or equivalent or enrollment towards a degree was required. Expectations included being a
positive role model for students and staff; communicating effectively with patients,
families, students, faculty, physicians, and staff; and demonstrating problem-solving,
decision-making, leadership, and group process skills. Staff who worked permanent
evening, night, and weekend shifts were encouraged to apply. This turned out to be an
unexpected benefit which will be discussed later.

Within the reorganization, the CNM positions were filled by experienced nurse
administrators who held a BSN (n=5) or MSN (n=2). They had 1 to 7 years of
administrative experience and had worked at the hospital 3 to 15 years. Applicants for the
ACNM positions came from the clinical staff (n=5) and the now disbanded unit
supervisor group (n=5). Two of the seven had BS degrees; four were enrolled in school;
four submitted plans to enroll in school. Their length of service ranged from 1 to 20
years. All were asked to submit a current resume and statements of 6-month goals upon
which their performance would be evaluated.

The CNM and ACNM candidates were interviewed by the chief nurse executive
(CNE). With each ACNM candidate, the CNE explored various facets of management
and leadership to ascertain what areas were of interest. ACNMs had the option to
concentrate on a specific management arena, such as unit financial management, staff
relations and counseling, quality improvement, staff development, and/or standards of
practice, during their traineeship period. All expressed trepidation about budgeting and
finance; most wanted to sample all aspects of the job rather than concentrate on a certain
area.

Three months after the departmental reorganization and appointment of the

ACNM into their new positions, all CNMs and ACNMs participated in a survey related
to the organizational change and role expectations. The survey was conducted by a MSN
graduate student during her administrative practicum in the facility. It would have been
desirable to evaluate the involved group prior to initiating the organizational change, and
then again after the change to determine if the organizational changes greatly affected the
staff. However, the goal was not to determine what work design was needed but rather to
see how the redesign had affected the staff.

The program poses no risk but many benefits for the hospital and the individual.
Several ACNMs had stated that they ventured forward to apply for the position because
they knew it was time limited. When the ACNM assessed her experience and decided she
didn't like the job, she had learned valuable information to help her set the direction of
her career. Just as important, she didn't have to resign to save face; she knew the position
would terminate after 12 months. The hospital didn't lose valuable talent. Another major
benefit was the support that the, ACNM provided for the CNM -- as well as the other way
around. Strong collegial bonds were formed that have continued beyond the term of the
ACNMs' appointments. We also found that ACNMs, who met regularly with the CNE,
collaborated with one another across unit and service lines. They gained a respect for
their different contributions and expertise and used one another for problem solving.

In June 1993, a questionnaire was distributed to all CNMs and ACNMs in

preparation for a management training seminar for both groups. A summary of their
responses reveals many strengths of the program and a few weaknesses. In their positive
comments they said that the program provided more visible and effective leadership role
models for the staff; provided more consistent management because either the CNM or
ACNM was available; increased communications for staff, patients, and physicians;
encouraged collaborative management; allowed for sharing of the workload -- especially
some of the paperwork; allowed the ACNM to get a "taste" of management without total
accountability; allowed management skills growth to a larger pool of staff; and offered a
unique opportunity to lay the foundation ion for a future shared governance model.

Disadvantages of the program were outlined including: 1 year was too short a time for the
ACNMs to assimilate management skills, the yearly changing of ACNMs could be
disruptive and confusing for the staff, the authority and responsibility of the ACNM were
not clearly defined, there were inconsistencies in how the role was developed from unit to
unit, and more continuing education was needed. Again, no dollars were needed to make
changes.
What We Learned

Even very Successful programs have problems. Here are a few minor issues we
dealt with. At least one ACNM did not want to give up her position and found it difficult
to return to the staff nurse role. As the 2nd year approached, on some units, some staff
began taking sides among the aspiring candidates and some wrote letters to the CNE
supporting their candidates. On one unit, the staff developed close loyalties to the ACNM
and did not want her to "retire." However, she worked closely with the incoming ACNM
and helped the staff make the transition. Though there were no complaints, there was
some speculation that after several years, the CNM could tire of being in the position of
constantly training a new ACNM. Perhaps this could be helped by planning a more
structured continuing education program for the ACNMs.

Summary

This innovative program was an easily administered and cost-effective method to

identify and develop new nurse leaders. Successful features of the program were (a) the
tenure in the ACNM's traineeship position was limited to 1 year, (b) the salary expense
was just over $1,000 per ACNM per year, (c) the ACNMs were protected from publicity
and visibility while they learned, and (d) potential nurse leaders were identified. After
selling the idea to the hospital and nursing management, the only major effort needed to
begin the program was the development of the ACNM job description and the selection
of candidates. The rewards far outweighed the initial effort.

Personal Reaction

This article shows how a nurse can be developed as a nurse leader who can lead
and management her own. They tried to re-shuffle the positions of each leaders to see if
they can handle other unit and if they are willing to give up their position. This study
intends to find out who are those nurse who have the potential to lead others and if the
current leaders are still capable of doing so.

REFERENCES

Bunsey, S., DeFazio, L.L.B., & Jones, S. (1991). Nurse managers: Role expectations and
job satisfaction. Applied Nursing Research, 4(1), 7-13.

Hackman, R., & Oldham, G. (1975). Development of the job diagnostic survey. Journal
of Applied Psychology, 60(2), 159-170.

Hackman, R., & Oldham, G. (1980). Work redesign. Menlo Park, CA: Addison-Wesley
Publishing Co.
Pederson, A. (1993). Qualities of the excellent head nurse. Nursing Administration
Quarterly, 18(1), 40-50.

The Pew Health Professions Commissions. (1994). Contemporary issues in health

professions education and workforce reform. Center for Health Professions, 1388 Sutter
Street, San Francisco, CA 94109.

ANN M. FONVILLE, MPH, RN, is a Doctoral Student, Teachers College, Columbia

University, New York, NY.

FRANCES R. KILLIAN, MSN, RN, CNA, is Supervisor, Laurens County Healthcare

System, Clinton, SC.

RUSSELL E. TRANBARGER, EdD, RN, is Associate Professor of Nursing, East

Carolina University School of Nursing, Greenville, NC.