Susan M. Dyess, PhD, RN, AHN-BC, NE-BC
Rose O. Sherman, EdD, RN, NEA-BC, FAAN
Beth A. Pratt, MSN, RN
Lenny Chiang-Hanisko, PhD, RN Abstract
With the growing complexity of healthcare practice environments and pending nurse leader retirements, the development of future nurse leaders is increasingly important. This article reports on focus group research conducted with Generation Y nurses prior to their initiating coursework in a Master’s Degree program designed to support development of future nurse leaders. Forty-four emerging nurse leaders across three program cohorts participated in this qualitative study conducted to capture perspectives about nursing leaders and leadership. Conventional content analysis was used to analyze and code the data into categories. We discuss the three major categories identified, including: idealistic expectations of leaders, leading in a challenging practice environment, and cautious but optimistic outlook about their own leadership and future, and study limitations. The conclusion offers implications for future nurse leader development. The findings provide important insight into the viewpoints of nurses today about leaders and leadership.
Citation: Dyess, S., Sherman, R., Pratt, B., Chiang-Hanisko, L., (January 14, 2016) “Growing Nurse Leaders: Their Perspectives on Nursing Leadership and Today’s Practice Environment” OJIN: The Online Journal of Issues in Nursing Vol. 21 No. 1.
This article reports on focus group research conducted as part of a larger study with each of three program cohorts prior to beginning their academic education. The findings indicate that future nurse leaders may be reluctant, even fearful, of entering formal leadership roles. Yet, they are also hopeful that their efforts can contribute to improving work environments, unite teams, and implement changes needed to advance healthcare. Their perspectives about leadership before they assume the role provide valuable insight into current nurse-nurse leader relationships and also have implications for the planning of future leadership development programs and succession planning efforts. Emerging Nurse Leader Development
Not only is there a strong business case for orderly transitions in organizations, but younger staff now look for these professional opportunities when seeking employment. Effective succession planning through the identification and development of emerging nurse leaders is now recognized as an essential business strategy for organizations (Kim, 2012). Nursing workforce predictions indicate that there could be a shortage of up to 67,000 nurse managers by 2020 (Shirey, 2006). Not only is there a strong business case for orderly transitions in organizations, but younger staff now look for these professional opportunities when seeking employment. Meister and Willyerd (2010) in their research with thousands of members of Generation Y found that an employer’s willingness to develop the skills and talents of their staff ranked first in 10 criteria used by this generation to select a new position.
Shirey (2009) describes the first ten years of nursing practice as the “promise phase.” She observes that it is during this phase that young nurses are both socialized into the profession but also gain the knowledge and skills to help position them for the future. Generation Y (born between 1980 and 2000) are in this phase of their careers and are ideal candidates for emerging leader programs. Successful experiences in developmental programs can translate into a nursing leadership career (Bulmer, 2013; Titzer, Shirey & Hauck, 2014). While most of their beliefs and values are not vastly dissimilar from other cohorts at a similar point in their development, Generation Y has two compelling differences in behavior from the generations who preceded them that need to be taken into consideration when doing leadership development. The first is their incorporation of technology as a “sixth sense” and a means of interacting with the world. The second is their expectation of organizational accommodation that is an outgrowth of how they were parented and treated throughout their education (McCready, 2011).
Leadership strategies and developmental activities that have worked well with other generations are not always as effective with our newest generation of nurses – Generation Y. It is this expectation of accommodation that has proven to be challenging for many nurse leaders. Leadership strategies and developmental activities that have worked well with other generations are not always as effective with our newest generation of nurses – Generation Y (Hutchinson, Brown & Longworth, 2012). Turnover in the first year of employment among this generation is a persistent problem in many organizations. Generation Y nurses are less accepting and more critical about workplace practices than the generations who have preceded them. The RN Work Project funded by the Robert Wood Johnson foundation is a longitudinal study that tracks a national sample of new nurses focusing on their career changes and work attitudes. Currently, 31% of new graduates leave their first job within the first two years and almost three quarters (73%) do not receive guidance to appraise gaps in practice or how to respond as a member of the professional team with practice environment improvement initiatives (RN Work Project, 2014).
Generation Y is optimistic about nursing and may leave employers but not the profession. In spite of this higher job turnover, Generation Y is optimistic about nursing and may leave employers but not the profession. In a recent nationwide study conducted by AMN Healthcare (2013), this age group was the most likely to recommend nursing as a career. They also report more interest in pursuing higher education in nursing. When satisfied with their jobs, they have been noted to have greater organizational commitment than either Generation X or the Baby Boomers (Keepnews, Brewer, Kovner & Shinn, 2010) but are also more likely to monitor and consider employment opportunities in other settings (Tourangeau, Thomson, Cummings & Cranley, 2013). Recruiting and retaining Generation Y nurses in leadership may prove challenging without significant changes in the current structure of roles. Fear of failure is a significant concern in this generation (American Psychological Association [APA], 2012), so leadership development programs that promote hope and encouragement about the progress that they are making is important feedback. Generation Y nurses are just beginning to move into leadership roles. There are few studies about their perceptions of current leaders and their potential contributions in these roles. In order to accomplish more effective succession planning, a better understanding is needed about motivational and environmental factors that could prove challenging in their willingness to become leaders and accept leadership responsibilities. Research Methodology
The qualitative findings presented in this article were part of a larger action research design promoted by Stringer (2007) that guided a three year funded project. Approvals for all aspects of the study were obtained from the University Institutional Review Board at Florida Atlantic University. Each year (2012, 2013, and 2014), a focus group was conducted with cohort members prior to the beginning of their coursework in a Master’s Degree program for Nursing Administration and Financial leadership. Each group was asked the same seven questions related to their perceptions about nursing leadership, the practice environment, healthcare challenges, and the future of healthcare (Table 1).
The focus groups were audio-taped and transcribed verbatim. Transcripts were independently coded by three nurse researchers with qualitative research experience using a conventional content analysis approach explained by Hsieh and Shannon (2005). This form of analysis was selected because the aim of this part of the study was to describe the phenomenon of perceptions of leadership from future nurse leaders without using predetermined categories. After an initial review of the texts, the codes were agreed upon by the three researchers. Then, consensus was reached on the categories that ultimately emerged. To ensure trustworthiness of the data and efforts of qualitative rigor, peer debriefing, thick description, ongoing reflective commentary, member checking and an audit trail were utilized (Lincoln & Guba, 1985).
Table 1. Focus Group Questions
Seven Lead Questions Can you tell me about your understanding of leadership? What do you hope to gain from leadership education? What concerns do you have that might prevent you from entering a formal leadership position? How do you think leadership influences practice, practice environments and patient outcomes? What is the practice environment like for you and your co-workers Can you describe your leadership vision for healthcare in 2020? Is there anything else that you would like to share?
The sample included 44 students who were enrolled in an Emerging Nurse Leader Master’s degree program. Prior to the beginning of their academic coursework, students were invited to participate in a focus group with other members of their program cohort. The demographics for all three cohorts are included in Table 2. The majority (54%) were in nursing practice for 3 years or less; while 86% were in practice for 6 years or less. The cohorts were predominantly female (96%). More than half (55%) of the students identified themselves as a member of an ethnic minority. The age range was 23 to 53 with a majority of the sample in the Generation Y cohort born between 1980 and 2000. The mean age for all participants was 31 years; however, this number was skewed by several older participants who entered nursing as a second career. A majority (84%) worked in the hospital environment. Of the 13 different hospital institutions represented, none had achieved Magnet® designation. Some of the participants had been in a charge or relief charge position prior to entering the program. Very few (8%) held formal leadership roles; and those who did were in the equivalent of an assistant nurse manager role.
Three major thematic categories were identified from analysis of the data. These categories included the following: idealistic expectations of leaders, leading in a challenging practice environment, and cautious but optimistic outlook about their own leadership and future (See Table 3).
Table 3. Summary of Categories
Idealistic expectations of leaders
Assist with patient care when needed
Know staff members
Advocate for staff members
Leading in a challenging practice environment
Meet performance goals and standards
Manage effectively policy and procedure changes
Cautious but optimistic outlook about their own leadership and future
Anticipate future roles and challenges
Confidence in their ability
Fear of failure
Responses to the focus group questions indicated that emerging nurse leaders have extremely high, possibly unrealistic, expectations of their leaders. Idealistic Expectations of Leaders. Responses to the focus group questions indicated that emerging nurse leaders have extremely high, possibly unrealistic, expectations of their leaders. Qualities they expect in a leader include flexibility, clinical expertise, and administrative capability. These emerging leaders also expect their leaders to be available and present on the unit to assist with patient care when needed. Their comments indicated a limited understanding of the range of responsibilities and time commitment associated with the role of nurse leader. As part of the idealism, they expect leaders to know their staff members thoroughly and participate with the staff in standard shift efforts such as answering the phone or passing medications when needed. Exemplars of this expected idealism are noted with the following quotes from participants who described the qualities of a nurse leader, “I think as a nurse leader you should always be one step ahead of others and be knowledgeable in a broad expanse of things,” and, “you can never ask your staff to do anything that you’re not willing to do yourself.” Others described an important quality for the leader is to be one of the “regular staff” such as, “and if they don’t see you as part of the team you can’t be the leader of the team without being part of the team.” Other aspects of the ideal leader are shared,
As a leader, you have responsibility for letting the community know the level of service the organization provides, the quality of the services that we provide and that also promoting healthcare as a whole, the health of the community but also for future employees that this may be a wonderful place to come work for so you’re kind of the PR person for the facility at the same time.
[Emerging leaders] recognize that their managers might feel sandwiched between the desires of higher level administration and the needs of front-line staff but still expect high level advocacy… In fact, the participants, not yet in leadership, were critical if they perceived their current nurse leaders to be unable to meet their clinical expectations of what a leader “should be.” One participant recalled a time when her charge-nurse refused to assist her to initiate an intravenous line. “No I can’t, I am too busy” was the reply from the leader. The emerging nurse leader then rhetorically asked, “doing what; sitting in front of a computer doing barely anything?” Others involved in the focus groups described their perception of not being supported …“my direct supervisor isn’t as involved as we actually think she should be between pre op and PACU (post anesthesia care unit). We have one supervisor and in certain situations we’re kind of left to fend for ourselves and make our own decisions.” In addition to constant support, the focus group participants voiced their expectation of nurse leaders to “know each staff member personally” and to “be available when needed” seemingly at a moment’s notice. The emerging professional leaders did acknowledge that this expectation of continuous accessibility to one’s manager is often challenging because many manage more than one unit. One participant communicated her observations of this challenge; “you have the nurse manager that is a leader of the NICU and the PICU and the Pediatric department and as a result, of that, hardly know staff –they’re never around and it is difficult to get to know them.”
The emerging leaders in the focus groups desired their nurse leaders to advocate for them as they serve in the capacity of an organizational bridge between administration and the front line staff. They recognize that their managers might feel sandwiched between the desires of higher level administration and the needs of front-line staff but still expect high level advocacy:
I think leadership is walking the fine line between what your organizational needs are versus what the personal needs of maybe your employees and your peers are also. There is such a pull between what is mandated maybe financially by the administrative entities versus what your employees feel are their needs, wants and what’s realistic between the two.
Overall, this category of idealistic expectations for nurse leaders was consistent across the three cohort groups and prominent in their voiced responses and in their non-verbal agreement to what was articulated. Heads nodded affirmatively when their peers expressed their perception of qualities needed in a nurse leader. Yet when they discussed their expectations of nurse leaders, participants simultaneously communicated the challenging realities of their practice setting and their impact on leaders.
The current practice environment is perceived to be challenging on many levels by the emerging leaders. Leading in a Challenging Practice Environment. The current practice environment is perceived to be challenging on many levels by the emerging leaders. This theme surfaced repeatedly in the focus groups. The participants communicated their perception that the current focus on achieving high scores on various satisfaction surveys and performance measures has captured everyone’s attention in the hospital and seemed to take precedence over all other initiatives. They did not seem to recognize the demands on leadership in a complicated practice environment where reimbursement is driven by meeting performance goals. Emerging leader comments indicated the frustration that they feel with these environmental challenges. One student noted, “they seem to emphasize the importance of core measures and checklists,” but “simple things like the vital machine or the dynamap wasn’t working. We only have like five for the floor and there’s two of them are broken. It’s kind of like something you would think would be easily manageable and easy to fix but still doesn’t get done.” The comments highlight the expectation of leading conspicuously in a challenging practice environment. For example, one focus group participant compared the practice environment to “emergency war-care” by vividly describing the perceived challenges of hospitals as practice settings:
We are in the front line fighting the war, but we are not getting all the ammunition that we need, because this group over here needs to go take that mountain. Then all of a sudden we have to turn around and go to this mountain to fight. Now we are fighting so much and pulling in every direction that we lost the main focus about what we need to do. Right now the hospitals are sick and they are only being managed to keep them alive, not heal. They are getting a heart transplant, but they have no kidneys and they have no brain.
Frequent policy and procedure modifications were noted by participants as adding to the volatile nature of a practice setting because changes were not always well communicated to staff by their leadership. One participant observed that “the boats are not always rowing in the same direction, because people are doing different things.” Another noted “the constant change” and an apparent “lack of commitment to staff satisfaction” amplifies the challenges of leadership.
Teamwork is important to emerging leaders in Generation Y. Poor teamwork was also cited as another perceived challenge in the current practice environment. Teamwork is important to emerging leaders in Generation Y. Several nurses indicated it was their perception that night shift had better teamwork than day shift: “nights always seem to work together, because they are always team players, and days they just do their own thing.” Some viewed the consistency of team members working together as essential, “when you work with different people from different weekends it changes things, like we don’t like it, it makes it harder.” Still others viewed newer nurses as better team players than established nurses. Nonetheless, the participants believe they will contribute solutions to the challenges with their leadership.
Despite challenges noted, they are willing to take leadership roles because they see the potential to change their environments… Cautious but Optimistic Outlook about their own Leadership and Future. Despite challenges noted, they are willing to take leadership roles because they see the potential to change their environments “through better teamwork,” “a healthier work environment,” and a “strong connection to front line staff.” This optimism is tempered by realism as one stated with wise anticipation of a future role in leadership, “I always say it’s easy to tell somebody what to do, if you’re not the one doing it.”
Still, each focus group participant sought admission to a Master’s program with a concentration on nursing leadership. A number of their admission essays reflected their “hopes of leadership” to include, “the ability to change some of the things that I’ve seen that I don’t’ like” by “having the tools to manage and balance what is to come.”
They expressed enthusiasm about their own abilities to lead in a different way. One emerging leader observed that as leaders they could be different from what they view in practice today:
The thing is you can be different… when you hear the complaints….if you hear, oh I’ve never seen the manager, they’re always in the office not doing anything, you can be that one walking outside and asking …“how’s everything, how you doing today, how’s your patients?” You can be that different one.
Their confidence in the ability of nurses to provide the leadership to change healthcare was expressed by a participant who noted, “I’d like to see that the nurses are spear-heading these things and are running organizations… so we won’t have such a big gap between what nurses are doing with patients and administration.”
Yet as the focus groups conversations advanced, they also talked about their fear of failure as nurse leaders. They had observed leaders in their environments lose their roles. One nurse jokingly stated “Your head will be the first one that’s going to be cut off.” Others were concerned about the difficulty of combining the sensitivity of a nurse with the coldness of business. There was anxiety about leading in an environment where there is an inability to share new ideas and say “no,” in addition to pressure to “do what’s not right for nursing.” Another participant expressed her concern as she hopes to assume the role of leadership:
There’s a utopia that you kind of think about before you really are in it. I am going to make it this way and everything better but it’s harder than you think. You have to really be committed to do leadership right. To know that your life is probably going to change, the hours you’re going to spend at work will change, and the commitment that you are going to make to your employees will change. Not just your employees and staff but to your employees as people. Being compassionate, having that open door not just for issues that occur on the floor but their own personal things that they are going to bring to you and that you’re going to have to figure out… it’s so stressful but if you are really in it and you’re really committed and your invested then leadership is worth it.
In the midst of their expression of idealism and challenges, the participants recognize that they are the future of nursing leadership. While they may be cautious about their future, they are ready to embrace all that comes with leadership,
We’re kind of the future of healthcare you know, we’re it so anything that we can take from this education or any further experiences will eventually kind of guide us towards what healthcare will be so it kind of depends on us. Discussion
In the midst of their expression of idealism and challenges, the participants recognize that they are the future of nursing leadership. A key concern for nurse leaders today is who will replace them when they retire. Nurse leaders may inadvertently sabotage succession planning efforts when they are not conscious about their leadership, or send negative verbal and non-verbal messages about leadership roles. Staff nurses have limited opportunity to observe their own managers and often have no idea about the scope of the role (Prestia, Dyess & Sherman, 2014). This limited view of leadership is unfortunate because with exposure to the leader role, nurses develop a deeper respect for the challenges faced by their current leaders. Our experience with this project indicates that once emerging leaders begin work with their nurse manager preceptors as part of practicum course work, they develop very different perceptions about the leadership role than were expressed in these focus groups. In their reflective journals kept during practicum experiences, they often observed that they gain a new appreciation of the range of leadership activities nurse leaders were engaged in throughout their daily routine.
Without intentional guidance, formal coaching, and role modeling, many young nurses may decide against becoming a leader based on what they observe in the practice environment. They may evaluate these roles as not being consistent with their personal values and beliefs. The future of nursing leadership could be in jeopardy if their decision is to just say no. Limitations
This study captured the perceptions of emerging nurse leaders from one geographic area at the beginning of their education program and prior to their acquisition of a formal leadership role during an era of significant healthcare transition. The results of this research are not intended to be generalizable across time or with a more geographically diverse group of young nurses. This is a study limitation, but these focus group findings are an important reminder about the gaps in communication and role understanding that often exist between nurse leaders and their staff. Conclusion: Implications for Nurse Leaders
the most significant contribution today’s leaders can make for the future is to develop their successors so they will adapt, prosper, and grow. With the expected large-scale retirements of many Baby Boomer nurses, the future of nursing leadership will be in the hands of Generation Y nurses early in the next decade. Viewpoints expressed by the participants in this research indicated that current nurse leader-staff relationships may not be as positive as is needed to establish a healthy and nurturing work environment. Unrelenting change in healthcare, focus on costs and increased span of control in many leadership roles have contributed to their perceptions.
Although not yet widely reported in the nursing literature, there is recent research to support the viewpoints of these emerging leaders that the current healthcare environment has taken a toll on leader-staff relations. Over the past seven years, the American Association of Critical Care Nurses (AACN) has funded research to study the work environments of critical care nurses as well as nurses in other high acuity areas such as the emergency department. A research team led by Dr. Beth Ulrich surveyed nurses nationally about each of the six key healthy work environment factors, asking specifically about perceptions of how well their frontline leaders and Chief Nursing Officers were doing on each of these dimensions. Studies were conducted in 2006, 2008, and 2013. The 2013 study included a very robust sample of 8000 nurses nationwide. The findings indicated a deterioration of scores at a statistically significant level on every dimension for both frontline managers and CNOs (Ulrich, Lavandero & Early 2014).
The study conducted by AACN and the research presented in this article should be a call to action for current nurse leaders. In addition to building more cohesive relationships with staff, there is clearly a need for leaders to do a more effective job of communicating with staff about the leadership role and responsibilities. The good news in this research is that Generation Y nurses are interested in nursing leadership and are confident about their ability to make positive changes in their environments. To alleviate their concerns about failure in the role, they will require structured leadership development programs and strong mentorship.
The shifts happening in the healthcare environment today demand that leaders challenge their thinking and practices to recognize that the crux of leadership is in the power of relationships. Growing future nurse leaders is a long term quest that requires both planning and action. Our emerging leaders will ultimately replace our current leaders and continue the very important work being done to improve nursing practice environments, and most importantly, patient outcomes. Yet succession planning is challenging today in a healthcare environment that is fast paced and constantly changing. Current nurse leaders are often so consumed with their day to day work, and they are unaware of the impressions that young emerging leaders may have about their roles and impact. Kouzes and Posner (2012), two well-known leadership experts in the field of business, have noted that the most significant contribution today’s leaders can make for the future is to develop their successors so they will adapt, prosper, and grow. Porter-O’Grady and Malloch (2015) advise that the shifts happening in the healthcare environment today demand that leaders challenge their thinking and practices to recognize that the crux of leadership is in the power of relationships. Leaders, they observed, will “increasingly devote their energies to helping others to adapt to the new rules for thriving in the world of work” (p. 22). The findings from this research indicate gaps in communication and understanding between nurse leaders and their staff that need to be bridged to recruit and retain Generation Y nurses into leadership roles.
Acknowledgement: The project described in this article is funded, in part, with a HRSA Advanced Nursing Education Grant D09HP22615-01-00. None of the authors has financial claims or conflicts of interest associated with this manuscript. Authors
Susan M. Dyess, PhD, RN, AHN-BC, NE-BC
Susan M. Dyess is an Associate Professor at Florida Atlantic University in Boca Raton, FL. She has been the project director for two key nursing leadership initiatives that supported novice nurse transition, and emerging nurse leader development. She is author or co-author on 15 publications in peer-reviewed journals.
Rose O. Sherman, EdD, RN, NEA-BC, FAAN
Rose O. Sherman is a Professor and Director of the Nursing Leadership Institute at Florida Atlantic University in Boca Raton, FL. She has written more than 60 peer-reviewed articles on nursing leadership topics and has received 2.5 million dollars in grant funding for leadership development research and program initiatives. Rose is an alumnus of the Robert Wood Johnson Executive Nurse Fellow Program and currently serves on the ANA Leadership Institute Advisory Board.
Beth A. Pratt, MSN, RN
Beth A. Pratt is a PhD student and research assistant at Florida Atlantic University in Boca Raton, FL. She is Vice President for the Nursing Student Council, Co-founder for the College of Nursing Student Organization, and Student Liaison for the Graduate Nurses Student Academy.
Lenny Chiang-Hanisko PhD, RN
Lenny Chiang-Hanisko is an Associate Professor at Florida Atlantic University in Boca Raton, FL. She is a qualitative researcher and has published numerous articles using phenomenology, grounded theory, ethnonursing, descriptive thematic analysis and content analysis methods. She is a Transcultural Nursing Scholar and currently member of the University Research Committee at Florida Atlantic University. She serves as a visiting scholar for several universities in Taiwan and China. References
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© 2016 OJIN: The Online Journal of Issues in Nursing
Article published January 14, 2016
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