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Changes in the healthcare system, such as value-based payment models which favor outcomes over volumes, along with increasing technological, quality, and patient demands, require a clinically expert nurse leader. To retain and recruit nurses in a diminishing workforce, and achieve the outcomes expected in today’s healthcare environment, a transformational leadership approach is recommended as a solution. Nurse managers will experience multiple challenges and will need to employ continuous education as well as obtain multiple venues of support to be successful. 

Introduction 

“Leadership is helping believe in a better tomorrow or a better outcome than you have today.”  

-Marissa Mayer, Former CEO of Yahoo 

Some people were born knowing they wanted to be leaders, and some stumble into it. No matter how you enter it, you can be a great leader, particularly with the proper support and preparation. There are many leadership roles, including nurse supervisor, nurse manager, chief nursing officer, etc. I choose not to define the differences between managers and leaders because all leadership levels contribute to ensuring a high-functioning healthcare environment. Often, the first step into leadership is the nurse manager. Therefore, that will be the focus of education.  

As a nurse manager, you will likely be required or have already achieved an advanced degree, at least at the master’s level. While this has or will prepare you with leadership tools and critical thinking skills, education, once obtained, is static. Continuous learning and availing yourself of new tools and concepts are required to solve complex and morphing issues that arise with new technology, a developing workforce, and societal changes that impact the health environment.

A Need for Quality Nursing Management and Leadership 

The nursing profession is experiencing a crisis of low morale and increasing technological, financial, quality, and human demands. Growing research indicates these demands, particularly the nursing shortage, are associated with higher rates of mortality, increased hospital readmission rates, and higher rates of incidents and infections (1).

Nurse-sensitive quality measures, such as infections, pressure-associated wounds, and falls, require specific and time-sensitive care and, when not met, result in poor outcomes that negatively affect the patient, family, and the organization. While these outcomes have always been nursing’s responsibility, the visibility is now raised to a detectable level. Today’s nurse leaders must not only be prepared to lead but also have the clinical expertise to ensure evidence-based practices are used for problem-solving and positive clinical outcomes (3). 

The elevated responsibilities of today’s nurses, high turnover rates among new graduate nurses, and the average age of bedside nurses being 50 years, all combined, paint a grim future for nursing that is now in the hands of nursing leaders to resolve (1).   Health Affairs published a workforce analysis in 2022 that showed that the Registered Nurse workforce decreased by 100,000 nurses from 2020 to 2021(1). According to the Bureau of Labor Statistics, the registered nurse workforce is expected to grow by 6%, equaling 195,400 nurses, by 2031(1).   

According to a 2024 survey by AMN, 31% of nurse leaders expect to leave their roles within the year(3). While there is great demand for nurse leaders, the need is greater for leaders with the characteristics and competencies to succeed.  ​

Competencies of Successful Nursing Management 

Once you become a nurse manager, your focus turns from supervising yourself and working as part of a team to influencing a group of independent and interdependent professionals to get the required outcomes. While clinical expertise is essential for a nurse manager, other vital characteristics pave the path to successful leadership. These are:   

1. Ability to collaborate with a team and build relationships 
2. A desire for continuous learning 
3. Effective two-way communication- listening, body language, and interaction with diverse individuals, both professionally and personally 
4. Ability to prioritize and organization skills 

These characteristics facilitate a nurse leader’s required competencies, gained over time through experience and continuous learning. The American Organization for Nurse Leadership identified five core competencies of nursing leaders (2):  ​

In today’s environment, communication and relationship building are essential characteristics for a nurse manager and one of the most crucial competencies to develop. A growing body of evidence shows that nursing leadership, particularly relational leadership, directly correlates with patient outcomes, work environments, and retention (7). A nurse manager’s challenges are frequently mired in emotion that innately comes with being and working with humans who are unique, passionate, and have needs. Ahead are some challenges a nurse manager is likely to encounter. 

Challenges of Nursing Management and Leadership 

Managerial Blues

Managerial blues are a phenomenon in which managers feel their supervisory role is less meaningful than their position as bedside nurses. This phenomenon could be particularly true for nurses moving into management after being at the bedside during the COVID-19 pandemic. Frequently, a confident nurse has a lot of autonomy during a crisis and achieves a sense of meaning with their accomplishments (18). The managerial blues are standard in many industries outside of nursing, and there are reasons beyond this that managers may become unsatisfied in their roles.   

• Thinking back, have you known a nurse leader who left the role because they felt it was less meaningful than bedside nursing?   
• What would have made a difference for the manager to be retained?  

Lack of Job Satisfaction  

With vacancy rates of nurses and nurse leaders above 7%, additional responsibilities become necessary, including managing more than one unit and possibly providing patient care. In addition to the 24-hour responsibility and the growing concern of appropriate staffing resources, stress begins to mount. The main reasons nurse managers leave, as cited by managers who wanted to leave, were nurse recruitment and retention, burnout, and labor shortages (2)). This is consistent with bedside nurse turnover reasons.  

Despite today’s nurse managers’ immense responsibility, surveys reported that a high percentage, 68%, were satisfied with their roles. Content nurse managers cited positive relationships with their managers as fundamental to their satisfaction (2). 

While both managers and nurses face familiar stressors, concern about job satisfaction need not be a limiting factor in deciding whether or not to assume a leadership role. For those motivated to improve their working environment, change can be energizing even with a surplus of responsibilities. Having an encouraging and supportive supervisor can also impart energy to balance the demands of a high-pressure role.  

• How does taking on different responsibilities affect your energy level? 
• How does your relationship with your immediate manager affect your job satisfaction? 
  

Interpersonal conflicts  

Interpersonal conflicts, such as incivility, vertical aggression, bullying, and passive-aggressive behavior, are some of the most challenging issues to confront and manage. However, nothing is more likely to take the joy out of nursing and negatively affect quality outcomes than not dealing with interpersonal conflicts (5). 

The most effective way to deal quickly with interpersonal conflicts is to understand their negative impact on the team. Until you gain experience managing interpersonal conflict, employ resources such as your immediate manager, more experienced nurse manager peers, and human resources to assist. Confidentiality, showing respect, seeking to understand, and leaving people with their dignity will help you manage with confidence.  

• How are interpersonal conflicts handled in your unit?  
• Thinking back on an interpersonal conflict you resolved, are there additional measures you would employ today?  

Recruitment and Retention 

The biggest challenge facing all nurse leaders in 2024 is recruiting and retaining nurses (3). As noted previously, positive relationships are critical to a high-functioning work environment and imperative for both the retention and recruitment of nurses. More so than money, workload, or other factors. In a quick look at recent subReddit r/nursing posts, a Redditor corroborates the need for a good working environment and the leader’s effect on that by describing his/her nurse manager:  

She is the type of manager who reads off the policy, neglects to address our concerns, and abandons any role in advocating for us, even if our concerns are valid. Despite these trying times in the healthcare setting as a whole, her demeanor and attitude, combined with passive-aggressive remarks, make morning huddles and day shifts absolutely awful. It’s to the point where nurses who float to our unit ask if this is how it goes every day… and the unfortunate answer is yes. 

I didn’t realize the extreme difference until I floated to another unit a few months ago and was so refreshed by the overall work environment. It was actually a busier floor and assignment overall, but the change in management style completely reversed my expectations for the day (11). 

Transformational leadership is one relational style that has positively affected clinical outcomes, nurse retention, and the working environment.  

Transformational Leadership 

Transformational leadership is a relational, evidence-based management practice cited by the AONL and over 20 nursing studies as one of the critical factors in improving mortality rates, hospital-acquired infections, and medication errors (1). The transformational leadership style also improves retention by creating positive work environments.  

Transformational leadership, also known as a transactional leadership style, addresses individuals’ higher-order needs to develop long-term solutions in place of reward and punishment-based actions. It promotes self-actualization and self-esteem by inspiring employees and building self-confidence. Transformational leaders set clear goals and encourage, recognize, and reward staff members to create future leaders.  

 It is essential to know your leadership style to recognize your natural response versus a needed response that can be learned and practiced. Not every person is inherently a transformational leader, but continuous learning about leadership styles helps one adapt their style to a needed response for a specific situation.  

Below are the characteristics and behaviors of a transformational leader (6):

Making the Transition 

The nurse manager’s transition can be difficult, and success requires accepting that about 80% of your role requires a communication transaction (6). In the article, Insights on Becoming a first-time Manager, Nancy Anderson, RN, gives some good advice based on her own mistakes assuming the new role (4):  

1. No one expects you to know everything, but they expect you to ask and listen. Leadership = less talking and more listening.  
2. Interruptions to your day and your to-do list will be the norm. Plan a specific time to get work done and communicate that; otherwise, accept that this is likely the most crucial part of your role.  
3. Shifting from co-worker to boss feels uncomfortable. Focus on treating everyone equally and setting boundaries.  
4. Leading people is not necessarily a part of the nurse manager role. It is the job.  
5. Round early and regularly with your staff and hold one-to-one meetings to learn their strengths and weaknesses.  

Here is a recent subReddit post of a nurse commenting on his/her manager, echoing the importance of availing yourself, as a leader, to your staff:  

Excellent attention to detail, terrible communication skills, poor people skills, and a bully all around. It doesn’t matter how on the ball you are; if you can’t deal with people and realize half of your job is dealing with your staff, you shouldn’t be in management (10).  

Another Redditor from the r/nursing subReddit group shared her feelings about her new nurse manager. This is a “what not to do” post:  

My new manager has worked in her position for six months and has yet to introduce herself to me formally. The only thing I get from her is passive-aggressive emails about what we’re doing wrong and how we need to get off her bad list for not getting our little managerial tasks done a month ahead of time (14).  

When Should I See Results? 

A new nurse manager’s ideal time to feel fully competent and achieve results as a relational leader is five years (2). This timeframe is based on the time it takes to develop relationships fully. According to Healthcare Source, a consulting company, the average number of people a nurse manager is responsible for is about 50 (15).

That span of control or number of people under your responsibility may be higher depending on your organization’s ideal staffing model and recruitment and retention strategies. The higher the number of individuals under your leadership, the harder it is to tend to individual support and development needs while managing numerous regulatory and quality commitments. However, there are many successful nurse managers, and here are some recommendations to get the support you need to thrive.  

• Seek the counsel of other nurse managers, whether new or experienced, to offer and get support. Having friendships among co-workers is a critical factor in achieving work-life satisfaction. Getting practical advice to solve issues or to validate you are not alone provides reassurance and builds confidence.  
• Set boundaries. Not only boundaries between your work and home life but limitations on your relationships with your responsible staff members.  
• Be participatory. You are not required to solve all the problems or know all the answers. Engage the team in problem-solving.  
• Seek the support of human resources. Understanding how and when the human resource team can intervene for support and assistance should be an early task in your orientation. You will engage with the HR team frequently before implementing changes, dealing with interpersonal conflicts, and recruitment and retention.  
• Be a continuous learner. Subscribe to relevant journals and continuing education, and stay current on evidence-based processes.  
• Determine the specific help that you need and ask for it regularly.  
• Avail yourself of your organization’s resources, including education, development, mentors, and support services.  
• Become a member of professional organizations focused on nurse leaders, such as the American Organization for Nursing Leadership, and pursue certification once you have the required years of experience.  

Tools for Continued Support and Development 

No matter the nurse manager’s experience, there is always the opportunity for the unexpected, whether that be among the workforce or health related. Side-by-side support is not a realistic expectation over the 24 hours in a day. Do not wait until you are experiencing a crisis to find resources, and instead, stay ahead of current trends and the struggles of other nurse managers. There are multiple resources to support you now, whether you seek to be a nurse manager or are currently in the role. Here are a few of my go-to support and education forums:  

Journals

Nursing Management: The Journal of Excellence in Nursing Leadership   

Published monthly. Provides strategic professional information nurses need to excel as healthcare leaders. Places special emphasis on the challenges you face and skills you need to succeed in today’s fast-paced nursing leadership environment. An independent platform for the expression of various opinions and views, the publication targets leadership concerns, including recruitment and retention, reimbursement issues, legal considerations, regulatory compliance, and professional development. 

Professional Organizations

American Nurses Association (ANA) or your state nursing association 

ANA recommends standards for clinical practice as well as safe practice environments and advocates for healthcare issues for nurses and the public. There are also leadership opportunities within this and other professional associations.  

American Organization for Nursing Leadership 

Known as the voice of nursing leadership. AONL changed its name from the American Organization of Nurse Executives (AONE) in 2019. AONL also offers Nurse leadership certification review courses as well as competency checklists and assessments.   

Blogs

Emergingrnleader.com: A Blog for Nursing Leadership Skills and Career Strategies.  

By Rose O. Sherman, EdD, RN, NEA-BC, FAAN. This is a helpful blog for leading in today’s health care environment with bite-size pieces of information and resources to learn more.

Podcasts

Today in Nursing Leadership from the AONL 

Most podcasts are under 10 minutes, and many are interviews with current nurse leaders and specific to recent research on leadership tactics such as “Reducing documentation burden to return joy to nursing” January 18, 2021 

Nurse Leader Network with Chris Recinos  

A good balance of education, career development, and self-care. Here is the description of the podcast:  

What happens when you provide nurse leaders with tools to learn, share and connect? You get the Nurse Leader Network! A podcast dedicated to building your career, helping you find your work-life balance, and creating a lasting social community (network) with other nurse leaders.

Conclusion 

The nursing profession faces a crisis of low morale, complex clinical needs, increasing responsibility for improved outcomes, and a diminishing workforce. The current environment requires clinically expert nurses who are influential in leadership roles.  

Since relational-style leadership positively affects retention and clinical outcomes, nurses must recognize their leadership style and seek the necessary education and support to become future transformational leaders.  

In one last subReddit post in the r/nursing forum, it is refreshing to see a nurse manager’s response to staff members’ concerns about their nurse managers’ leadership style. As expected from a transformational leader who is doing a form of rounding, he/she is listening, and here is his/her response to nurse colleagues:  

Thank you for this thread. I am new to management and appreciate all of your comments. I want to listen to people and minimize my mistakes. Wishing you all healthy and happy work environments (7).  

 ​

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