Ask Linda McQuaid, RN, Medical Care Manager at UnitedHealthcare Community Plan of Ohio, about the current state of nurse leadership, and the 35-year nursing industry veteran laughs. “There is a lot more credentialing going on, but I don’t see much improvement in the quality of [nurse] leadership. Advanced degrees do not make nurses leaders,” she says.
McQuaid, who has worked in a range of settings, including hospitals, nursing homes, and home health care, feels that pathways for her generation of nurses, baby boomers, are lacking throughout the industry, and younger generations of nurses are being put into the limited number of leadership roles without enough hands-on patient experience.
Many of her concerns are echoed by her NEJM Catalyst Insights Council peers in the results of our recent survey on nurse leadership. For instance, 63% of Council members say fewer than 25% of leadership roles in their organizations are filled by nurses, demonstrating a lack of opportunity for advancement.
“In the military, nurses run medical units; doctors do operations,” she says, adding that it’s time for the rest of health care to catch up in terms of respect and opportunities for nurse leaders.
Although McQuaid herself has been able to rise into leadership roles without an advanced degree, she says most openings require one. “I find that [requirement] frustrating” because nurses with experience are exactly who should be leading, she says, stressing that they have more time with patients than anyone else and, therefore, best know their issues.
McQuaid also questions how realistic it is to expect experienced nurses to take on the financial burden of an advanced education. “By the time I go part time to school at my age and graduate, I have only 10 to 15 years until retirement. That’s not enough time to pay my loans back,” she says, adding it winds up “not being worth it.” Fewer than half of survey respondents, 46%, say their organization offers courses such as continuing education for nurse leadership, which would leave many to seek out degrees on their own.
Xiaoyan Huang, MD, MHCM, FACC, Medical Director of Clinical Transformation at the Providence Heart Institute in Portland, Oregon, says her parent health system, Providence St. Joseph Health, is among the organizations that do offer formal nurse leadership training.
“We have a robust system-level and deliberate effort that fosters leadership,” she says. The Nursing Institute, as the initiative is called, features six options for clinical, administrative, and academic growth, including mentorship (which only 40% of respondents say their organization offers), research and innovation, and a clinical academy with general and specialty training.
Huang says she can understand the frustration nurses like McQuaid feel as they look at the odds for gaining a leadership position. Most organizations, Huang finds, are incredibly siloed — meaning nurses climb their own vertical pathway — and “have a mind-set of only one CNO for the entire hospital. With hundreds of nurses on staff, the opportunity-to-eligible ratio can seem too low.” (According to survey respondents, 79% of respondents say they have a CNO at their organization.)
“If an organization has 500 nurses and 20 middle managers and 5 upper managers, most of the nurses are going to look around and say it’s probably not going to be me that gets promoted,” McQuaid says. Only two-thirds of survey respondents say there is a leadership path for nurses at their organization.
Huang says one approach would be to open up more administrative leadership positions to nurses, which already are open to non-physicians. She also agrees that making people get advanced degrees is not always the answer to finding good leaders. “People have intrinsic skills no matter what title may be after their name. We should not classify leaders based on training and roles,” she says.
However, Huang, in observing the millennial generation of nurses she works with, is confident change is happening. The team-based approach to care should provide nurses the opportunity to obtain leadership skills along with their clinical training, she says.
Huang notes that although physician leaders are not directly involved in nurse leadership development currently, she hopes that will change as organizations begin to integrate their physician and nursing training and leadership development.