Survey Snapshot: Do Nurse Leaders Need Advanced Degrees?

Insights Report · December 20, 2018

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.

Nurses Fill a Quarter or Less of Leadership Roles at More Than Half of Health Care Organizations

From the Leadership Insights Report: Nurses as Leaders: Broad Acceptance, Room to Grow. Click To Enlarge.

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.

Two-Thirds of Organizations Have a Nurse Leader Career Path

From the Leadership Insights Report: Nurses as Leaders: Broad Acceptance, Room to Grow. Click To Enlarge.

“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.

Call for submissions:

Now inviting expert articles, longform articles, and case studies for peer review


A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

More From Leadership
Sands01_pullquote clinical research partnership for learning health care

Real-World Advice for Generating Real-World Evidence

If envisioned and implemented properly, a partnership between clinical delivery systems and clinical research programs can get us closer to the goal of achieving learning within the care continuum and discovering evidence that is available when it is needed.

The Largest Share of Organizations Do Not Have a Formal Strategy for Clinician Engagement

Leadership Survey: Why Clinicians Are Not Engaged, and What Leaders Must Do About It

Clinician engagement is vital for improving clinical quality and patient satisfaction, as well as the job satisfaction of clinicians themselves. Yet nearly half of health care organizations are not very effective or not at all effective at clinician engagement.

Rowe01_pullquote - clinician well-being - fighting clinician burnout and creating culture of wellness takes all stakeholders

Defending the Term “Burnout”: A Useful Tool in the Quest to Ease Clinician Suffering

Health care leaders must take a preemptive approach to clinician well-being that is supported by all stakeholders and prioritized on an equal footing with essential clinical and financial measures.

Screenshot from the NewYork Quality Care Chronic Condition Dashboard

Success in a Hospital-Integrated Accountable Care Organization

How NewYork Quality Care achieved shared savings — by strengthening collaboration, enhancing care management with telehealth, and transparently sharing performance data.

Miller03_pullquote social determinants whole-person

How a State Advances Whole-Person Health Care

Pennsylvania addresses social determinants of health by bringing together managed care and social services organizations to expand access to vital resources.

Abigail Geisinger Scholars Program for Medical Students -Ryu02_pullquote

Why a Teaching Hospital Offers an Employment-Based Tuition Waiver Program

Geisinger Commonwealth School of Medicine subsidizes medical students’ education in exchange for their willingness to practice at Geisinger Health System.

Michael Dowling and Charles Kenney headshots

Rebooting Health Care: An Optimistic Outlook

The U.S. health care system may seem broken, but it’s on its way to greatness, according to the authors of Health Care Reboot. They discuss their optimism for U.S. health care reform, particularly on the social determinants of health, payment, consumerism, and technology.

Action Steps for Risk-Share Contracts for Medical Devices

Challenges and Best Practices for Health Systems to Consider When Implementing Risk-Share Contracts for Medical Devices

When done right, value-based contracting for medical devices can ameliorate shrinking margins at health systems, leading to a virtuous circle.

Health Care Organizational Culture Emphasizes Patient Care Only Slightly More Than the Bottom Line

Survey Snapshot: Who Should Lead Culture Change?

NEJM Catalyst Insights Council members feel that culture change at their organizations is heading in the right direction, but differ on who it should come from, and reveal too much balance between emphasis on bottom line and emphasis on patient care.

Culture Change Within Health Care Organizations Is Changing for the Better

Leadership Survey: Organizational Culture Is the Key to Better Health Care

Although three-quarters of Insights Council survey respondents say culture change is a high or moderate priority at their organizations, survey results show a lot of work on organizational culture remains to be done.


A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »


Leading Transformation

280 Articles

Ripe for Disruption: Why and How…

For big tech companies like Amazon, Apple, and Google, the health care sector looks ripe…

Physician Burnout

52 Articles

Survey Snapshot: How Do You Know…

The NEJM Catalyst Insights Council discusses strategies for clinical engagement.

The Next Frontier in Reducing Costs…

To create meaningful point-of-care guidance so that patients can make informed medical and financial decisions,…

Insights Council

Have a voice. Join other health care leaders effecting change, shaping tomorrow.

Apply Now