Leadership Survey: Nurses as Leaders: Broad Acceptance, Room to Grow

Insights Report · December 6, 2018

Analysis of the NEJM Catalyst Insights Council Survey on Nurse Leaders. Qualified executives, clinical leaders, and clinicians may join the Insights Council and share their perspectives on health care delivery transformation.

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Advisor Analysis

By Stephen Swensen and Susan Robel

In a recent survey of the NEJM Catalyst Insights Council — comprising clinicians, clinical leaders, and health care executives — nearly three-quarters of respondents say nurse leaders should be considered the equal of physician leaders in care delivery. “I think organizations are now realizing leadership training and leadership positions for nurses are [very critical] investments to the success of their foundation, which is patient care,” says Susan Robel, RN, BSN, MHA, NEA-BC, CPXP, Executive Vice President, Chief Nursing Officer, and Chief Patient Experience Officer at Geisinger.

Nurse Leaders and Physician Leaders Should Be Considered Equals in Care Delivery - but Views of Nurses and Non-Nurses Differ

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

Yet there is work to be done to fill the pipeline of nurse leaders, from the patient floor to the C-suite, according to the survey. Nearly two-thirds of respondents (63%) estimate that less than a quarter of the leadership roles in their organizations are filled by nurses.

Stephen Swensen, MD, MMM, FACR, Professor Emeritus, Mayo Clinic College of Medicine, Senior Fellow, Institute for Healthcare Improvement, and Theme Leader for NEJM Catalyst’s Leadership theme, says if the lack of representation of nurses among the leadership ranks is not corrected, it will have a negative impact on an organization’s ability to transform care delivery.

The survey finds that disinterest in leadership roles runs high, with more than half of respondents (58%) estimating that fewer than a quarter of nurses are interested in leadership roles. “You’ve got these nurses who spend these years training, love what they do, and don’t want to move beyond it,” Swensen says, adding that organizations should entice nurses to leave the bedside and take on leadership roles.

Whether the disinterest comes from truly not wanting to do more than care for patients or because many nurses don’t see a pathway to leadership in their organization is hard to pin down, Swensen says. As an example, non-nurse respondents (68%) were more likely to say there is a leadership career path at their organization than nurse respondents (48%).

There are also very real barriers to advancement, Swensen says, pointing to an inherent gender bias and nurses being perceived as “doers” rather than strategists — which respondents rank as the third-greatest barrier preventing nurses from entering leadership roles.

Robel sees change on the horizon. The whole pipeline of nursing development, from schooling to industry associations, is beginning to cultivate leadership skills among nurses.

For instance, Geisinger and its nursing academic partners have changed their internships and externships to be much more strategic, extending beyond patient care to leadership and team development at the bedside. “Students are being shown how to use their skills in prioritization and decision-making,” Robel says.

Robel is the executive sponsor for Geisinger’s Nurses Emerging as Leaders program “to plan the bench” for nurse leaders. Program participants receive training, mentorship, and advanced education. “If we’re saying that we want nurses to be part of the C-suite and on a leadership track, well, we also have to invest in the education of that individual,” she says. Popular advanced degrees are master’s degrees in health care administration or business administration.

Integrated, team-based training is important but not widespread, Swensen says. “Leadership development should be team-based, not discipline-based or professional-based,” he says. Nurses likely would gain greater confidence in a multidisciplinary team environment, and others on the care team would become far more comfortable with nurses in a leadership role.

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.

While academic centers and larger health systems have the ability to offer leadership tracks for nurses, Robel says the smaller hospitals will find it more difficult. Yet the ongoing consolidation of health care organizations can help in this regard. Geisinger acquired community hospitals “where nurses wore so many hats, they didn’t have the time to go back to school,” she says. The organization also couldn’t afford their education or leadership training. “It’s not that they didn’t want to do the training. Some of them just didn’t see the value of it. When we merged, the opportunities grew for those nurses.”

Nurses may have to be willing to take on the education expense themselves when their organizations can’t or won’t, according to Swensen. “Most of the nurses in this country are in small-to-midsize community hospitals and don’t have access to robust and formal leadership programs,” he says. But the benefits that nurses will gain from advanced degrees and other professional training are worth the time and expense, he stresses.

Robel believes that much of the wariness among nurses to pursue education and leadership roles is dissipating as baby boomers retire and millennials populate the workforce. “Millennials are in a job for two or three years and they are ready to move on and get more training and more education. They are movers and shakers. They won’t be at the same nursing job for 20 or 30 years,” she says. “The ambition they have is truly inspirational.”


Should nurse leaders be considered the equal of physician leaders in care delivery? Why? Repondents who say no:

“Different expectations regarding productivity etc., not to say they are not valuable and bring great ideas, but there is a qualitative difference.”
— Clinician at a midsized for-profit physician organization in the West

“Different roles, different educational backgrounds, make cross coverage difficult. If all physicians are not equally skilled in ALL aspects of medicine does it not follow that an individual without regard to the academic letters of achievement after their name would not be universally capable in all areas? The thoughtless push towards equality and diversity mandated by quota has the capacity to dumb down a system best illustrated by the aphorism if your only tool is a hammer the whole world is a nail.”
— Clinician at a large nonprofit health system in the Midwest

“Some should just like some MDs should not. But in general the MDs are the subject matter experts in care delivery.”
— Program director at a large for-profit teaching hospital in the South


Should nurse leaders be considered the equal of physician leaders in care delivery? Why? Repondents who say yes:

“Nursing is a distinct profession which interacts with, serves, and educates patients more than any other healthcare profession. Nurse leaders should, at the least, be considered equals with physician leaders in health system leadership and strategic care delivery.”
— Director of a community hospital in the South

“Doctors and nurses should be leadership partners in healthcare delivery. Major academic medical centers may attract patients and grant money by recruiting doctors who are leaders in their field. Nursing, however, is what drives every day patient care. If the nursing care at an organization is sub-par, patients will not come for care no matter how prestigious the doctors are.”
— Director of a small nonprofit teaching hospital in the Northeast

“Because medicine is a team sport.”
— Executive at a small nonprofit community hospital in the Northeast

Download the full report for additional verbatim comments from Insights Council members.

Charts and Commentary

by NEJM Catalyst

We surveyed members of the NEJM Catalyst Insights Council — who comprise health care executives, clinical leaders, and clinicians — about nurse leadership. The survey explores the percentage of leadership roles filled by nurses and the percentage of nurses interested in leadership roles, recognition of nurses’ leadership abilities, Chief Nursing Officer inclusion in strategic decision-making, leadership career paths for nurses, formal training offerings for nurse leadership, barriers preventing nurses from leadership roles, and nurse leaders and physician leaders as equals in care delivery. Completed surveys from 682 respondents are included in the analysis.

Nearly two-thirds of Council members (63%) estimate that less than a quarter of the leadership roles at their organization are filled by nurses. But nurse respondents are more likely than non-nurse respondents to estimate the percentage of leadership roles at their organization at half or more. In a written comment, one clinician says, “Nurses, especially those with advanced degrees and experience, make skilled leaders because they have more experience at the bedside and can often see issues with a variety of solutions that may not be seen by someone who has less time available with the patients and the health system as whole.”

Tradition Is the Main Barrier Preventing Nurses from Leadership Roles

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

Download the full report to see the complete set of charts and commentary, data segmentation, the respondent profile, and survey methodology.

Download Full Report

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