Over the decades, the role of the frontline nurse manager has evolved from head nurse to nurse leader. With this evolution, the traditional managerial functions of planning, leading, organizing, and controlling a unit or division have expanded to include additional leadership competencies, such as:

• communicating the organization’s vision and mission to staff
• providing consistent feedback to staff that encompasses both positive and developmental coaching
• devising strategies to ensure staff are consistently achieving the expected clinical and “people” skills
• building a cohesive team that works 24/7.

While the responsibilities and skills of the frontline nurse leader have expanded, recent research suggests that compared to those in mid- and executive-level nursing roles, frontline nurse leaders have fewer developmental opportunities. So while their role has expanded, they lack adequate resources to support success. This dilemma may have its roots in the “can do” mentality many nurses adopt early in their careers—the attitude that “we’ll figure out a way to make it happen.”

Working around the gap

Like bedside nurses who create “workarounds” to compensate for lack of resources, frontline nurse leaders with limited developmental opportunities are forced to devise workarounds to bridge the gaps in their career-growth experiences. But these workarounds aren’t long-term solutions. Warning signs of a widening gap between role responsibility and developmental opportunities include increased staff turnover, decreased patient-satisfaction scores, declining clinical outcomes, and units or divisions exceeding their budgets.

By the time these warnings appear, the developmental gap may be acute. Like a patient with an acute condition, a frontline leader suffers more the longer her developmental needs go “untreated.” If these needs aren’t addressed, she may make serious mistakes and “righting the ship” may prove much harder; more aggressive procedures, monitoring, and mentoring will be needed to return the work environment to a healthier state.

Linking patients to care providers

Viewing patients as their most precious asset, frontline leaders are vital to their organization’s ability to deliver high-quality care. Besides ensuring that staff members have the clinical expertise and tools to provide safe care, the frontline leader serves as a direct link among patients, families, and the senior management team. From a high-performance organizational perspective, the frontline leader is a critical building block that enables the hospital to achieve its mission and vision and maintain its values.

High-Performance Model

Organizations embracing a high-performance strategy have an obligation to give frontline nurse leaders the developmental opportunities they need to enhance their careers. In return, frontline leaders are obligated to take advantage of these opportunities.

The High-Performance Model developed by Psychological Associates, a human resource development firm, views the development of frontline nurse leaders as a two-way street. It can be used to help a team devise a developmental process for frontline leaders; this promotes a data-driven strategy that helps align leadership competencies and behaviors with the organization’s values, mission, and vision. (See High-Performance Model: Improving developmental opportunities by clicking on the pdf icon above.)

Based on insights gained over 50 years of helping organizations develop leaders, the Model encompasses four strategies. Each focuses on creating developmental opportunities that link the organization’s purpose and direction with the leader’s role, current skill set, and expertise needed to lead in the future. Each strategy also encompasses tools the nurse leader can use to energize staff members by helping them understand how their work relates to the organization’s purpose, direction, and delivery of optimal patient care. The four strategies are:

• Know where you’re going.
• Ensure that people have what it takes.
• Develop and enable them.
• Keep them on track.

Know where you’re going

Knowing where you’re going requires both a keen understanding of the hospital’s mission, vision, and values and an ability to articulate to staff members how their actions relate to these. Frontline leaders who know where they’re going can help staff “connect the dots” and help them understand and commit to providing patient care that aligns with the organization’s goals and values.

Ensure that people have what it takes

To do this, organization leaders must define the competencies that frontline nurse leaders need to succeed and must devise an assessment process that measures these capabilities. They can begin by asking senior leaders in the organization to identify the leadership characteristics and behaviors required for frontline nurse leaders to execute the hospital’s mission, vision, and values. Defining and measuring competencies also will help ensure that frontline leaders are promoted because their skill level is commensurate with their role—not just because they’re great clinicians.

Develop and enable them

The hospital has an ongoing commitment to providing frontline leaders with growth opportunities by offering mentors, coaching them on strategies they can use to integrate their values into work practices, giving them training opportunities to acquire new skills, and providing continual developmental building blocks that reinforce leadership competencies.

Keep them on track

This strategy involves data-driven behavioral feedback that focuses on how the manager’s behavior affects staff, peers, superiors, patient satisfaction, and the hospital’s mission, vision, and values. Performance reviews should set clear objectives and expectations, and allow frontline leaders to share their perceptions about their performance. These attributes, anchored in leadership behavioral competencies and combined with feedback from one’s boss, help frontline leaders stay on track.

Although most healthcare organizations have a performance review process, many leaders are uncomfortable giving employees candid feedback or discussing performance problems with them. Instead of setting clear expectations, they couch their feedback in safe terms that lead to assumptions and misperceptions regarding the behaviors and competencies expected of frontline leaders.

The backbone of the organization

Frontline nurse leaders must be able to size up situations and people. They must monitor staff continually to ensure they’re achieving expectations, provide positive feedback to those who’ve performed well, communicate to others when their performance has been mediocre or poor, and be able to manage disagreement. Competent frontline leaders believe people have value and aren’t a means to an end, but rather a means to consistently achieving results.

Frontline nurse leaders are an organization’s backbone. Their development is crucial to an organization’s ability to handle the challenges of the dynamic healthcare environment.

Selected references

American Association of Critical-Care Nurses. AACN standards for establishing and sustaining healthy work environments: a journey to excellence. Aliso Viejo, CA: American Association of Critical-Care Nurses; 2005.

Buckingham M. What great managers do. Harvard Business Review. 2005;83(3):70-79.

O’Neal E, Morjikian RL, Cherner D, Hirschkorn C, West T. Developing nursing leaders: an overview of trends and programs. JONA. 2008;38(4):178-183.

Ulrich BT, Lavandero R, Hart KA, et al. Critical care nurses’ work environments 2008: a follow-up report. Crit Care Nurse. 2009;29:93-102.

Cindy Lefton is vice president of Organizational Consulting at Psychological Associates in St. Louis, Missouri.