Nurse Executive Leadership Skills and Competencies in Healthcare

Introduction to Nurse Leadership Competencies

The healthcare workplace can be compared to what a person sees when looking through a kaleidoscope: numerous different patterns appear as moments pass. The widely publicized shortage of nurses and the high turnover rates among nurses are among the most problematic of these patterns. The dependence of healthcare institutions on nurse-managers for the retention and recruitment of nurses is steadily increasing (Contino, 2004). Critical care nurses have arrived at leadership positions through a number of routes, most of which do not include any formal educational or managerial training. Effective strategies are therefore needed for critical care leaders so they can inspire staff and manage departmental operations effectively to achieve positive results.

One strategy being used by professional nursing associations, chief nursing officers, and employers is to create and implement formalized critical care leadership and managerial training programs that are evidence-based and results-oriented. An under-use of evidence-based research in the development of healthcare leaders was reported by Vance and Larson (2002) in "Leadership Research in Business and Health Care." What little evidence-based research is available regarding healthcare is poorly translated and mainly descriptive.

The practical managerial skills essential for critical care nurses in formal managerial roles have been compiled in this article, along with leadership skills that can prove very helpful for nurses. These skills are based on leadership and managerial experience as well as findings from expert business resources and healthcare professionals (Contino, 2004). The responsibilities of critical care managers are reflected in highly dynamic and divergent leadership skills. The need for open-minded leaders who work alongside their peers and colleagues to prepare for multifaceted daily challenges is also illustrated through these skills. Leadership skills have been grouped into four categories:

1. Organizational management; 2. Communication; 3. Analysis/strategy; and 4. Creation/vision. Each category includes key abilities and skills that can help leaders become more effective. These skills are discussed separately to explain each one more clearly and to demonstrate how they can be applied. Although the nature of this topic is extensive, the examples provided here are brief; additional resources and information can be found in the cited references (Contino, 2004). Administrative teams can use these leadership skills to create competency-based development programs and job descriptions for nurse-leaders.

Organizational Management Skills

Healthcare organizations can benefit by drawing on the experiences of other successful institutions. In Built to Last (Collins and Porras, 1997), a study of successful corporate habits demonstrates that continuity of leadership and ongoing leader development are very important for institutional success. When employees are taught how to manage human resources, revenue, information, expenses, time, change, equipment, and information technology, both the organization and its stakeholders benefit.

The "Level 5 leader" is described by Collins (2001) in Good to Great as someone who builds lasting greatness through professional will and personal humility, training employees to always do what is right. A Level 5 leader gives credit to others for successes while taking personal responsibility for failures, and motivates others through inspired standards. Collins argues that Level 5 leadership is one of the most important determinants of organizational greatness. Effective management of others as well as oneself is the essence of "great" leadership; it is therefore very important for leaders to know how to manage their own emotional responses in various situations.

Retention and recruitment efforts rely heavily on how nurse-managers are perceived by staff members. Wieck and colleagues (2002) suggested areas that current and future leaders can work on for improvement, indicating that both emerging and established workforces want their leaders to demonstrate optimism, honesty, and integrity. Employees want leaders who have good communication skills and are receptive to the needs and wants of others. They also want leaders to be approachable, motivational, empowering, and fair (Wieck et al., 2002). A survey titled "Reversing the Flight of Talent," conducted on 1,600 staff nurses, found that nurses want effective nurse-leaders to work for. Among the nurses surveyed, 84% were considering leaving their jobs due to dissatisfaction with their managers, and 43% considered leaving even though they were satisfied with their managers (Denby et al., 2000). Incorporating these research findings into the healthcare system can help improve the leadership skills of leaders.

Effective leaders use successful strategies to manage their time. Leaders frequently waste precious hours and minutes on insignificant tasks such as sorting mail, answering non-critical requests, or filing. Effective leaders use self-discipline to organize these tasks and prioritize projects. Nurses can develop time management skills by following the guidance of experts such as Stephen Covey (1998), who describes a time management matrix in The 7 Habits of Highly Effective People. This matrix helps leaders understand the relationship between non-urgent, urgent, unimportant, and important activities, enabling better allocation of time to urgent matters.

Time can be used effectively when building employee self-esteem, as illustrated by the one-minute praise concept described in One Minute Manager (Blanchard and Johnson, 1982). Another important skill for an effective leader is finding quick, creative, and individualized ways to thank colleagues, staff members, and customers. Personal knowledge of staff members improves retention and builds morale (Snow, 2002).

Delegation skills are also essential for effective time management. Leaders do not need to do everything themselves; their main responsibilities are to monitor ongoing processes, ensure project completion, and verify that interventions produce results (Gregg, 2002). Assigning appropriate projects and tasks to nurses and administrative employees helps leaders maximize their effectiveness. Ales (1995) describes a four-step process for effective delegation: deciding which tasks can be delegated, ensuring they are assigned to the right person, communicating the assignment clearly, and continuing to manage the flow of information — a step that plays a critical role in a leader's success (Gregg, 2002).

Managing data related to performance measurements and budget targets becomes very difficult without regular statistics. Extensive data has been made available on benchmarks such as pressure ulcers, nursing skill mix, patient falls, and hours per patient per day. Critical care nurses gather large amounts of data regarding patients, and nurse-managers are similarly required to do so with operational data.

Managing Human Resources and Change

The management of human resources — especially nursing resources — is a major component of the nurse-leader's role. Considerable time and attention must be devoted to understanding people, since, much like a disease, a proper diagnosis makes it easier to implement effective interventions. Geddes and colleagues (1999) concluded that there is a need for fiscal accountability, personnel management, and quality-enhancing management strategies. Training nurse-leaders to engage and involve critical care nurses should be a standard component of leadership education. Kouzes and Posner (1999) concluded that genuine caring for people is at the heart of effective leadership among critical care nurses.

The way critical care nurses treat their colleagues not only increases staff satisfaction but also improves patient safety. Hospital policies and human resource development guide nurse-leaders in their decision-making. The current shortage of nurses and high turnover rates highlight the need to work closely with human resource professionals (Contino, 2004). These professionals can track the reasons behind high vacancy rates, turnover, and exceptional retention within critical care units. Mark and Critten (1998) suggested that the HR department should focus more on organizational intelligence and facilitating organizational creativity and learning. Siddiqui and Kleiner (1998) reviewed human resources operational management and concluded that healthcare organizations should adopt the latest methods used by HR professionals, including promoting from within the organization, encouraging diversity, and conducting cross-training of personnel whenever possible.

Ridenour (1996) reported that leadership competencies influence patients' ongoing learning, resource utilization, outcomes, compliance, and strategic planning. How employees are mentored and treated is a crucial factor in retention; therefore, interpersonal skills should be part of management training. Leaders can develop an atmosphere of understanding by using personality-profiling tools. For these tools to be effective, they must be applicable, nonjudgmental, easily understandable, and accurate.

The Myers-Briggs Type Indicator (2004) is recognized as one of the most effective tools of this kind, measuring individual preferences across four basic scales: extraversion/introversion, sensate/intuitive, thinking/feeling, and judging/perceiving. The combination of these preferences yields 16 possible personality types. Understanding personality types helps leaders empathize with others and better interpret their responses. The Keirsey Temperament Sorter (2004) is another profiling tool built on the theory that every personality has two sides, sorting individuals into four temperament categories: artisan (impulsive), guardian (responsible), idealist (oriented toward personal growth), and rational (inclined toward objective analysis). Time Typing (2004) is a newer profile that uses "Past," "Present," and "Future" as metaphors for knowledge, control, and opportunity respectively, helping individuals understand their motivators, preferred reward systems, and communication styles.

Understanding cultural diversity and norms is as important as understanding individuals. Dreher and Macnaughton (2002) contended that cultural competence is, in essence, nursing competence. As communities become more diverse, leaders must adopt strategies for teaching and motivating people from varied backgrounds and skill sets. Leadership mentoring bridges the subjective and regulatory aspects of human resource management by pairing novice leaders with experienced ones. Montgomery (2001) describes a mentoring method in which a doctoral student is guided by an experienced professor in administrative experience and leadership.

Critical care leaders must respond to new regulations, hospital closures, consolidations, and changing economic conditions. Understanding how leaders implement change in a rapidly evolving environment has become essential (Simpson, 1996). Nurse-leaders exert significant influence on the change process (Mathena, 2002), and Menix (2000) noted that nurse managers may be unable to manage change effectively without proper education and training. Nagaike (1997) applied categories of change to healthcare organizations and concluded that flexible plans and clear, accurate communication are essential for providing quality care and effective management.

It is important for leaders to be able to evaluate the change process in order to respond to and implement required changes. Within healthcare organizations, Deming's Plan-Do-Study-Act (PDSA) model of change (1993) is widely practiced: (1) Plan — identify and clearly describe the problem; (2) Do — create and apply a solution; (3) Study — examine the problem, identify root causes, and map the process; (4) Act — assess the results and make adjustments as needed. This concept was first discussed by Shewhart (2001) in 1939 and gained widespread recognition in the 1950s when Deming encouraged the Japanese to adopt continuous quality improvement practices. Carney (2002) presented a change management model that helps leaders evaluate the change process by understanding the reasons nurses accept or resist change, enabling leaders to better explain why change is necessary.

Conclusion

It is clear that executive nurse leadership plays an important role in offering strategic, expert, and evidence-based advice to boards and in ensuring that policy, purchasing, reporting, monitoring, and macro-level decision-making are contextualized within the realities of patient care and population health. The leadership role of executive nurses encompasses risk management, the development and implementation of funding models, the creation of business plans, and the ongoing refinement of services, all while maximizing the value derived from funding reforms. High-quality, high-performing healthcare comprises executive nurses partnered with chief executive and medical leaders. Many countries require nursing executive positions to be filled in health services as part of accreditation and licensing requirements in order to meet legal standards (Centre for Healthcare Improvement, Queensland Health, 2012).

The executive nursing leadership role carries significant support for the delivery of efficient, safe, and high-quality health services. Executive nurses are assets to healthcare organizations, and their expertise and knowledge should be valued. Their leadership paves the way to quality healthcare for the consumers they serve.