Leadership roles in nursing are complex, and the leaders of tomorrow need development, mentoring, and skill building, consistent with the mission of the American Organization for Nursing Leadership (AONL) to influence healthcare delivery through innovative and expert nursing leadership (Begley, 2019). Senior nurse leaders are nurse executives who assume roles as nursing directors, associate nursing directors, or assistant vice presidents of nursing. Senior nurse leaders may transition into new roles because of organizational need, extended vacancies, increased pay, or as a stepping stone to other opportunities (Bleich, 2017). They may be selected based on clinical expertise or prior experience, without fully understanding the culture of the clinical practice environment. In addition, they are frequently poorly prepared, trained, or mentored to lead with agility, professionalism, and emotional intelligence in new organizational roles (Bellack & Dickow, 2019; Miltner et al., 2015; Patterson & Krouse, 2015; Thompson & Miller, 2018; West et al., 2016).
Meeting the internal professional development needs of senior nurse leaders has been challenging for organizations, as many workplaces do not have structured orientation programs or sustained support to adequately provide for the learning needs of novice senior nurse leaders (Akerjordet et al., 2018; Beal & Riley, 2019; Miles & Scott, 2019; Miltner et al., 2015; Siren & Gehrs, 2018; West et al., 2016). Professional development educators can play an integral role in customizing situation-specific learning for senior nurse leader onboarding based on the findings of this qualitative research study. The practical implications of these findings are that they can be used by professional development practitioners to create roadmaps with structured onboarding and orientation activities that will support the role transitions of senior nurse leaders.
The aim of this study was to describe the lived experiences of novice senior nurse leaders who have transitioned to new organizational roles within a healthcare organization in the southeast United States in order to understand the professional development needs that novice senior nurse leaders encounter on their journey to effective leadership and role mastery.
BACKGROUND
Nurses experience many transitions throughout their professional careers as new graduates or as experienced nurses entering new specialties or new organizational roles. Transitions can be complex, multifaceted, and timeless and may cause nurses to experience shock, anxiety, discomfort, confusion, and instability, as old roles are left behind and new role identities are not yet fully developed (Arrowsmith et al., 2016). Transitions are unique experiences to individuals, but all nurses desire successful or healthy transitions, where they are able to master certain behaviors, sentiments, or cues associated with their new roles (Meleis, 2018). How nurses navigate transitions is a perplexing phenomenon. Little is known about what nurses in transition actually experience, what they feel, how they think, or how they act. A better understanding of the transition experience will help educators and other organizational leaders to support nurses at all levels of their professional development.
Senior nurse leaders possess key roles in organizations, facilitating work place culture, positive patient outcomes, and staff retention and engagement (Giordano-Mulligan & Eckardt, 2019) many times in the midst of highly dynamic and rapidly changing environments. Senior nurse leaders must acquire a core set of skills and competencies in order to meet the demands of the role. The AONL (2015) advocates that senior nurse leaders possess competencies in five domains: communication and relationship management, knowledge of the healthcare environment, leadership, professionalism, and business skills and principles. Novice senior nurse leaders may possess depth in clinical skill or even managerial leadership experience. They may possess a specialized body of knowledge related to graduate education or nurse executive certification, yet they too experience change and instability during times of transition while learning to lead at new organizational levels. Many workplaces do not have models or structures in place to support the learning needs of novice senior nurse leaders (Beal & Riley, 2019; Miles & Scott, 2019; Miltner et al., 2015; Ramseur et al., 2018; Siren & Gehrs, 2018; West et al., 2016), but the competencies developed within the first 90 days of moving into new leadership roles are critical to effective leadership development (Bellack & Dickow, 2019). Leader preparation can be inconsistent and ineffective, tasking individual organizations to develop and formalize nursing leadership preparation in order to grow successful leaders.
Organizations must build structured onboarding and orientation plans or roadmaps to help novice senior nurse leaders through their transitions, and professional development educators are instrumental in spearheading these efforts. The AONL competencies must be customized to fit the culture, services, and practices of the workplace environment (Waxman et al., 2017), but they must also be tailored to meet the situation-specific needs of each novice senior nurse leader.
METHODS
A qualitative interpretive phenomenological study was conducted to understand the professional development needs of nine novice senior nurse leaders from one healthcare organization. The senior nurse leaders were purposively selected and interviewed because of the rich information they were able to provide about their role transitions. The interview process concluded with the ninth participant since data saturation was reached.
The study participants were from a growing academic health system with active succession planning, possessing at least 6 months of experience, but less than 24 months of experience in their current senior nurse leader roles to be considered a novice. Each of the nine participants signed an informed consent, provided basic demographic information (see Table 1), and agreed to have face-to-face interviews that were audio-recorded. The study commenced only after all required human subjects permissions were obtained. Each audio recording was transcribed by a transcription service, and the verbatim transcripts were validated by participants and used for data analysis and interpretation.
Data were collected using the hermeneutic interview, where the primary focus of the interview was the intense dialogue between the researcher and the participants. The active role of the researcher, the openness of the dialogue, and the sharing of beliefs among the researcher and the participants created a process of shared inquiry, where assumptions and biases could be tested, or thoughts could be clarified or expounded upon (Dinkins, 2005). This type of dialogue was critical in understanding each participant's experience and what it meant to them.
FINDINGS/DISCUSSION
The descriptions and meanings of participants' experiences were analyzed through a comprehensive data analysis plan. Crist and Tanner (2003) provided a step-by-step process of interpretation and analysis that included an early focus on lines of inquiry; identification of central concerns, exemplars, and paradigm cases; observation of shared meanings; formation of final interpretations; and dissemination of those interpretations. Through this iterative process of data analysis, the study findings emerged as themes (see Table 2) based on the transitions theory framework (Meleis et al., 2000).
Theme 1: Lacking Clear Role Transition Expectations
The lack of clear role expectations was a central concern that emerged very early in data collection. Each of the nine participants shared that they had not been given clear expectations about one or more components of their role. One participant's experience is highlighted as a paradigm case:
I think every week somebody would say, "What exactly is your role? What are you doing?" I was always left to say, "Well, I'm supporting the director." Then[horizontal ellipsis]the whole time I felt kind of lost[horizontal ellipsis]I could not do an elevator speech to my role[horizontal ellipsis]it was hard figuring that out. It kept reinforcing this thought[horizontal ellipsis]"I do not know, and, stop asking me. I'll let you know when I figure it out." Nobody knew what it was I was supposed to be doing[horizontal ellipsis]. It was a little scary.
The paradigm case illustrates important concerns that all participants shared. They could not clearly articulate the expectations of their roles. Feelings of frustration, intimidation, discomfort, uncertainty, defeat, and even grief were shared by participants, which were contrasted with moments of enjoyment or enlightenment. Five of the nine participants experienced a role dichotomy as they managed responsibilities of their old roles as manager, educator, or coordinator, while taking on responsibilities of their new roles. This division of responsibilities resulted in participants "feeling very pulled" as they vacillated between moments of confidence versus doubt and success versus failure. Participants wore multiple hats and experienced a host of emotions, thoughts, and feelings that changed with each new situation they encountered in their respective roles.
Theme 2: Shifting the Continuum of Competence
Similarly, senior nurse leaders experienced shifts in their level of competence. Competence at the senior nurse leader level was a fluid concept, which many participants verbalized as a comfort or confidence level in accomplishing certain tasks. For instance, making quick and accurate decisions, possessing situational knowledge, delegating effectively, embracing change, and knowing the business and the stakeholders were just a few of the responsibilities or tasks that they had hoped to learn and ultimately master. Participants in all phases of transition (see Table 1) voiced insecurities related to their level of competence at any given point in time. One participant is presented as a paradigm case:
I think in some areas, I'm still a novice. In other areas, I'm kind of in between. There's a lot of days that I leave here thinking, "I think I might have figured this out." I'm able to answer a lot of questions, and I know what it is I need to get done this week. I'm feeling comfortable and confident that I'm not going to completely fail. Then there's mornings that I walk in thinking, "I have no idea why people are trusting me to do this job"[horizontal ellipsis]I really float back and forth between "Do I really have what is needed to know what I'm doing?" [and] "Am I really making the right decisions?"
The floating back and forth of how the participants described their level of competence is consistent with the development of their new identity as senior nurse leaders and the level of role mastery they had hoped to achieve. Both of these concepts, role identity and role mastery, are intended outcomes of a healthy transition. Participants described themselves as still being very much in transition and that, with time and exposure, they had hoped to reach a greater level of comfort; however, some were unsure if they would ever reach a point of mastery. Similarly, the concept of role identity was difficult for some to articulate, because they were not yet sure of who they would become as a senior nurse leader, but many described their identity as being consistent with their style of leadership.
Theme 3: Seeking a Safe Place
As novice senior nurse leaders aspired to learn their roles and acquire their new identities, participants sought to find a safe place amidst the somewhat chaotic environments they were poised to lead in. The most important tenet of the safe place was relationship building. All nine participants spoke of the important relationships they had formed, either within their network of peers or with a close mentor. The importance of such relationships is exemplified in the following case of how mentorship matters:
We worked together for a few years. I asked formally for her to be my mentor, after a year or two of working together, and she did[horizontal ellipsis]. Our paths have gone apart[horizontal ellipsis]we sort of went our separate ways a little bit but have really kept that relationship[horizontal ellipsis]I go talk to her about things professionally[horizontal ellipsis]what my next steps are. What I think I want my future to look like[horizontal ellipsis]I call my mentor for larger issues, where I'm having trouble[horizontal ellipsis]I get validation from probably primarily my mentor[horizontal ellipsis]. We have dinner once a month or so. I just tell her that she's filling up my balloon, and hopefully it does not deflate before the next time I see her.
Participants felt empowered from the validation and support they received from their safe place despite any fluctuations in confidence or changes within the environment itself, and this was integral to their development as senior nurse leaders.
Theme 4: A Wonderment of Learning
The learning environment that each participant described was a culmination of the prior experiences they brought to the role, challenges within the work environment, and the onboarding and orientation experience they shared. The blending of these experiences created a sense of wonderment for each participant. For some, it was wonderment in the sense of surprise (not knowing, until tested, what they did not know), or for others, it was a state of bewilderment, related to not having a structured or planned orientation, and for yet others, there was amazement over what they were able to accomplish with limited resources:
* Participant 1 described learning as "trial by fire" and being a "fish out of water."
* Participant 2 learned by "see one, do one, teach one."
* Participant 3 did not believe there was a transition.
* Participant 4 learned by "trial and error."
* Participant 5 said that "basic needs" were not addressed during onboarding.
* Participant 6 said you have to "learn as you go."
* Participant 7 said the role was developed without "planning" or "structure."
* Participant 8 said "you ask a lot of questions" to learn the role.
* Participant 9 described learning as "drinking from the fire hose."
The participants in this study collectively possessed a wealth of knowledge, experience, and education to prepare them for the senior nurse leader role. Five participants had over 20 years of nursing experience, whereas four had 10-19 years of nursing experience. All fulfilled prior managerial roles, with five having over 6 years of experience in their respective roles and four possessing 2-5 years of managerial experience. One participant held a bachelor's degree; seven held master's degrees, primarily in nursing or business administration; and one held a doctor of nursing practice degree. Despite the vast array of preparedness, each participant described unique challenges (a different kind of chaos) during their transition but felt that graduate education was an integral component of their development as senior nurse leaders.
Dinkins (2005) believed, based on a Socratic-hermeneutic approach, that the "ideal" experience provided as much insight as the actual (real) experience, but that the ideal and the actual were not necessarily the same. As a result of the process of shared inquiry, participants provided valuable insight about what they believed the ideal transition experience should be. The participants' collective interpretations of the ideal experience are noted below:
A perfect new leader onboarding program would include[horizontal ellipsis]
"An intense orientation to the culture of the organization, clear expectations of the role, a more interactive, supportive environment from leaders and peers, a roadmap, and a formalized plan for meeting important stakeholders."
"An orientation that has a defined sequence of steps, a timeline, a list of resources, discussion time allotted for challenging situations, finding common ground, having clear expectations of role, and having resources within organization," to include "mentorship" and "shadowing[horizontal ellipsis]"
One participant summed their experience this way: "You have to know the culture to be successful in it," and having a "roadmap" would have been extremely advantageous.
DISCUSSION
Describing and interpreting the key findings of this study is a prerequisite to understanding the role development of the novice senior nurse leader in transition. Transition is change, and how individuals respond to change becomes a key component in understanding their transitions (Meleis et al., 2000). The participants of this study commonly experienced disruptions and fluctuations in their role transitions, but their experiences were consistent with what is known about situational transitions. However, as individuals shared their stories, they developed a heightened sense of awareness, learning more about how their transition made them feel. They identified barriers within their respective environments, such as critical events, that contributed to the fluidity of the learning environment, but they also verbalized ways to connect with others, become more situated in their roles, and develop confidence, as they relied on their safe place. Role mastery and role identity were outcomes that each one aspired to attain, and with the development and support of an orientation program for novice senior nurse leaders, these outcomes may be realized in a more effective and timely manner.
LIMITATIONS AND IMPLICATIONS
Senior nurse leader development is needed to secure the future of nursing as a way of retaining current senior nurse leaders, recruiting new talent, and replacing a retiring workforce. The manner in which senior nurse leaders grow, develop, and lead with mastery is crucial to the development of strong nursing teams, scholarly nursing practice, and innovative vision, which shapes the culture of the organization. A roadmap (customized plan) for the onboarding of novice senior nurse leaders within the current organization is presented in Table 3. The roadmap proposes a 90-day plan for onboarding a new senior nurse leader based on the AONL (2015) nurse executive competencies and based on what participants believed the ideal learning experience should include. The learning activities built within each competency domain (AONL, 2015) have been customized to meet the learning needs of novice senior nurse leaders based upon the findings of this qualitative study.
The findings of this study yield some limitations worth noting. Response bias was minimized through the use of rapport building with participants, indirect questioning techniques, and self-disclosure-techniques that have been suggested by Bergen and Labonte (2019). The sample size was small, and as such, the findings are not generalizable to the entire population of senior nurse leaders. The data obtained, based on subjective experiences, may not be significant or meaningful for all settings or to all readers, as these experiences may differ from those of novice senior nurse leaders from other healthcare organizations. However, the manner in which the information has been interpreted and disseminated to readers in the form of exemplars and paradigm cases that illustrate aspects of the themes may be transferable to other organizations. Senior nurse leaders may be able to identify these themes within the context of their own organizations. Professional development practitioners may be able to work with their own organizational leadership to develop a roadmap specific to the culture of their organization, using some of the tools and strategies identified in this study. Future qualitative research is warranted to learn about role transitions for novice senior nurse leaders in other settings, backgrounds, and contexts.
More research will contribute to the development of a conceptual definition of novice senior nurse learning. This conceptual definition should include the minimum requirements necessary for novice senior nurse leader development and may lead to the development of new policies and procedures around nurse executive certification and graduate education requirements. Novice senior nurse leaders would benefit from a structured and planned onboarding program, as presented in Table 3, one that would facilitate nurse leader transitions with ease.
References