In the classic editorial, "Career Development in Nursing," Dr Angela Barron McBride1 states that characteristics of a nursing career include lifelong work, a strong commitment to nursing, a desire to benefit the public, expectations of personal growth, responsibility, personal values that overlap with professional values, and the drive to nurture future nurses. Each successful nurse possesses these characteristics, perhaps in differing ratios. Success in a nursing career can be measured with these characteristics. Using this measurement, each nurse's career can be successful. A successful nurse is not necessarily the chief nurse executive, the nurse manager, or the charge nurse. The successful nurse is the nurse who is comfortable with the direction of his or her career and the place this career has in his or her life.
Mentoring and leadership in nursing are also lifelong processes. Many perinatal nurses are satisfied with the care they provide to women and families and the connections they have developed over the course of their nursing experiences. But as the Baby Boom ages, "Boomer" nurses are retiring and younger nurses will have to step up and enter into the leadership and management positions that will be vacated.
Leadership in nursing can take many forms. The RN at the bedside is a leader of the team caring for the woman in labor. This team may include certified nursing assistants, obstetrical technicians, the front-desk staff, students, resident physicians, and the woman's family. The charge nurse is a leader of the team on the unit at any given time and may be responsible for coordination that includes outside scheduling, delegation of tasks, student assignments, preceptor and mentoring assignments, learning activities such as drills, and patient care, among others. The nurse manager leads the unit and is responsible internally to the unit and externally to hospital leadership and must be proficient in problem solving, budgets, quality maintenance, staff education and development, among many other balls he or she juggles. The obstetrical team also includes obstetricians, anesthesia personnel, clinical nurse specialists, nurse-midwives, housekeeping staff, and dietary staff, at the least.
This may seem overwhelming, but this scenario takes place every day in every unit. The challenge to all perinatal nurses is to continue to grow as nurses and as leaders. The challenge to leadership is to identify those nurses who are ready to move into a different level of leadership and to foster this desire. This identification and promotion of nurses as leaders often begin with nurse-to-nurse mentoring. Mentoring is a broader concept than precepting. Mentoring is a longer-term relationship that hopefully becomes an established relationship that includes precepting, role modeling, and coaching, as well as dialogue and collaboration.2 The goal of mentoring is not necessarily to produce a nurse manager but to produce an engaged nurse who can provide expert care for laboring and birthing women and who can also recognize and understand the environment he or she is working within. The engaged nurse takes responsibility for patient care outcomes and can design, implement, and evaluate an individualized plan of care for each woman he or she cares for.3
Galuska4 describes the challenge to nurses as 2-fold, (1) to ensure that nurses in all areas of nursing, including direct patient care and management, are skilled, knowledgeable, and prepared for the level of leadership they aspire to achieve and (2) that nursing as a profession is able to develop these skills and knowledge at every level of leadership.4 Nurses in every role demonstrate leadership skills, including oversight for quality, responsibility for systems improvement, collaborative practice, communication, teamwork, conflict resolution, advocacy for patients and for nursing, and influence on policy, both public and institutional.4 In a meta-synthesis of quality studies of leadership development, Galuska4 identified 3 themes that affect leadership growth or failure to thrive. These themes are opportunity structure, relationship factors, and the organization's culture for growth.4 These 3 domains not only can provide opportunities for growth but can also create barriers to the development of leadership.
How can current nursing leadership and management facilitate leadership development among those nurses interested in exploring and taking on this role? This question has meaning beyond the individual nurse. Career advancement programs and opportunities have positive effects on employee motivation, job satisfaction, staff retention, staff productivity, and quality of work.5 Nurses who perceive no opportunities for growth in their environment do not perform at higher levels because they see no need to do this. The nurse who is satisfied and fulfilled in the staff position still needs professional challenges and interactions both to remain current in practice and to provide the best possible patient care. The perinatal unit that does not nurture engaged nurses will have problems with adapting to changing practices and accommodating new paradigms of care.
The next level of leadership development is the transition from staff nurse to frontline leader or charge nurse. Evans and Reiser6 point out that changes in professional roles are, in reality, situational transitions. This change requires the nurse to restructure his or her learned responses to expanded responsibilities, goals, self-identity, and professional identity.6 Nurses who aspire to leadership roles may be driven by the needs for achievement and recognition, which can be difficult for nurses to admit to themselves. Often nurses who are considered for leadership mentoring may experience the identities of both the new role and the former role. This can be confusing for the nurse and for the former colleagues he or she may be in a position of authority over. Nurse leaders especially may slip between roles as leadership and as bedside nurse. Often his or her competence as a bedside nurse has led to the consideration for increased responsibility and leadership on the unit.
Nurse managers who plan to mentor former staff nurses for positions of increased leadership need to recognize that leaders also require goals, process, and development. New leaders cannot be expected to excel immediately in a new role, and these new leaders will need development strategies and mentoring to design these strategies and the process to fulfill the expectations of the position. Barriers to a successful transition to leadership may include unclear expectations of the new leader, failure to provide a focused process for progression into the new role, and inadequate support systems. A mentor can build on the positive experiences and skills the bedside nurse has and teach the nurse how to relate these skills to the management role. For example, each expert bedside perinatal nurse can build collaborative relationships with families and with midwives and physicians, can multitask, and can understand the "big picture" and the small details. All of these skills can translate into unit management. As staff nurses advance into a leadership role, they may find themselves in a mentoring role, which may be an unfamiliar responsibility for a new leader. It is important to consider that every leader is also a learner.
The next step in perinatal nurse leadership is the role of the nurse manager. Ward7 noted that a majority of nurse managers followed an inadvertent path to success. Most described a leadership trajectory that began with an intense desire to improve a specific area of nursing care they were involved with on the unit.7 The advantage of promoting passionate, focused nurses into leadership is that they are passionate, knowledgeable, and focused. The disadvantage of this process is that leadership competences can be a specific skill set that passionate bedside perinatal nurses may not possess. Not only successful nurse managers must be committed to quality care for women and families but they must also own additional parameters for unit management, including financial performance, patient satisfaction, clinical quality of both nursing and medicine, human resources, and program development, among others. Laborde and Lee8 point out that productivity, morale, and retention suffer when nurses are promoted into leadership positions without the management skills, knowledge, and education. For example, a postpartum nurse may be enthusiastic about the need for a lactation consultant to see all patients. The unit nurse manager needs to consider costs for personnel, guidelines for consultation, possible billing opportunities, possibilities for training existing personnel or adding personnel, physician commentaries, patient and family acceptance, and other concerns and questions. The committed bedside nurse may view the nurse manager as a barrier to optimal patient care. The effective nurse manager will have the communication skills to relay the issues to the staff while working toward better bedside care for families.
In this circumstance, just as in the transition from a bedside nurse to a charge nurse, a mentor can be invaluable. A mentor can suggest paths to success, can relate his or her own experiences as a guide, and can be a sounding board for the new nurse manager. Mentoring has been described as a relational learning experience2 and reinforces the context of lifelong learning. The best mentoring relationships encourage innovation within the perinatal unit while building for success through fiscal management and quality maintenance.
Promotion from within the unit can be stressful if the unit culture is unrewarding and envious. The relationship with staff who were former colleagues may cause role stress if the new manager is unable to define his or her new role appropriately. The new manager may feel isolated from former sources of support and camaraderie. Conversely, hiring a manager from outside the unit may be viewed by staff as unsupportive and judgmental. This new manager may not understand the culture of the unit and may also lack a support system before he or she has time to build a new network. In both situations, mentoring from upper management is essential for the new manager's success. New managers benefit from mentoring not just for day-to-day task completion but also for guidance regarding risk taking, knowing when to speak up, understanding the challenges and rewards of change, and navigating the political landscape of the organization.4 The Table 1 lists the elements found in nursing leader from an analysis of literature by Evans and Reiser.6
Finally, as talented perinatal nurse managers move into roles with increased responsibilities, the perinatal team can support him or her within the organization. All areas of nursing feel unique and all are unique. However, leadership by nurses with perinatal experience furthers the perinatal mission within a hospital and enables the nursing perspective to enhance the medical perspective. Nurses are often on the forefront of progressive perinatal and prenatal practices, including water birth, CenteringPregnancy, and increased breast-feeding support. Nurses with perinatal backgrounds understand the unique staffing needs of a perinatal unit and the emphasis on the mother-infant dyad as the patient. By mentoring and growing the leadership capabilities of bedside perinatal nurses, these perspectives can reach into the upper levels of nursing and hospital management and from there into leadership roles in policy-making positions.
The author would like to thank Cathy Collins-Fulea, CNM, and Diane Angelini, CNM, for mentoring throughout her career.
-Jackie Tillett, ND, CNM, FACNM
Clinical Professor
Department of Obstetrics and Gynecology
University of Wisconsin School of Medicine and Public Health
Madison, Wisconsin
References