Leadership Immersion and Aspiring Leader Programs Designed to Improve Nurses' Well-Being and Competence: Integral Features During the COVID-19 Pandemic.

Nurse leaders play integral roles in the healthcare system as they focus on patient quality of care and safety at a high level and lead teams of frontline staff. Nurse leadership turnover during COVID-19 poses challenges not only for continuity of patient care but also for organizations who may fail to meet their specific goals. When a nurse leader role is not filled, gaps in care delivery occur. Our Institution developed the Leadership Immersion and Aspiring Leader Programs prior to COVID-19 that provide application to theory opportunities to new nursing leaders who are prepared to fill leadership positions. 2022 by Elsevier Inc.

Nurse leaders experience turnover and burnout that negatively impact patient care and organizational goals

The COVID-19 pandemic has compelled nurse leaders to adapt to the challenging environment

The Leadership Immersion and Aspiring Leader Programs at our institution educate new nursing leaders who are equipped to fill leadership positions

A nurse leader performs myriad vital duties in a health care system such as acting as the strategic lead for patient care initiatives; directing a group of caregivers; influencing others through effective communication and interpersonal skills; implementing evidence-based practices and rolling them out to others on the health care team; and mentoring other caregivers. Nurse leaders possess unique attributes that allow them to perform effectively in their positions, including critical thinking skills; ability to envision a positive future and lead in arduous times; and unceasing self-improvement and a higher level of excellence.

The intensification of the COVID-19 pandemic since the first 4 cases of “pneumonia of unknown etiology” in Wuhan, China, on December 29, 2019, , has augmented the turnover rate of nurse leaders and nurses in general. Nurse turnover refers to a nurse leaving an organization for any reason such as retirement, changing professions, or desiring to work in a different organization. In the 2021 NSI National Health Care Retention & RN Staffing Report comprised of 226 facilities from 37 U.S. states, the turnover rate for staff registered nurses (RNs) rose to an all-time high of 18.7%, representing the largest annual increase in 7 years and a 2.8% increase from 2019.5, 6, 7 Regional and specialty differences were apparent, with higher nurse turnover in step-down (24.4%), behavioral health (22.7%), and emergency (20%). These specialties were most impacted by the frontline care of patients during the COVID-19 pandemic, leading to burnout. The primary reasons for nurse turnover were relocation and career advancement (tied for 1st) followed by retirement. At least 50% of RNs are >50 years old, with 1 million RNs attaining retirement age within the next 10-15 years.

Nurse turnover negatively impacts patient care, morale among peers, and effective communication. Furthermore, the costs associated with replacing a nurse represent a financial burden on the health care system. It has been reported that the average cost of nurse turnover to the organization ranges between $37,770 and $58,400 per nurse, reflecting a loss of $5.2-$8.1 million annually. Numerous factors may account for this elevated turnover, including nurses feeling underappreciated, insufficient staffing, mentally and physically demanding workload, family needs, lack of nurse leadership engagement, and inadequate compensation. , , These findings are corroborated by the 2021 Future of Work in Nursing Survey of 400 frontline nurses who were asked about working during COVID-19. Over half of the respondents stated that they were seeking another career path, a nondirect patient care role, or planning to retire or leave the workforce entirely, while only 17% were more likely to stay in the nursing profession due to their experiences during COVID-19. Additionally, higher turnover rates have been observed at facilities that were for-profit, chain-owned, or predominantly Medicaid funded.

In conjunction with the high nurse turnover is the alarming nursing shortage. Nurses are in short supply due to a variety of factors, including the aging population, lower numbers of nursing graduates attributed to fewer faculty members, burnout, retirement, and violence/aggression in the workplace.11, 12, 13, 14 Negative repercussions of the nursing shortage may consist of patient errors and higher patient morbidity and mortality. Burnout does not only affect frontline and direct care nursing staff, but nurse leaders are also afflicted by it. Nurse leaders work in the same at-risk environments while simultaneously experiencing disciplinary, organization, and operation stress.

To address both the soaring nurse turnover rates and the nursing shortage, our institution developed two unique leadership courses. Our health care system has 4 adult hospitals and 1 children’s hospital, with a total of 1837 beds. The Aspiring Leader Program was geared toward nurses who have had no formal leadership exposure/experience, while the Leadership Immersion Program was aimed at training nurses to develop skills needed for a managerial role. The goals of these programs were to develop a network at our institution to broaden knowledge and reach and to learn the tasks associated with daily work.

Leadership Immersion and Aspiring Leader Programs

In March 2019 and November 2020, our institution designed two nursing leader programs to offer practical experience and insight. In March 2019, the Leadership Immersion Program was developed to ensure continuity and smooth transitions when filling leadership positions to guarantee safe, quality patient care and to promote the well-being of the team. The goal was to create a course for those wishing to pursue a career path in nursing leadership. Our institution has short-term openings to cover for leaves and vacancies, and we wanted to have a select group of people whom we could prepare in advance for interim leadership roles.

Started in November 2020, the Aspiring Leader Program was aimed at frontline nurses who may be interested in the leadership path and wanted to learn more about leadership. The goal was to grow a bench of relief assistant nurse managers (ANMs) or frontline nurses who can be promoted to the role of ANM. This course provided an open nonthreatening environment for frontline nurses to better understand the work of a frontline leader to align with our institutional goals.

Admission to the Leadership Immersion and Aspiring Leader Courses

Eligibility for the 12-month Leadership Immersion Program required a current position in good standing as an ANM or house supervisor with a minimum of a BSN degree. Applicants should have a minimum experience of at least 6 months in the role prior to entry in the course. Eligibility for the 8-month Aspiring Leader Program required a current position in good standing as an RN, although a BSN was desired. Applicants should have a minimum experience of at least 1 year in the role prior to entry in the program. Both programs required participants to commit to a flexible schedule for training and mentoring.

The nurse manager reviewed all applications to ensure that the applicants were a good fit for the programs and not on disciplinary action. The nurse directors then performed a final blinded selection. All applicants were internal in our institution. There was no cost to either the participant or our institution as both courses were mentoring experience with mentors at our institution.

Course Material

Both courses encompassed the dimensions of leadership as developed by the Center for Nursing Leadership and suggested by the American Organization of Nurse Leaders. The courses were structured as a combination of mentor/mentee relationships and hands-on education. For example, when learning how to interview candidates, the participants in the courses would participate with the mentor and then lead the interview. They also watched how to post a position and subsequently posted a position themselves. Both courses involved reading and discussing the following 2 leadership books ([1] Eat that Cookie!: Make Workplace Positivity Pay Off… For Individuals, Teams, and Organizations and [2] Hey Cupcake! We are All Leaders, both written by Liz Jazwiec, RN). ,

The curriculum of the Leadership Immersion Course is shown in Table 1 . The course was eligible for leaders from all specialties. We encouraged interim opportunities outside a person’s area of specialty to enhance confidence, learning, and networking. It convened monthly for 2 hours of hands-on and personal interactions with content experts across each domain. Table 2 depicts the curriculum of the Aspiring Leader Course. It met monthly for 60-90 minutes.

Table 1

Curriculum for the Leadership Immersion Program at Our Institution (12 Months)

Month	Topic	Details
1	Establishing the relationship	Setting expectations for meeting frequency
		Defining preference for information delivery
		Understanding importance of deadline adherence and reasonable timelines
		Clarification of work style and habits
		Jointly identify mutual expectations in areas like confidentiality, when and where to meet
2	Human resource management	Familiarity with the hiring process and behavioral-based interviewing
		Apply recruitment techniques, appropriate staff selection skills, and retainment strategies
		Understanding employee engagement strategies and interpretation of results
		Learning techniques for coaching/staff feedback
		Identifying/taking action with employees in urgent situations
		Awareness of staff accountability strategies and risk avoidance techniques
3	Financial management	Understanding productivity standards
		Monitor and analyze a budget to identify and explain waste
		Create action plans to reduce future financial waste
		Conduct an ongoing evaluation of productivity
		Understand process of capital budgeting (justification, cost/benefit analysis, process for requesting)
		Understand the relationship between value-based purchasing and quality outcomes on reimbursement
		Recognize the importance of maximized care efficiency and throughput
4	Quality/safety/risk outcomes	Identify key quality outcomes
		Define data collection and reporting methodologies
		Understand sentinel events and reporting obligations
		Analyze survey and regulatory readiness requirements
		Assess patient satisfaction and develop strategies for improvement
5	Human resource leadership skills	Identify methods to assess and promote staff satisfaction
		Facilitate leadership and growth among staff
		Learning techniques for coaching/staff feedback
		Conduct staff evaluations and assist staff with goal setting
		Intentional rounding/delivering real time feedback to staff
6	Process improvement and change management	Identify key performance indicators
		Learn steps of process improvement at our institution
7	Relationship management and influencing behaviors	Learn effective steps for conflict management
		Understand steps required to act as a change agent
		Apply leadership theory to practice
8	Diversity	Understand cultural competency
		Identify and develop ideas of social justice and generational diversity
		Understand components of patient experience and how to influence outcomes
9	Personal and professional accountability	a
10	Career planning	a
11	Nurturing the intellectual and emotional self	a
12	Reflection and goal evaluation	a

During the final 4 months of the program, participants explore opportunities for personal and professional growth including membership in professional organizations, educational advancement, and placement onto system leadership teams. Participants also lead mentor interactions and display leadership behavior.

Table 2

Curriculum for the Aspiring Leader Program at Our Institution (8 Months)

Month	Topic	Details
1	Establishing the relationship	Setting expectations for meeting frequency
		Defining preference for information delivery
		Understanding importance of deadline adherence and reasonable timelines
		Clarification of work style and habits
		Jointly identify mutual expectations in areas like confidentiality, when and where to meet
2	Process improvement	Identify key performance indicators
		Learn steps of process improvement at our institution
		Identify one clinical problem you would like to solve on your unit
3	Scheduling/staffing/assignments	Establish competency in accurately utilizing the workload tool for shift assignments
		Learn nuances of challenging staffing situations
		Troubleshooting patient assignments
		Practice making equitable assignments
		Review staffing guidelines and staffing escalation process
4	Operations	Review operations initiatives and gain understanding of capacity management
		Learn about the focus of throughput and the impact it has on capacity management
		Learn about bed ahead
		Review the escalation process for admissions
		Discuss discharge center process and utilization
5	Quality/safety	Identify key quality outcomes
		Define data collection and reporting methodologies
		Understand sentinel events and reporting obligations
		Analyze survey and regulatory readiness requirements
		Assess patient satisfaction and develop strategies for improvement
6	Crucial/critical conversations	Addressing critical safety/quality/behavior situations in real time
		Key words to use/key words to avoid
		Leveraging relationships while maintaining boundaries
		Defusing conflict among staff members
7	Service/diversity/patient experience	Understand cultural competency
		Identify and develop ideas of social justice and generational diversity
		Understand components of patient experience and how to influence outcomes
8	Personal and professional accountability	Develop personal and professional goals to guide your practice
		Identify ethical behavior standards in the nursing role
		Create an individual development plan

Completion of the Leadership Immersion and Aspiring Leader Programs

Of the 10 individuals who completed the first 3 cohorts of the Leadership Immersion Program, 5 (50%) were promoted to nurse managers (NMs) (Figure 1 ). Of the 5 people in the first 3 cohorts who have not become NMs, 3 (60%) have served in interim NM roles. In cohort 4, 3 (75%) have assumed interim NM positions. Four (33%) of the 12 individuals who have completed the Aspiring Leader Program have been promoted, specifically 3 ANMs and 1 NM (Figure 2 ). All participants have remained at our institution. Of the 26 individuals whom we are following up for these 2 programs, 25 (96%) are still at our institution. Only one individual has completed the program and left. By investing in the growth of the participants in these courses, improved retention has resulted.

Figure 1

Career Advancement for Participants in the Leadership Immersion Course at Our Institution

Figure 2

Career Advancement for Participants in the Aspiring Leader Course at Our Institution

Discussion

The Bureau of Labor Statistics projects that RNs will be among the top occupations for job growth between 2016 and 2026 with 3.4 million RNs by 2026, reflecting a 15% increase. Despite this nursing demand, younger nurses are leaving the nursing profession to start families, nurses in the baby boomer generation are caring for their parents, more nurses are retiring, and others are seeking work in non–clinical care positions. Juggling a life-work balance is a challenge for nurses of all ages.

In the survey by Lavoie-Tremblay et al of 1705 frontline nurses and licensed practical nurses, 782 cared for patients with COVID-19. The latter nurses reported high chronic fatigue, poor quality of care, lower work satisfaction, and a higher intention to leave their organization. These authors concluded that nurse administrators needed to support nurses during the pandemic with respect to education, training, and policy development which would augment quality of care and retention. Al Zamel et al reported that a lack of nurse leadership is a crucial factor in nurses’ intention to leaving their position. The leadership style of NMs also impacts turnover rate. , The questionnaire of 250 nurses developed by Suliman et al investigated NMs’ leadership styles: transactional (leaders give contingent rewards); transformational (leaders inspire and motivate); and passive-avoidant (leaders are absent). The respondents reported that most of their NMs exhibited a transactional leadership style, although the transformational leadership style was determined to reduce predicted nurse turnover. These authors recommended that NMs should enroll in training programs on effective leadership to enhance nurses’ job satisfaction and reduce turnover.

Several strategies have been proposed to decrease nurse turnover, with strong nursing leadership as a pivotal component (Table 3 ). , , , , , Nurse leaders should be more engaged, offer support, and regularly communicate with nursing team members. Additionally, nurse leaders should request feedback and suggestions to improve internal processes at the organization. Other key elements to reduce nurse turnover include building retention capacity, managing vacancy rates, strengthening recruitment, and limiting labor expenditures.

Table 3

Strategies to Reduce Nurse Turnover

Flexible work schedule

Onboarding and training

Meaningful recognition and communication

Career development and continuing education

Mental health resources (for nurses struggling with mental health concerns and exhaustion)

Breaks to recharge

Educate nurse leaders to inspire and motivate

Incentive payments

Boost morale and engagement

Virtual care technology (telemedicine to allow remote work)

Reskill in certain nursing areas

Nurse leaders and educators have faced numerous challenges instigated by the COVID-19 pandemic, with the need for increased flexibility and innovation. By building a strong bench with our two leadership courses, we were able to educate nurses who either had no leadership experience through the Aspiring Leader Course or who wanted to assume more managerial roles through the Leadership Immersion Course. The models for these courses may be applied to other hospital settings in a metropolitan community.

Conclusion

Prepandemic concerns that spurred the rise in the nurse turnover rate and global nursing shortage were exacerbated during the COVID-19 pandemic. Implementing several alterations in the nursing workplace may mitigate a nurse’s desire to leave, such as increased compensation, flexible scheduling, virtual or remote options, additional mental health support, and continued ability to float across units. Our two leadership courses have proven invaluable to face the challenges associated with COVID-19. Nurses have acquired the knowledge, skills, practical experiences, and insight to step into leadership roles at our institution.