Associate Professor
O’Hara Hall #118, Scranton, PA 18510-4595
717-941-7755, (FAX) 717-941-4201
The need for nurses to be educated in management is examined in relation to the effects of management education in other fields such as business. Four methods of educating nurse managers in the USA are described: Inservice education, post-basic certificate education, management education provided within a four-year baccalaureate program of study such as nursing or health administration, and a graduate level program of University study. Factors that contribute to developing quality nurse managers are noted, with the resultant impact on staff nurses and patient care. The paper then addresses concerns and cost related to educating nurses for management positions. Finally, the outcomes of providing nurses with a formal education in management are suggested based on the literature.
Key words: Nursing education, Management, OutcomesThe author would like to thank her Undergraduate Research Assistants in Department of Nursing,
University of Scranton, Pennsylvania, USA, for their assistance in the preparation of this paper.
Partially supported by NIH/NINR F32NR07076-01A1.
Health care is becoming increasingly complex throughout the world as all people continue to need health care in a time of ever diminishing resources that must be skillfully managed. Many American International Health Alliance (AIHA) partnerships are recognizing the importance of nurses and physicians working together to reform their health care systems. The executive director of AIHA, James P. Smith, has written that “ideas, achievements, and strengths of individual nurse leaders and physicians in CEE/NIS have a significant effect on the health care reform process”.1 Educating nurses in management skills has been a vehicle for strengthening the role nurses are prepared to play in health care reform.
Nurses have unceasingly been part of the health care provider team but because of the different levels of education provided for “nursing”, there has been no consistency in the nursing role. As in the business field, a team of health care providers needs managing but team members may not intuitively be able to manage. The world of business has traditionally provided training in management to individuals identified as having leadership potential; nurses have not traditionally been considered in that world. However, collaborative international nursing research has demonstrated that progressive education with a participative approach to decision-making and management skills such as conflict resolution can succeed in varied environments, including the world of nursing, when a culturally sensitive method is used.2 Methods such as the “assessment center” 3 reported by large business employers can be adapted to effectively evaluate and develop nurse managers. 4 Thus capable nurses at many levels can be motivated and provided with opportunities to develop the knowledge base and skills needed to succeed as managers.
Preparation of nurse managers in the United States of America (USA) has included four educational models: Inservice education, post-basic certificate education, management education provided within a four-year baccalaureate program of study such as nursing or health administration, and a graduate level program of University study. As in the USA, nursing management in the UK also involves development of individuals because “personal and professional accountability of individual nurses has become an established practice since the introduction of the Code of Professional Conduct in 1984”. 5 Preparation of nurse managers in the United Kingdom (UK) as post-registration education has been delineated in terms of a “mentorship” associated with a long-term apprenticeship, a “preceptorship” which is a shorter relationship, and “clinical supervision” which may include inservice educational programs.6
3.1 Inservice programs
Inservice programs are usually on-the-job education and training sessions of limited duration. Sessions are often less than one day in length and are topically focused. Topics taught conventionally include problem solving, conflict resolution, the decision making process, unit or team management, and quality improvement. A problem-solving method that has been successfully used in inservice programs is exemplified in “Action Learning” when nurse managers discuss an issue they have experienced, review it, develop conclusions, and decide on the next steps to take to resolve the issue. 7 In other sessions, nurses who have budgeting responsibility may attend programs on financial management. Employers are also providing increased opportunities for middle level managers to participate in a traineeship or internship with an upper level manager as preceptor. The in-house training program works best if the preceptor has the proficiency needed to negotiate learning objectives and has interpersonal and teaching skills as well as an ability to help the trainee self-evaluate. 8 An example of a five-month inservice program of management education for Operating Room (OR) nurse managers is described by Binger and Mailhot as thirty-two seminars teaching “progressive disciplinary action, diagnosing and handling conflict, defensible decision making and time management”. 9
3.2 Post-registration programs
Preparation of nurse managers in post-registration courses involves a formalized model of instruction designed to build on previous nursing education obtained in three or two year “diploma” or Junior College programs. The format is similar to inservice programs in the relatively short length (8-16 hours) of the topical units. There is an intensive focus on specific subjects over a delineated period of time. In the USA, the result of this type of program is attainment of a Certificate in Nursing Administration or Health Administration. Time for completion varies, usually requiring one year (approximately 360 hours) in the USA. A similar program in Russia requires 144 hours for certification. 10
3.3 Baccalaureate Programs
Increasingly health care agencies in the USA are mandating that nurses have a minimum of a baccalaureate degree to hold an entry level management position (e.g., Head Nurse) because leadership / management courses are an integral part of most University undergraduate educational programs in the USA that award a Bachelors degree in Nursing or in Health Administration (for post-registration nurses). These formal courses are incorporated within four years of full-time study or may be completed over one to two years of full-time study following a Registered Nurse (RN) education program. A survey of RNs in 1992 by the Division of Nursing in the US Public Health Service found that approximately 30% of all managers had at least a baccalaureate degree in nursing, while an additional 7.8% of middle level managers and 22.9% of upper level managers had educational preparation at the Master and above level. 11
3.4 Graduate management programs
Graduate education in management involves advanced programs of study that result in Master of Science in Nursing (MSN), Master of Nursing Administration (MNA), or Master of Health Administration (MHA) degrees. Nurses usually spend two years in full-time study or four to six years in part-time study to attain these credentials. Large hospital and health care systems in the USA are now searching for nurses prepared at a doctoral level (EdD, PhD, or DNSc) to oversee the complex management demands they face in an era of cost-containment as the bottom line for continued viability.
The educational process is only one, albeit a primary, factor that results in quality nurse managers. Quality nurse managers result from gaining not only knowledge but also becoming empowered. “Empowerment is … an enabling process …arising form a mutual sharing of resources and opportunities which enhances decision making to achieve change.” 12 Nurses such as those who have been educated in management and become empowered have been described as having increased self-esteem, being able to set realistic goals, controlling the change process, and being able to communicate a sense of “hope” for the future to physicians, staff nurses, and patients. 13 Management educated nurses have an impact on their staff and patient care.
4.1 Impact on staff nurses
One strength of educating nursing leaders has been the impact on staff nurses, especially in settings that are undergoing changing organizational structures and downsizing (or the newer term - rightsizing). An axiom of quality improvement training , “People support what they help to create”14, helps explain the success of nurses as managers. Their cooperative , collaborative style of leadership can be effectively used in nursing’s traditionally all-female work groups. 15 Gotoh reported a “marked positive change” in her unit following a nursing management education program; staff nurses desired to stay on the unit resulting in lower turnover rates and appropriate disciplinary actions. 16
In twenty years of literature from the USA and UK, a key to nurse manager effectiveness within health care organizations was empowering the “nurses they supervise to initiate change that will improve patient care. 17 Multiple areas of impact on patient care have been described following education of nurse managers: 1) Patients learn self-care strategies; 2) Continuity of care is supported through acceptance of team roles; 3) Use of expensive medications and therapies can be controlled; 4) Nosocomial infections can be decreased; 5) Patients can be discharged earlier; and 6) Patient satisfaction with hospital care is improved. 18,19,20
5. Concerns about Nursing Management Education
In spite of these positive effects, nursing management education has been
criticized on the grounds that desired organizational outcomes cannot be achieved by
education alone. There is truth in that premise. 21 Acceptance of nurses as
managers will need salary and other rank indicators commensurate with educational
preparation. Nevertheless, the availability of employment presently is stimulating an
interest in management education in Central and Eastern Europe (CEE). However long-term
success in the achievement of managerial goals will be dependent on physician support of
nurse managers for without capable physician/ nurse teams to implement systematic change,
management education alone will not be enough. Finally, the cost of education, although
some programs may be financed by government stipends or other funding sources, remains a
concern because without being able to demonstrate the cost-effectiveness of management
education, the system will flounder. Cost analysis must ask questions such as whether
management education for nurses results in wise use of resources, what are the financial
benefits to the hospital system, and what are the cost-benefits between educating nurses
who know the system versus employing business managers without a health system background.
This issue of whether management education results in fiscal awareness and responsibility
has been examined in the nursing literature for the past decade.
The literature 22 describes how nurses educated in management could minimize losses related to unit functioning in a variety of ways:
• Risk can be managed with less insurance cost
• Cost of materials and supplies can be controlled
• Individual nurses work more efficiently
• Staff to patient ratio can be adjusted to patient acuity
• Support services can be used more effectively at less cost
• Job satisfaction results in less absenteeism
• Staff productivity increases overall
• By being educated to understand the realities of health care management and provided with a chance to develop management skills, nurses have both expanded opportunities and responsibilities that can impact not only the financial arena of health care but provide safer and more satisfactory patient care - the center of the system .
1. Smith JP. A note from the Executive Director. Common Health 1995,3 (3), p. 3.
2. Schmieding NJ, Kokuyama T. The need for and process of collaborative international research: a replication study of Japanese staff nurse perceptions of head nurses’ actions. J Adv Nsg 1995, 21, p. 820-826.
3. Bray D, Grant D. The assessment center in the measurement of potential for business management. Psych Monographs 1966, p. 80.
4. Blaney DR, Hobson CJ, Meade ME, Scodro J. The assessment center: Evaluating managerial potential. Nsg Management 1993, 24 (2), p. 54,56,58.
5. Fowler J. The organization of clinical supervision within the nursing profession: a review of the literature. J. Adv Nsg 1996, 23, p.471-478.
6. UKCC. The report of the post-registration education and practice project (PREPP). ‘London: UKCC for Nsg, Midwifery & Health Visiting, 1990.
7. Neubauer J. The learning network: Leadership development for the next millennium. JONA 1995, 25 (2), p. 23-32.
8. Burrnard P. A supporting act. Nsg Times 1988, 84 (46), p. 27-28.
9. Binger JL, Mailhot CB. Learning how to manage. AORN J 1985, 41, p.1060-61, 1064-68.
10. Bakhtina I, Mikheyeva T. A case study of the St. Petersburg postgraduate nursing school. Common Health 1995, 3 (3), p. 8, 16-17.
11. PHS Division of Nursing. Highest educational preparation of RNs responsible for managing nursing services by managerial level 1992. Washington DC: National Sample Survey of RNs Division of Nsg, Bureau of Health Professions, HRSA, PHS, 1995.
12. Rodwell CM. An analysis of the concept of empowerment. J Adv Nsg 1996, 3, p.305-313.
13. Mason DJ, Backer BA, Georges CA. Towards a feminist model for the political empowerment of nurses. Image 1991, 23 (2), p. 72-77.
14. Cleland CF. The crucible of health care reform in CEE: Managing change/ managing implementation. J Health Admin Ed 1994, 12 (4), p. 485-517.
15. Richardson S, Valentine P, Wood M, Godkin D. Leadership: A nursing perspective. Can J of NR 1995, 26 (4), p. 83-96.
16. Gotoh H. Continuing education changes nursing. Japanese J of Nsg Admin 1992, 2 (1), p. 62-69.
17. Cameron-Buccheri R, Ogier ME. The USA’s nurse managers and UK’s ward sisters: Critical roles for empowerment. J. Clinical Nsg 1994, 3(4), p. 205-11.
18. Ibid
19. Arnold L, Didichenko V. Hillary Rodham Clinton endorses partnership program in Kyyiv. Common Health 1995, 3 (3), p. 24-25.
20. Hamill M. Estonian nurses capitalize on learning. Common Health 1996, 4(1), p. 26-27.
21. Hart E, Anthrop C. Action research as a professionalizing strategy: issues and dilemmas. J Adv Nsg 1996, 23, p. 454-461.
22. Goddard NL. Financial management. In Vestal KW. Management concepts for the new nurse. Philadelphia: JB Lippincott, 1987, p.127-152.