How Nurses Can Lean In to Management


How Nurses Can Lean In to Management

Bridging the Gender Gap in Healthcare Leadership

By Daria Waszak, RN, MSN, CEN, COHN-S
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Female nurses can feel overwhelmed by the pressure to do it all: take on that nurse manager job and spearhead quality improvement projects while simultaneously raising perfect children, exercising regularly, making home-cooked meals and so on. But do you have to do all those things? According to author and Facebook COO Sheryl Sandberg, the answer is no.

In her controversial new book, Lean In: Women, Work and the Will to Lead, Sandberg believes that instead of trying to do it all and please everyone, women should reevaluate their priorities. She suggests that the pressure of societal expectations is one of the major reasons — along with limited ambition, lack of confidence and fear of failure — that women still “lean back” rather than pursue senior leadership positions.

There is a significant gender gap at Fortune 500 companies, where only 4.2 percent of CEOs are female, and a similar gap exists in the medical industry. Although the female-dominated nursing profession is the largest healthcare occupation, men hold a disproportionate number of leadership positions. Men only make up about 8 percent of nurses, but comprise 57 percent of healthcare management roles.  

A nurse with the desire and skillset should definitely “lean in” to nursing management and an effective nurse manager should “lean in” by taking an active role in running the organization. “There are many women RNs in nursing leadership roles such as nurse manager, nurse director and chief nursing officer, which is usually a senior executive position,” says Patricia McFarland, RN, M.S., FAAN, the CEO of the Association of California Nurse Leaders. “However, generally there aren’t many women or nurses — whether male or female — in other ‘C-suite’ positions, such as hospital president, chief operating officer and chief financial officer.”
According to research conducted in 2006 by the American College of Healthcare Executives, the number of women entering CEO positions in healthcare is on the rise, but there is still a big gap in salaries: Male healthcare executives earn an average of $23,200 more per year than female executives with the same education and experience.

If more women were in decision-making roles, it would bring different and valuable perspectives to the table and help women achieve more equal roles (and pay) in the workplace.

Facing Our Fears

“The wonderful thing about nursing is that there are many choices,” says Debra Costa, RN, MSN, clinical systems project manager at Kaiser Permanente in Pasadena. “With those choices, nurses can select what they do in their careers. However, I believe that there are several reasons that nurses may choose to ‘lean back’ and not pursue those options.”

“Many nurses tend to want to be everything to everyone — it is just our nature,” says Angela Simpkins, RN, BSN, director of patient care services for TotalCare Birth Center at Loma Linda Children’s Hospital. “There are many nurses that I personally work with that I have asked to take on leadership roles who are hesitant because of fear of letting down their families and their many obligations.” She notes that another consideration is the need to separate work and personal life. “As a nurse manager,” she says, “you take your work and worries of the department home with you daily.”

“Some of the reasons nurses don’t pursue leadership roles may be that they will put in many hours at a salary wage in a management position,” Costa adds. “Most nurses can make more money if they stay in a staff nurse role, for example, and work overtime.”
Shirley Johnson, RN, BSN, MBA, chief nursing and patient services officer for City of Hope, says nurses often sell themselves short by not aiming high enough in their career pursuits. “As Sheryl Sandberg stated in Lean In,” Johnson says, “I believe at the root of why some nurses may take themselves out of consideration for advancement in leadership positions is the fear of failure.”
That fear can become a self-fulfilled prophecy: Success demands an unwavering will to achieve and believe in one’s self, which fear undermines. The same fear can also contribute to other problems that hamper women’s achievement, including a reluctance to take credit for and tout accomplishments, which makes it harder to network effectively or to ask for a promotion or a raise.

Defying the Comfort Zone

Another challenge for nurses in achieving leadership roles is developing the necessary managerial skills. “As nurses, we tend to be very focused on being the best clinicians we can be in our early careers and focus primarily on developing our clinical skills,” says Johnson. “Developing leadership skills in a framework of professional practice is not always articulated well.”

Nurses may also be unclear about what will be expected of them as managers and reluctant to take the risk of trying something new and unknown. “One reason why women RNs don’t apply for non-nursing executive positions is that they don’t believe they have the qualifications for these roles,” says McFarland. “Women are much less likely than men to apply for a position where they don’t feel they have most or all of the qualifications.”

Nanette Buenavidez, RN, nurse manager at Arrowhead Regional Medical Center in San Bernardino, believes that nurses should take on new roles as a way to develop and sharpen leadership skills. “Unless the individual nurse begins to actively participate in decision-making and is regularly exposed to situations that positively reinforce his or her newly developing skillset,” she says, a nurse “may opt to remain within his or her comfort level.” When that happens, Buenavidez warns, nurses “may question their ability to be an effective leader and lack the confidence to advance.”

Taking on a new, challenging position can be uncomfortable, especially if the role is non-clinical or outside your area of specialization, but is a great way to grow, both personally and professionally. “Most nurses who become effective managers generally have the ambition to achieve a position of making a difference on a larger scale,” says Rosanne Maehara, RN-C, BSN, director of telemetry at St. Vincent Medical Center.

Important facets of management and leadership include making decisions and communicating them effectively as well as the ability to identify the strengths of others and maximize their efforts through clear vision and direction. Paradoxically, Simpkins notes that one of the hardest parts of being in charge is being “willing to give up control and delegate to others.” She suggests that potential nurse leaders be given opportunities to practice delegating tasks. “It is also important to understand that there will be hard decisions to be made,” she says, “and making sure your team understands the reasons behind the decision is key to [earning] trust and support from your staff.”

Learning from Leaders

Another useful step for prospective nurse leaders is to find a mentor, whether it’s through a formal mentorship program, a professional association or just a personal acquaintance. Mentoring by more experienced leaders can provide invaluable, personalized guidance. Buenavidez suggests that nurses “choose a mentor who models the behaviors that they find valuable in a leader.”

Johnson adds that it’s important to look at the big picture and the role that leadership plays in it. “I encourage nurses to view the scope of their work from a clinical perspective, a leadership perspective and a scientist perspective, regardless of what nursing role they are in at the time,” she says. “Being able to identify the leadership roles that nurses play in direct care is a building block for development of future leadership-specific roles.”

As Sandberg suggests, you don’t need to feel bound by traditional career paths if they don’t suit you. Find a path that challenges and inspires you and push yourself to learn a new skill every year.

“No one is ever perfectly prepared to step into a leadership role,” says Simpkins. “Often, leadership roles are given to the nurses who stand out — exceptional nurses.” The qualities that make a good floor nurse, such as critical thinking, organizational skills and a team player attitude are all beneficial in a leadership role.

McFarland remembers an opportunity she had earlier in her career: While she was filling in as interim nurse manager, there was an emergency on her unit. She handled the situation so well she was recommended for an opening for an associate director of nursing.  
“I didn’t feel I was qualified for the role and thought that I hadn’t been a manager long enough to take the next step to the director level,” McFarland says. “Although I was leaning back, my boss really pushed me to accept the promotion. I did and it was one of the most rewarding jobs of my career.” 



How can nurse managers develop their staff’s potential for the management career track? Here are five pieces of advice from nurse leaders:

1.    Assign responsibilities that allow nurses to utilize their strengths while
giving them adequate guidance, feedback and praise. As a general rule, assign nurses a little more responsibility than they would feel comfortable with.

2.    Provide opportunities for nurses to participate in project management, process improvement, committees and shared governance.

3.    Be a role model in the performance of the job duties and actively discuss the concepts that you are modeling, such as consistency, predictability,
transparency and compassion.

4.    Communicate with authenticity, intelligence and integrity. Admit your errors and treat others fairly and respectfully.

5.    Focus on succession planning. A good manager actively looks to identify members of his or her staff who one day can take over leadership roles.

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