A New Nurse Manager Orientation Program

By Jaime Caron, MBA, DNP, RN, NEA-BC Jul 08, 2024

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Being a nurse manager is challenging, but the role has become tougher since the COVID-19 pandemic with more staff turnover and increased burnout for both staff and managers.

Being a nurse manager is challenging, but the role has become tougher since the COVID-19 pandemic with more staff turnover and increased burnout for both staff and managers. Some facilities offered formal education for the role, but many didn't, or it was inconsistent. Often the most experienced nurse was promoted out of the ranks, and the next day they were designated a manager with little or no education to prepare them for the work they would be doing - and minimal preparation to handle important work, such as staff engagement, patients' experience, financial oversight, change management and performance improvement. There is generally little to no standardization in onboarding and orientation processes for new nurse managers, making it a smart investment to create these processes. The return on investment will be seen in retention, satisfaction and quality of care.

Nurse Manager Turnover: How We Got Here

In my leadership journey, I have moved from one hospital system with a 41% nurse manager turnover rate over the previous two years to another with an over 70% nurse manager turnover rate in the same timeframe. Yes, the pandemic had something to do with this increased turnover rate; but not all of it. In their 2014 publication, Titzer and team predicted nurse manager turnover would result in 67,000 vacancies by 2020 in the United States. NSI Nursing Solutions noted nurse manager/director turnover at 10.9% in 2022. With more than a 10% turnover in both nurse managers and staff RNs according to NSI, there is a revolving door in these positions, making it difficult to maintain skill mix and competence. A 2014 study by Warshawsky and Havens revealed that 30% of respondents were planning to leave their nurse manager positions due to burnout. Jiloty and Olivo reported that the average healthcare manager worked 56 hours per week in 2014. The impact of this workload on nurse managers personally and professionally was grueling before the pandemic, but the pandemic only increased the negative impact.

My Path to Nursing Management

I became a nurse manager because I believed my business background could be an asset. Nursing was a second career for me. I first fell in love with the bedside, but soon, my Lean Six Sigma business mind was buzzing. My first career was with a Japanese robotics company, where I believe I learned what I really needed to know about this world. As their bookkeeper, I learned not only how to manage financial processes, but I learned Lean Six Sigma techniques. I also learned the important skill of how to drive a forklift truck, but that's another story. I feel that my work in the robotics industry combined with the knowledge I gained about Lean methodology helped prepare me for my role in nursing management.

As a new nurse manager, I went into my nursing unit and reorganized everything. I left no corner unturned. As I started to ask questions, no one seemed to have answers for me. I did what any 30-something "annoying" new nurse manager would do: I asked everyone everything, put together binders of my findings and forged ahead.

At some point, a sage director offered our cohort of new managers an AACN course covering the essentials of nurse management orientation, the "Fundamental Skills for Nurse Managers" course. It was the best gift ever.

I geeked out on hours per patient day (HPPD) and the jubilation to finally understand this nursing management phenomenon. I started honing my nurse leader craft and began moving the dial on experience, engagement and quality on the unit. With this AACN course, I bridged that knowledge gap and learned how to lead change effectively.

As discussed earlier, there was a history of some nurse managers staying in their roles for shorter periods. I personally moved on after just three years in the role to the next level of leadership. My experience as a nurse manager made me think, "How can we do this better?" When you Google "nurse manager training," what mostly comes up are job postings. This result indicates that real education and not just on-the-job training for this role is needed.

My Nurse Manager Project

Once I decided to pursue my doctoral degree, there was only one problem that I passionately wanted to solve: nurse manager onboarding. We needed to get away from just handing over the keys to the office with a shiny laptop. Overseeing healthcare's largest workforce needs advanced education and carefully crafted onboarding for the unique skills needed for the nurse manager role. We have carefully curated all sorts of transition-to-practice and excellence programs for our bedside nurses but have largely neglected to standardize the same experiences for their leaders. Today's healthcare environment demands more than a task-efficient manager. It necessitates a leader of change in this dynamic environment, which is more challenging than ever.

Developing a Nurse Manager Orientation Program

Together with my colleague Jennifer Stebbins, we developed a Nurse Manager Onboarding Program and delivered it to 30 nurse managers at an academic medical center over about three months. The core curriculum centered on AACN's "Fundamental Skills for Nurse Managers." The synchronous virtual sessions were set up to occur after the participants were given time to complete asynchronous online modules. The subject matter experts serving as instructors were given the course syllabus to understand the content and tailor their materials. As an example for the finance module, the director of finance gave a presentation on basic finance concepts and then showed participants how to navigate the financial system by pulling reports relevant to their roles. The session also included a breakdown of an operational budget, helping learners understand how the productivity measure HPPD was used to calculate staffing. Learners were given the opportunity to ask questions, and then the real learning started.

The post-program survey revealed that 100% of participants found the program to be very good or excellent. The most important result to me was that 100% of participants reported increased confidence. In the role of nurse manager, confidence is key. You will never be perfect, but being confident in this role can translate into retention and job satisfaction. Improved job satisfaction will ultimately make the job more alluring and bring emerging leaders away from the bedside and into the nurse manager space.

Aligning organizational practices with the modules in "Fundamental Skills for Nurse Managers" brought so much value to participants, and most reported this course as one of their main points of satisfaction. Subject matter experts were eager to share their knowledge, and giving participants the opportunity to be learners, despite already being onboarded in their roles, proved incredibly valuable. Many participants reported that they wished they had known this information or had these resources sooner.

Tips for Setting Up Your Nurse Manager Orientation

We learned a lot by creating the nurse manager orientation course. Here are a few of our lessons learned if you are thinking about developing your own program:

  • Complete an initial assessment - First and foremost, find out what your team needs. We often jump to solution island; your top priorities may not be theirs.
  • Find subject matter experts - Your subject matter experts are likely aware of the opportunities and resources, and collaboration with these groups will build strong cross-functional teams.
  • Support your team's time - Offer dedicated time for their learning. Encourage nurse managers to schedule time off on their calendars, or allow them to work from home to be out of the fray and able to focus.
  • Practice meaningful recognition - Recognize nurse managers for prioritizing their learning. It is not easy to do in the hospital environment. There is a lot of responsibility and pressure to perform in this role, so seeing the importance sets them on a path to lifelong learning, which is a key to retention.

Nurse Manager Education Is Essential

There are a lot of challenges in the healthcare environment. Nurse managers are critical to keeping staff and patients safe. Bottom line: Standardize effective education for nurse managers. Properly teaching your new nurse managers will provide a significant return on investment!

What will your new nurse manager program look like?