1. Wilmoth, Margaret C. PhD, MSS, RN, FAAN
  2. Shapiro, Susan E. PhD, RN, FAAN


In their 2010 report on The Future of Nursing, the Institute of Medicine called for nurses to be prepared to lead in all areas of healthcare. However, the nursing profession lacks consensus on a framework to guide the development of nurses as leaders and has yet to define essential leader competencies. This article reviews the Army's intentional, sequential, and progressive leader development program that is grounded in essential leader competencies. The applicability of this model to nursing is discussed, and examples of how it could be applied are highlighted. This article proposes the use of the military framework as a successful model for the intentional development of nurses as leaders to meet the triple aims of better care for patients, better health for populations, and reduced costs of care through more efficient use of resources.


Article Content

The passage of the Affordable Care Act1 coupled with publication of the IOM report, The Future of Nursing: Leading Change, Advancing Health2 (IOM report), both of which call for nurses to be "prepared to lead,"2(p14) has brought renewed interest, excitement, and commitment in the nursing community to better prepare nurses to be leaders in academia, industry, and in professional organizations. Along with this renewed interest comes the implied imperative to adopt a common framework for intentional leadership development so nurses are prepared to lead at any level in any healthcare organization, and so those organizations can expect consistent core competencies from nurse leaders at each of the different levels.


The focus on developing nurses as leaders is not a new effort. The American Association of Colleges of Nursing (AACN) has identified organizational and systems leadership as 1 of the essential learning outcomes for baccalaureate, master's, and doctoral education.3 The American Organization of Nurse Executives (AONE), the only nursing organization with the sole focus on nursing leadership, has spearheaded efforts around nursing leadership, including offering 2 levels of certification in nursing leadership. Nursing specialty organizations such as the Oncology Nursing Society, the AACN, and the Emergency Nurses Association have created programs for leadership development and, along with the American Nurse Credentialing Center, offer certifications in leadership. The numbers of books and manuscripts on nursing leadership have also increased in recent years. A cursory search of the CINAHL database using the search term "leadership development" yielded 109 publications from January 1, 1996, to December 31, 2000; 316 from 2001 to 2005; and an increase to 440 from 2006 to 2011.


The IOM report2 suggested that nurses need 2 sets of competencies to be effective leaders: 1st, a common set that provides a foundation for future leadership opportunities and, 2nd, more specific set tailored to context, time, and place. However, a thorough discussion of the competencies required for each set was not included in the report. The report did not provide or suggest a framework or blueprint for how to achieve these competencies, nor was there discussion of a process for identifying nurses who demonstrate nascent leadership skills and supporting their development in that direction. Indeed, it is common practice in acute care settings to promote staff nurses into formal leadership roles such as nurse manager (NM) because of their demonstrated clinical competence, not necessarily their demonstrated leadership behaviors.4


In addition to the lack of consensus on a common framework to use in leader development or the necessary competencies nursing leaders should possess at each level of leadership, there has been little conversation about when to begin cultivating nurses' leadership skills, how to develop nurses as leaders, or who should be responsible for the development plan. What role does academia have in developing nurses as leaders, and what responsibility does industry have? All of these aspects of intentional nursing leadership development remain unresolved at present.


In recent years, healthcare, including nursing, has turned to the aviation and nuclear power industries to identify best practices in ways to improve safety and quality outcomes.5 In much the same way, they have turned to nonhealthcare business enterprises for best practices in financial and supply chain management.6 There has not, however, been a similar practice around models of successful leadership development in other industries that might serve as examples for intentionally developing nurse leaders over an entire career. This article presents the military's leadership development program as a potential framework that may be useful in the intentional development of nurses, beginning with individual nurses at the most local level, for example, shift charge nurses and moving through the upper levels of corporate management, whether the nurses are working in healthcare, academia, government, or other large organizations. The military framework and this proposal both assume the baccalaureate level of education as the foundation on which to begin the intentional development of leaders.


Military Approach to Leader Development

The military's leadership development program has 2 interrelated foci: 1st, that leadership is a core competency for all personnel and, 2nd, that the next generation of squad/unit leaders, organizational level leaders, and strategic leaders is identified and developed in a continuous and iterative process. Leader development in the military requires the same level of intention, attention, and support that, in the healthcare industry, is usually reserved solely for specialty clinical development. The intentional development of officers, enlisted personnel, and civilian employees as leaders ensures that they are proficient in their military occupational specialty (MOS) and results in a workforce in which everyone has some level of leadership accountability. Continuous development of leaders occurs through a balanced approach, including institutional schooling, self-development, realistic training, and professional experience.7 This leadership training is done in an iterative manner across the continuum of a career and in conjunction with ongoing skills training in whatever the MOS may require to ensure proficiency.


The recognition that leadership is a special skill is nothing new. Indeed, Sun Tzu, an ancient Chinese warrior, identified 5 key traits that leaders must have: intelligence, credibility, humaneness, courage, and discipline.8 Millennia later, these characteristics remain essential in any leader, no matter the organization or profession. In a similar way, the US Army7 has also identified core leadership competencies, along with specific behaviors that are essential for each competency. For example, for the competency "leads," specific behaviors include leads others, extends influence beyond immediate chain of command, and leads by example.7 The Army core leader competencies are grounded in the Army values of loyalty, duty, respect, selfless service, honor, integrity, and personal courage. These competencies emerged from a detailed self-examination of the way leaders were being trained,9 resulting in changes in the Army leadership component of their field manual.7 Other service branches have slightly different core values, but the leadership competencies are similar.10


The Army defines leadership as "the process of influencing people by providing purpose, direction, and motivation, while operating to accomplish the mission and improve the organization,"5(glossary, 3) and it recognizes 3 levels of leadership with line authority, each with increasing responsibility and increasing accountability: direct, organizational, and strategic. As might be expected, this model also guides the intentional leadership development of health professionals in the military. For example, the "Army Nursing Leader Capabilities Map" is based on these 3 levels of leadership, each with defined and required civilian and military educational preparation requirements, and all interrelated with 5 key constructs of leader development: foundational thinking, personal journey disciplines, systems thinking, succession planning, and change management.11


Levels of Leadership

Direct Level

The most basic level of military leadership is direct leadership; here the leader is able to interact directly with those being led; this may be at the level of the squad, platoon, team, or small staff section.7 Direct leadership is viewed as face-to-face leadership; those who lead at this level have the responsibility to develop subordinates at an individual level and impact the larger organization indirectly as members of high-performing teams that are key to achieving organizational outcomes and retaining employees.4,7 Direct leaders typically experience relative levels of certainty and are close enough to identify and address operational problems at the most concrete level.7 Officers at the rank of 2nd or 1st lieutenant, or captain, and enlisted/noncommissioned officers at the rank of specialist and sergeant through 1st sergeant are examples of leaders at the direct level. Analogous direct leaders in nursing practice would be those who influence several nurses or those who have 5 to 50 direct reports, such as those in the charge nurse or NM roles; in academia, direct leaders would be course coordinators or program directors.


It is now common in many organizations that nurses obtain a minimum of a BSN degree before moving from direct clinical care to direct management.12 The nurse corps of the armed forces commission only nurses holding the BSN, with the exception of the Army Reserve, where nurses must earn the BSN before promotion to the rank of captain. This is consistent with the IOM report recommendations2 and is supported by the AACN Essentials of Baccalaureate Education for Professional Nursing Practice (Baccalaureate Essentials).13 The Baccalaureate Essentials focus on basic leadership competencies related to quality care and patient safety at the microsystem level. Leadership skills enumerated in the document include ethical and critical decision making, effective working relationships, mutually respectful interprofessional communication and collaboration, care coordination, effective delegation, and beginning skills in conflict resolution.13


Newly practicing nurses and new nursing faculty need time to acclimate both to their new professional role and to the organization. During this acclimation period, usually in the 1st or 2nd year out of their initial preparation, supervisors should identify behaviors of potential leaders in their scope of responsibility.14 Institutions that are serious about identifying high-performing individuals who may be tapped for further leadership development can create appropriate diagnostic tools14 to assist in this process. Those who have been identified as potential future leaders should be encouraged to further their professional development through appropriate programs either in the employment setting or through outside organizations such as AONE or other suitable organizations.


Emerging direct level leader training may take many different forms, depending on the size of the organization and the nature of the work. However, crucial aspects of training regardless of organization are (a) identification of potential leaders as early in their careers as possible, (b) organizational investment in developing their emerging leaders before the new leaders make the formal transition, and (c) identified and trained mentors for new leaders who will work with them as they move from staff roles to leadership roles.14,15 The nursing profession and healthcare systems are wasting precious time and human capital, not to mention other resources, by failing to begin the intentional development of nurses as leaders at the beginning of their career.


Organizational Level

The next level of leadership is organizational leadership7; these leaders typically influence from 100 to thousands of employees and lead others indirectly. Leaders at this level focus on setting policy and managing priorities and resources, but their distance from their employees makes it more difficult to judge the immediate results of policy implementation.7 This distance also makes it important for organizational leaders to get out of the office and use personal observation to ensure that priorities are understood and implemented as intended across the enterprise.7 There is less certainty and much more complexity at the organizational level of leadership. There is not much "black and white"; instead, there are many shades of gray. Communicating in a variety of ways, especially by listening, becomes very important at this level; as has been noted, there is rarely a leader who has failed by communicating too much with those being led.16 Ranks in the Army at this level include lieutenant colonels to brigadier generals, and sergeant majors and command sergeant majors. In nursing practice, department or division directors may be at this level, while in academia, department chairs and assistant/associate deans would be leaders at this level.


Organizational leaders are charged with leveraging resources prudently to ensure achieving the strategic plan, as well as working collaboratively across disciplines and leading others in a more indirect manner.17 Nurses new to this level often have difficulty in pivoting from naming and identifying "all things nursing" to having a broader framework for their work.17 The AACN's Master's Essentials18 focuses on organizational and system leadership, providing the appropriate educational foundation for aspiring organizational leaders.


Many organizations begin formally developing nurses as leaders once they arrive at the organizational level of leadership; however, while nurses promoted to this level have had many years of clinical and direct level management experience, they often have had little formal leadership preparation. This would be analogous to delaying formal leader training until an officer is promoted to the level of command of a 1-star general in the Army. Delaying preparation to this point in an officer's career is unthinkable in the military, and the Army has recognized the inefficiency of such a training model. Nursing practice and academic environments should heed that lesson.


Strategic Level

Strategic levels of military leadership are typically general or flag officers or senior executive service selectees serving at the highest levels. Leaders at this level are responsible for very large organizations, influencing thousands of people.7 An important skill of the strategic leader is ability to achieve consensus and sustain coalitions across a variety of organizations.7 High levels of uncertainty are typical at this level, with complex problems and demands coming from a variety of directions. Strategic leaders must look forward and envision the future, which then drives planning and the commitment of resources.7 They must learn to leverage technology to their advantage. The abilities to communicate a vision, serve as a catalyst for change and transformation, process (often incomplete) information quickly, and make decisions based on this incomplete picture are hallmarks of leaders at this level.7


Given their distance from the lowest level of their organization, a critical skill of strategic leaders is the ability to identify and select talented personnel for key positions. Nurses who lead multiple hospital systems or similar multi-unit organizations and deans of schools of nursing, as well as nurses serving at high levels of the state or federal government, are examples of nurse leaders at the strategic level. Like general officer positions in the Army, there are only a few of these positions in any organization, and they help determine the overall success of any hospital, health system, or school of nursing. Preparing for this level of leadership requires continuing formal graduate education and continued professional development in both leadership and management.7,19 The AACN Doctoral Essentials20 addresses this level of leadership by focusing on system level strategic planning, policy development, and organizational accountability for clinical and system outcomes. Successful strategic leaders constantly scan their environment for organizational level leaders who exhibit the interest and ability to develop to the next level, and they offer those organizational leaders opportunities to enhance their knowledge and skills and take advantage of strategic leader positions as they arise.21 The Table 1 outlines the 3 levels of leadership and gives examples of military ranks and comparative civilian nursing professional roles.

Table 1 - Click to enlarge in new windowTable 1. Levels of Leadership and Examples of Occupational Roles

A Lifetime of Leadership Development

The profession of nursing must be as intentional as the military in developing nurses as leaders if nursing is to achieve sits potential as a force in shaping healthcare; expecting nurses to be leaders will not make it so.17 This urgent need requires an overarching framework to ensure that leader development continually occurs at all levels. While not every nurse is suited to formal leadership positions, all nurses must possess some basic leadership competencies such as effective interpersonal communication, critical thinking, and the ability to adapt to change, so they can advocate for their patients and for the reforms necessary to achieve a high-functioning healthcare system.2


One critique of the current state of leadership preparation in nursing is that when it does occur the training is specific to the institution's business practices with limited focus on developing leadership skills. The military framework of leader development,7 with its focus on the level of leadership rather than a particular position, would allow for the transferability of leader skills across institutions. Intentionally developing nurses as leaders using highly successful framework such as the military's would create a workforce prepared to help meet the complex challenges facing healthcare in the early part of this century.


The Figure 1 presents a conceptual framework for intentional nursing leadership development, starting from a BSN foundation and progressing from unit to strategic levels of leadership. Because becoming a leader is a lifelong process, requiring effort and intention,22 it should be viewed as a shared responsibility between the practice setting (whatever that setting may be) and education and requires real partnerships.

Figure 1 - Click to enlarge in new windowFigure 1. Model for intentional development of nurse leaders.

Along with formal education and work-based leadership training, leaders at all levels and in all settings should engage in an ongoing program of self-directed reading about leaders and leadership, as well as personal reflection about their own experiences on which they can build their career paths.7,22 The Army, for example, has developed a program of independent reading about leaders, leadership practices, and theories, which may be combined with periodicals and formal or informal journal clubs to keep current with best practices and innovations. Materials should include classic readings about leadership both in nursing and in other fields, in order to stimulate creative thinking in our own profession. A proposed list of readings in Table, Supplemental Digital Content 1, is modeled after the Army Chief of Staff's Professional Reading List,


There is 1 aspect of the military model that bears special mention, and that is preparing personnel for the next level of leadership before they assume the role, using a talent development-based framework.24 As a result of this process, the military always has a talent pool ready to assume formal leader roles as they become vacant. This is not the usual case for nursing. In the acute care setting, for example, there is little attention paid to developing the leadership capacity of bedside staff nurses until they move into either a charge nurse or NM position, often leaving units without the bench strength needed to assume leadership responsibilities when the identified charge nurse or manager is absent. Failing to develop and nurture the leadership potential in all nurses, regardless of their "occupational specialty"-to borrow the military designation-is a waste of human capital the profession and industry can no longer afford.



Nursing faculty frequently tell students that they are "the next generation of nursing leaders," yet aside from the 1 course on leadership in most undergraduate programs, attention is almost exclusively focused on acquiring clinical skills. Employers of newly licensed nurses are likewise focused on clinical skill acquisition and may neglect to include the time and support needed to help new nurses acquire the leadership skills they will need to be successful clinicians and team members. The nursing profession can no longer afford to use this laissez-faire approach to leader development if it is to fulfill the potential described in the IOM report.2 The profession must heed the report's call to develop nurses as leaders by intentionally adapting to and adopting a framework of leader development. The successful leader development model used by the military has been used successfully in business25 and in military of nursing; there is no reason to think it could not form the basis for intentional leadership development across the entire profession. Adoption of a progressive, sequential program of learning and application of leader skills across a career trajectory, from direct level leadership to strategic levels of leadership, will allow nurses to achieve their maximum leadership potential and for the profession to be engaged as equal partners in achieving the goals of better care for patients, better health for populations, and improved efficiencies leading to reduced overall costs of care.26




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