1. Adams, Jeffrey M. PhD, RN, NEA-BC, FAAN


This department highlights emerging nursing leaders who have demonstrated great potential in advancing innovation and patient care leadership in practice, policy, research, education, and theory. This interview profiles Nora Warshawsky, PhD, RN, CNE, assistant professor, University of Kentucky School of Nursing.


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Adams: Dr Warshawsky, thank you for speaking with me today.

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Warshawsky: Jeff, I appreciate the opportunity to further the message of the importance of nurse managers (NMs) and administrators.


Adams: Can you talk a little about yourself, your career and influence trajectory?


Warshawsky: My earliest nursing influence was my aunt who was the director of nursing at Arlington Hospital in Arlington, Virginia, in the 1970s. She taught me that a nurse leader's job is to take care of the frontline staff so that they can provide quality care to patients. That lesson resonated with me and formed the foundation of my philosophy of management. I had several other mentors early in my career. Two of my early leadership mentors were Dr Joyce Bacheller and Dr Karen Drenkard. I was an assistant NM to Joyce, and Karen was the director of surgical services at Fairfax Hospital. Both Joyce and Karen are master architects of professional nursing practice environments. They embraced shared governance, and I incorporated empowered nursing practice into my leadership philosophy. My experience at Fairfax became my benchmark to which all other organizations were compared.


Over the course of my years in practice, I worked in 9 different hospitals across the United States, partly because we relocated with husband's job and partly because I had a high need to be challenged. I had the opportunity to observe how different organizations responded to national mandates and standards. There were differences in the local environments and resources of hospitals in each site. I observed how leaders shaped their organizational cultures uniquely in response to similar external forces.


These observations led me to doctoral study at the University of North Carolina at Chapel Hill. I found my interests were a natural fit with Dr Donna Havens, my most recent mentor. She introduced me to the academic study of how nurse leaders shape professional practice environments. I knew from personal experience that leadership effectiveness varied based on factors that were not always in the leader's control, and thus, I focused my scholarship on understanding the variations in organizational context influencing the work of NMs and building on the qualitative work of Drs Maria Shirey, Rose Sherman, and Barbara Mackoff.


Adams: Discuss why this is important to the nurse administrator readers of JONA.


Warshawsky: Hospitals are bureaucracies composed of multiple layers that are growing in complexity. NMs play an essential role and are critical to their success. We must understand how best to optimize the work and experience of NMs. The evidence links NM leadership to nurse satisfaction and retention, professional practice environments, employee engagement, use of research, and patient quality and safety.1 In fact, 1 of my study participants nicely summed up the importance of NMs, "All roads lead to the NM." Although we can see the effects of NMs, it is difficult to study NMs themselves. They are difficult to reach and often limited in numbers in some organization. Numbers range from 3 in small hospitals to 50 in larger centers. To add perspective, a 600-bed hospital has approximately 1800 nurses and only 40 NMs. So much of the research on nurse satisfaction and work environments has been done from the clinical nurse perspective. When I conducted my studies, I had high response rates and fully completed surveys, which is often the challenge in survey research. Participants provided extensive comments. It was clear they had something to say and wanted their voices heard. I hope my research captures that voice. What I'm learning so far is that there are similarities in the domains of practice environments for NMs compared with nurses. What is different is the impact of each domain on the job performance and satisfaction of NMs.


Adams: What is something you are especially proud of or a unique contribution?


Warshawsky: The work that I've been engaged in over the last 10 years is aligning and has the potential to impact the work of nurse leaders on a broad scale. In my faculty role, I am supporting nurse leaders to practice evidence-based leadership. In my service role, I am working with nurse leaders in Kentucky to create a Center for Nursing. I am also beginning a new appointment to the American Nurses Credentialing Center's Commission on Pathway to Excellence. The core of my vision is that if we can prepare high-quality leaders who can craft environments supporting professional nursing practice, we will achieve exemplary patient outcomes. I am proud that this work resonates with nurse leaders. I will soon expand the use of the NM Practice Environment Scale2 to include nurse directors at the service line level.


Adams: As an educator, how do you feel we can best prepare the next generation of nurses to lead and advance the profession?


Warshawsky: We need consistent educational standards for nurse leaders at all levels. CGEAN has consistently advocated for graduate education for all nurse leaders.3 It is clear that to become an advanced practice RN a nurse must complete graduate education and achieve certification before practice. Nurse leaders follow the opposite path. They get the position, work for 2 years, and get certified, and graduate education may not be a requirement for their role. We need to encourage our emerging leaders to get graduate education in administration science early so that they can learn evidence-based management skills rather than trial and error. Nurse leaders need graduate education grounded in the domains of nursing, business, and sociology. Early in nurses' careers, we need to introduce those who seek leadership opportunity, or those we identify as having leadership potential, to mentored leadership roles such as shared governance or assistant NM roles. These apprentice-type opportunities provide time and experience to develop style and skills in a protected environment. As nurse leaders mature in their roles, we need to keep them challenged. If the organization does not have opportunities within, we need to help nurse leaders identify external leadership opportunities. I'd love to see sabbaticals for NMs to provide advanced training to develop focused expertise in areas such as patient safety and quality, innovation, or policy.


Adams: What is one thing you'd like the JONA readers to know?


Warshawsky: It is imperative to better understand the influence the environment has on nurse leaders, as individuals and their effectiveness, particularly as we roll out healthcare reform in the United States. I believe that nurse leaders want to be evidence based in their decision making. Much of the evidence for nursing administrative science is generated in Canada because there are more funding options than we have. Nursing administration research is not high on funding priorities in the United States. This is partly because nurse leaders are 1 or 2 steps removed from the direct link to patient outcomes. In order to explore the relationships between nurse leaders and nurse and patient outcomes, researchers need to link standardized outcome measures to individual managers and leaders. Researchers must partner with nurse leaders to create research opportunities. Second, nursing administration research is not always easy to conduct. Because the numbers of NMs per organization is small, many healthcare organizations are needed to obtain a sizeable sample.


Adams: Dr Warshawsky, thank you for you commitment to nursing leadership.


Warshawsky: Jeff, thank you, and thank you to those who participate in this research and continue to push our profession forward.




1. Cummings GG, MacGregor T, Davey M. Leadership styles and outcome patterns for the nursing workforce and work environment: a systematic review. Int J Nurs Stud. 2010; 47( 3): 363-385. [Context Link]


2. Warshawsky NE, Rayens MK, Lake SW, Havens DS. The Nurse Manager Practice Environment Scale: development and psychometric testing. J Nurs Adm. 2013; 43( 5): 250-257. [Context Link]


3. Yoder-Wise PS, Scott ES, Sullivan DT. Expanding leadership capacity: education levels for nurse leaders. J Nurs Adm. 2013; 43( 6): 326-328. [Context Link]