Nurse managers are the 'CEOs' of their patient care area, and it's the CNO's job to support them, according to this nurse leader.

It's a new year, and people all around the world are setting new goals and resolutions for themselves, including CNOs.

In 2025, CNOs and other nurse leaders will have to keep track of many different trends and challenges, including the ones facing a critical part of the workforce: nurse managers.

Nurse managers are vital to the success of a health system. According to the Trends and Innovations Nurse Manager Retention report that was released by the American Organization of Nursing Leadership (AONL) and Laudio in the fall of 2024, nurse manager retention is key to building a sustainable and high-performing healthcare setting.

However, the report says that nurse manager turnover is highest within the first four years of leadership, and according to Robyn Begley, chief executive officer of AONL, and senior vice president and chief nursing officer at the American Hospital Association (AHA), this is due to very high levels of stress and burnout.

"As a former nurse manager earlier in my career," Begley said, "I can tell you it was the most challenging role that I've had in nursing leadership in my entire career."

Nurse manager challenges

Nurse managers are responsible for patient care, their nurses, 24/7 staffing for their units, budgeting, and compliance with regulations. Begley explained that it's not easy for nurses to move to a nurse manager role, and it should require formal training in leadership, management, and administrative skills.

"They are really the CEOs of their patient care area," Begley said. "Transitioning from a clinical role to a managerial role requires different competencies."

Nurse managers work long hours and have to constantly be available in case something goes wrong, and this can have a large impact on their personal lives and wellbeing.

“Hospitals and healthcare settings are very frequently 24/7 operations," Begley said. "Work-life balance gets a lot of attention, and this really is one of those areas [where] it's challenging for a nurse manager, and this can strain their wellbeing."

Organizational culture also has a large impact on nurse managers, and, according to Begley, it can influence a nurse manager's job satisfaction. CNOs need to make sure that support systems are available.

"Some new managers may feel isolated or perhaps unsupported," Begley said, "finding it difficult to navigate their new responsibilities and feel confident in their roles, especially in those first few years."

The nurse manager's role may also be ambiguous, so Begley recommends clarifying their responsibilities as best as possible to avoid confusion and lack of direction.

"Many times, if a new initiative comes into play, who is left to actually make sure that it gets implemented and outcomes are monitored and measured?" Begley said, "it's the nurse manager."

Nurse manager turnover also greatly affects the rest of the staff. Begley explained that strong, effective communication and trust takes time to build, and frequent turnover disrupts that process and makes it difficult for staff to develop meaningful relationships with their managers.

"Frequent changes in management can create a sense of uncertainty and instability among those units that have frequent turnover," Begley said. "This can lead to decreased morale and job satisfactions, as employees, the nurses, the nursing assistants, and the clerical support on those units may feel that their work environment is unpredictable."

Improving nurse manager retention

Begley had several tips for CNOs who want to improve their nurse manager retention. As CNOs continue to build an engaging and psychologically safe environment for nurses, they must also think about nurse managers and how they can feel safe speaking up, surfacing concerns, and potentially disagreeing without negative repercussions.

"They understand what it's like on the front line and they have to feel free to be able to communicate that back to executive nursing leadership," Begley said. "They have to feel like they can tell it like it is and not sugarcoat some of the messaging that they really do need to communicate to their leadership team."

Additionally, Begley suggested that CNOs allocate resources and advocate for the funding to provide formal training to their nurses who are aspiring to become managers or leaders.

"It takes continuing leadership development and education because we know there's always something new to learn and things are changing in healthcare very rapidly," Begley said.

CNOs also need to be showing up for their nurse managers in tangible ways.

"Nurse managers told us how important it is to actually see their leadership and to have communication and conversations with them," Begley said. "Not just fly by rounds where leaders will stroll through a unit, say hi, try to check in with the staff quickly, but really scheduled time for managers to be able to engage in dialogue is what is required."

Meeting nurse manager expectations

In the report, nurse managers had four priorities that they want CNOs and other nurse leaders to focus on: ensuring a healthy work environment, promoting leadership development, identifying new leaders early, and addressing role complexity.

Begley emphasized the necessity of succession planning for upper management and for executive management, and that there needs to be planning for every level of leadership.

"That involves a formal plan, a succession planning framework, that includes purpose, level, assessment, and nurturing," Begley said. "We know with the baby boomer retirements that we are creating space in leadership in nursing, as well as in many other professions."

The career trajectory of many nurses nowadays is also vastly different than what it used to be, Begley explained.

"There are some young up-and-comers who are very willing and able to take on more, to learn and aspire to be leaders," Begley said, "so these organizations need to do a deep dive and do that assessment and really figure out what their staff nurses desire to do in the future."

Health systems need to provide exposure to what nurses at different levels do, and provide formal education and leadership development, according to Begley.

"It's wonderful if nurses decide to stay on the clinical track and become more proficient in a specialty area, or go into a clinical track for advanced education," Begley said, "but there are also nurses that want to pursue nursing leadership as their specialty, and they also require a career plan."

In terms of role complexity, Begley said AONL is focusing not only on span of control, but also on what leaders can do to take some of the burden away from the nurse manager.

"Clerical work could be done by an assistant, by someone who is perhaps not a nursing leader or a nurse manager, but can do things like scheduling, managing logistics of their unit, [or] supplies," Begley said. "It's so complicated when we look at what [nurse managers] are actually accountable for."

Begley also emphasized the issue of having four generations in the workforce. One solution is technology and innovation, and having nurse leaders at all levels embracing technology and learning how to use it.

"These are skills that perhaps a decade ago or more, nurses weren't innately exposed to in their education," Begley said, "but we know now that technology and innovation is truly the key to the future of transforming healthcare and helping our communities become healthier."

To read more about AONL's previous spring report on nurse manager span of control, click here. 

Here's what CNOs were reading in 2024 on HealthLeaders.

2024 was quite the year for healthcare.

This year, CNOs and other nurse leaders faced a wide array of challenges, from expanding the nursing workforce through recruitment and retention, to tackling new technologies like AI and virtual nursing, and to addressing nurse burnout and wellbeing. Many of these issues are expected to continue, while more will appear on the horizon in the new year.

Here are the top five nursing stories from HealthLeaders in 2024. 

1. Will There Be a Surplus of Nurses by 2028? It Depends - Read here
2. Top 3 Trends in Nursing in 2024, So Far - Read here
3. Here's How the Chevron Decision Will Impact Healthcare - Read here
4. Nursing Needs a Reality Check: Changing Expectations - Read here
5. You Won't Need As Many Nurses. Sooner Than You Think. - Read here

Virtual nursing is so transformative that we are near the first generation of nurses who may never touch the patient.

Editor's Note: This is an excerpt from a larger cover story, which can be found here.

2024 was a year for great innovation.

Health systems made great strides toward implementing new technologies into workflows, including AI, robotics, and wearables. Perhaps the biggest leap forward was made in the realm of virtual care, especially in nursing.

Back in August, HealthLeaders spoke with nurse leaders who are turning to virtual nursing to address staffing and wellbeing, and to learn how they will adapt and advance to this new technology.

The future is now

The use of telemedicine following the COVID-19 pandemic kick started the virtual nursing movement. And while some systems are just getting started, many have been utilizing virtual nursing for years and continue to expand.

In fact, according to Steve Klahn, system clinical director for virtual medicine at Houston Methodist, virtual nursing roles are about to expand exponentially. Klahn predicted that within the next five to 10 years, 60% to 70% of nursing positions across the industry will become virtual or have a virtual component. 

"I'd say well over half," Klahn said, "just with [the] massive growth and expansion over the last two years." 

Klahn explained that this is largely due to the response to virtual nursing programs. 

"This is going to stick with us for a while," Klahn said, "understandably so, because there's such positive response to programs that are engaging a virtual component or fully virtual." 

Dr. Shakira Henderson, dean and chief administrative officer and associate vice president for nursing education, practice, and research at the University of Florida College of Nursing, and the system CNE of UF Health, said this strategy will transform the landscape of nursing by enhancing care and improving efficiency. 

"One of the facts that struck me was that we are going to produce now the first generation of nurses who could potentially never touch a patient," Henderson said. 

Get ready for the new care model 

Leaders must keep in mind that with every new wave of technology, there will be an adjustment period as the technology is integrated with workflows. That won’t be any different with virtual nursing. 

Klahn said the standard care model for nursing will be highly comprehensive, due to the integration of virtual nursing. It will include both task-driven support from remote nurses and a new way of collecting biometric data. 

Nurses will soon be able to monitor a wide variety of healthcare data including blood pressure, heart rate, and respiratory rates through remote patient monitoring, according to Klahn. The collected data can be automated and synthesized through a software system and delivered to the experienced clinical personnel that are remotely supporting bedside teams. 

This new model also enables non-traditional nursing ratios in the form of paired nursing teams, where the bedside nurse can take on more patients while moving a portion of their workload to the virtual nurse. 

"Now you can actually have one or two nurses supporting a much larger group of patient populations," Klahn said, "and truly load balancing and taking those calls as they come in and reducing the wait times for that process." 

Some of the obvious solutions for health systems are not even options for rural hospitals, says this CNO.

On this episode of HL Shorts, we hear from Keri Brookshire-Heavin, senior vice president, chief nursing officer, and chief operating officer at Phelps Health, about how the healthcare needs of rural communities differ from those in urban areas.