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A Journey to Leadership: Designing a Nursing
Leadership Development Program
Sandra Swearingen, PhD, RN
abstract
Nursing leadership development is important in to-
day’s changing health care climate. Nurse leaders affect
staff satisfaction, patient outcomes, and the fiscal status
of most health care organizations. This article delineates
why leadership development is important to nursing, how
to strengthen nursing leadership, how to design a method-
ology for building an internal nursing leadership develop-
ment program based on levels of curriculum content, and
what members of an organization can help teach the cur-
riculum.
J Contin Educ Nurs 2009;40(3):107-112.
H ealth care leaders, including nurses, frequently
learn needed business skills on the job and do
not always have a good understanding of what they are
practicing. Administration will often ask nurses to lead
but rarely supplies the tools or time to achieve the tasks
of leadership (Harkins, Butz, & Taheri, 2006). Kerfoot
(2008) states that many nurses become formal leaders
without formal leadership or on-the-job education or
experience needed to succeed. Even organizations that
provide for leadership development frequently for-
get that there are leaders at every level, including the
bedside, as in charge nurses or team leaders (Gaguski,
2008).
In the author’s experience, many supervisors expect
new nurse leaders to learn the same way that they did:
through trial and error. In today’s fast-paced climate,
trial-and-error learning in leadership often equates to
failure for nursing leaders. Supervisors who are encour-
aging at the beginning of the relationship often claim
leaders are just not a good fit and do not demonstrate
The Journal of Continuing Education in Nursing · March 2009 · Vol 40, No 3
the leadership skills needed to remain in a leadership
position. Formal orientation or training for a leader-
ship position in nursing is often scanty, if not totally
absent.
This article is targeted at facilities that need or want
to develop their nursing leaders to improve staff satisfac-
tion, patient outcomes, fiscal status, and overall organi-
zational success.
Why Leadership Development is
Important to Nursing
Staff Retention
The continuing nursing shortage presents a need for
strong, innovative leaders to attract and retain the nurs-
ing work force, deliver quality patient care, and ensure
fiscally sound health care providers (Blanchard & Player,
2008). Retention of nursing employees is a strong reason
for good leadership. On the basis of research that found
a statistically significant relationship between leadership
style and staff nurses’ intent to stay, Ribelin (2003) states
that “nurses don’t leave hospitals, they leave managers”
(p. 18). The study revealed the better the staff’s percep-
tion of the leader, the greater their intent to stay (Ri-
belin). The best way to impact turnover is to give lead-
ers the knowledge needed to create a work climate that
motivates and engages employees (Bernthal, Wellins, &
Walker, 2004).
Dr. Swearingen is Director of Leadership Development and The
Center for Nursing Research and Innovation, Florida Hospital, Or-
lando, Florida.
The author discloses that she has no significant financial interests in
any product or class of products discussed directly or indirectly in this
activity, including research support.
Address correspondence to Sandra Swearingen, PhD, RN, Leader-
ship Development, 115 Boston Avenue, Suite 2300, Altamonte Springs,
FL 32701.
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Jones (2004) published an economic analysis of the
cost of turnover for registered nurses and found that at
one 600-bed acute care facility, turnover costs $62,100 to
$67,100 per staff nurse. Given the difference in salaries
between staff nurses and those in leadership positions,
the cost of leadership turnover increases exponentially.
Compared to other industries, turnover in health care is
higher among first-level leaders such as charge nurses,
assistant nurse managers, and nurse managers than it is
among senior-level leaders such as directors, chief nurs-
ing officers, vice presidents, and patient care administra-
tors (Bernthal et al., 2004). Jones and Gates (2007) found
that to improve nurse retention, strong, top-level nurs-
ing leadership must transform the workplace and sup-
portive nursing supervision must be present at all levels
of the organization.
Patient Outcomes
Wong and Cummings (2007) performed a systematic
review of studies to determine the relationship between
patient outcomes and nursing leadership. After com-
pleting their search and retrieval process, they retained
seven quantitative articles. Literature reviews found
evidence of significant relationships between positive
leadership behaviors and patient outcomes. Nurse lead-
ers who used their leadership skills to transform the
strategy of patient care delivery in an organization im-
proved patient outcomes, which included reducing pa-
tient mortality and adverse events and increasing patient
satisfaction. Effective nursing leadership is essential in
establishing positive practice environments. The nurse
leader plays a key role in managing staff and financial
resources needed to deliver effective patient care (Pat-
rick & White, 2005).
Fiscal Impact
Nursing managers have fiscal responsibility for mil-
lions of dollars in revenue and expenses associated with
running a nursing unit. In most institutions, nursing is
the largest cost center. Nursing leaders must control
their budget and make sound fiscal decisions about is-
sues that affect patient safety, care, outcomes, and satis-
faction and staff satisfaction. Nurse leaders must spend
their allotted budget wisely. In addition, nursing leaders
cannot separate high-quality patient care from effective
fiscal practices (Pearce, 2008).
A study performed by Pappas (2008) regarding the
costs of adverse events and effective levels of nurse staff-
ing established that poor patient care outcomes are cor-
related with increased costs. Because nursing leadership
has a direct impact on patient care outcomes (Wong &
Cummings, 2007), it also has a direct impact on the costs
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associated with caring for patients. The lower the quality
of nursing leadership, the higher the costs for the organi-
zation. This is especially relevant if lower-quality health
care results in adverse patient events. Synchronized
enhancements in patient care and hospital costs are es-
sential to hospital success in this era of declining reim-
bursements, staffing shortages, and published outcomes
(Pappas).
What Can Be Done to Strengthen Nursing
Leadership
There are many ways to strengthen nursing leader-
ship teams at most institutions, including continuing
education at the master’s level or higher, as under-
graduate programs may have only one or two leader-
ship classes. Organizations can send nurse leaders to
external programs sponsored by nursing schools, pri-
vate companies, or nursing professional associations.
In these programs, participants usually receive days or
weeks of intense leadership training that may or may
not fit the culture of their organization. Additionally,
if the new leaders return to organizations that do not
have methodologies that support them as they test their
new skills, sustainability and application of their train-
ing may not be evident.
After trying many of the alternatives, the author’s
hospital decided to fund a nursing leadership develop-
ment department to focus on building a program to de-
velop and manage nursing talent at the hospital’s eight
campuses. The total bed count for the eight hospitals
is more than 2,000, and approximately 4,800 registered
nurses, with 500 or more being in a formal leadership
role at any one time, work at these institutions. Despite
the large number of nursing leaders, the program started
with only one registered nurse serving as coordinator.
Although the program currently provides more than
3,000 hours of education annually to nursing staff in
leadership, it only requires two full-time equivalents as
its core staff.
Cost does not have to be the deciding factor in pro-
viding in-house nursing leadership education. Formation
of a nursing leadership development program requires a
good plan, hard work, and a desire to make nurses the
best leaders possible.
How to Design a Leadership Development
Program
Assessment
Assessment is the starting point for all patient care
activities. It is also the starting point when designing a
leadership development program. The organization must
be assessed to determine what needs to be taught imme-
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Table 1
QUestions organizations must address when building Nursing Leadership Development
programs
Area of Interest Questions Relevance of Answers
Nursing unit financials Are there indications of overages in supplies or This is a good indication that nurse leaders may
overtime, or is understaffing present? need further education in budget and labor man-
Does budget preparation time equate with crisis agement.
time at the facility?

Patients Are patients satisfied with the services they are Negative findings in any of these areas may dem-
receiving? onstrate that leaders need education in relation to
What is the fall rate? patient satisfaction, quality improvement, or case
management.
What is the length of stay on the unit?

Staff Are staff satisfied with their work environment? Issues in relation to any of these may demonstrate
What is the retention rate? that leaders need development in coaching,
mentoring, staff relationships, empowerment, or
What is the vacancy rate? retention and recruitment.

Strategic organizational What goals can nursing affect?
and nursing goals for What is the vision of executive leadership?
the current year
What are the mission, vision, values, and philoso-
phy of the organization and nursing department?
These are all areas that nurse leaders must be
able to support and foster. Review of the mission,
vision, values, and philosophy will help to ensure
that leaders have the organizational foundation
and direction that will drive the leadership educa-
tion process.

External environmental Are there external organizations that are offering If external leadership development exists that meets
scan leadership education? the needs of the organization, it may be more
Do the local academic organizations have a formal cost-effective to send leaders to existing programs
leadership development program? than to build one.
The downside of this approach is the loss of the
ability to direct education to specific organiza-
tional goals that may drive organization effective-
ness.

diately, what needs to be taught within the next year, and
what needs to be taught eventually.
Many tools exist for assessing the needs of nursing
departments and their nurses. Nursing leaders should
be asked what they think they need to learn. Execu-
tive leadership should be asked what they expect nurs-
ing leaders to know. Assessment can be accomplished
through written questionnaires, Internet surveys, inter-
views of staff and executives, review of previous in-ser-
vice education forms to determine interest in continuing
education in leadership topics, and casual conversations.
Once individuals in the department have expressed what
they want in relation to leadership education, the next
step is to examine outcomes demonstrated by leaders.
Table 1 lists questions that organizations must answer
to build leadership development programs tailored to
their needs.
Building the Curriculum
Once assessment is complete, it should be decided
which employees should be educated first. The author
recommends that the building of curriculum begin at the
lowest level of front-line nursing leadership in an organi-
zation. This will allow curriculum to be built up to meet
the needs of increasing levels of leadership responsibil-
ity.
Experience and job function are determinants of
levels of education for leaders. The levels, built around
Benner’s (1984) novice to expert framework, range
from 100 to 600. Table 2 details the framework used for
nursing leadership development at the author’s hospi-
tal. Experienced nurse managers who are in leadership
orientation in a new organization will be designated
as novices. They must learn the tasks and expectations
of their current role. Leaders must pass through the
novice stage of education with each new job or orga-
nization.
The 100-level curriculum begins with the Nurse
Leader Task Resource, a program that demonstrates
new leaders’ tasks (e.g., what computer programs to use,
what meetings to attend, and other responsibilities). This
ensures success of the new leaders.

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Leadership Development Framework used by one Hospital
Benner Level of Leadership Development
Designation and Offerings
Novice 100—4 sessions per year/16 hours
per session
100—3-day sessions held 2 to 3 times Grass Roots Initiative
per month
200—4 sessions per year/24 hours
per session
Advanced beginner 300—2 sessions per year/8 hours per
month for 12 months/96 hours per
session
Competent 400—1 session per year/8 hours per
month for 12 months/96 hours per
session
Proficient 500—2 to 4 workshops per year/4
hours each
Self-study packets for “on-the-go”
learning
Expert 600—2 to 4 workshops per year/4
hours each
Self-study packets for “on-the-go”
learning
This level also includes a Grass Roots Initiative pro-
gram for informal leaders in the nursing department.
The Grass Roots Initiative, directed at Nurse Practice
Councils, is part of the organization’s strategy to pro-
mote shared governance for nursing staff. This inten-
sive program is offered to individual unit practice coun-
cils over three 8-hour days. The Grass Roots Initiative
teaches staff-level nurses initial leadership skills such as
team building and DMIAC (design, measure, improve,
analyze, and control) process improvement concepts.
DMIAC is a Six Sigma problem-solving methodol-
ogy. Teams, in cooperation with unit managers, iden-
tify three areas of concern on their specific unit directed
at patient safety and quality care. Teams choose which
area to focus on and begin the process of problem solv-
ing using the DMIAC process improvement format.
The leadership development department electronically
tracks solutions implemented by unit-based teams to
ensure their sustainability. If issues arise during the
course of implementation, the leadership development
department assists the teams in overcoming obstacles to
success. Teams achieve success when established metrics
are positively affected.
The program designates charge nurses or team lead-
ers as novices at the 200 level. They must understand the
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Table 2
Target Audience Curriculum Focus
New leaders in the organization Tasks of the job
Basic problem solving
Team building
Charge nurses and team Initial team leadership skills
leaders Basic skills needed for shift leader-
ship responsibilities
Assistant nurse managers Advanced skills needed for shift
leadership and initial skills needed
for unit-based leadership
Nurse managers Unit-based leadership skills and
initial skills needed for leadership
across service lines
Directors Leadership skills based on service
line
Executives Broad, strategy-building leadership
development skills
organizational culture and therefore require education
regarding the organization’s mission, vision, values, and
philosophy. Individuals at the 200 level typically want
to learn skills to help them handle daily issues in their
assigned units. If education does not pertain to their day-
to-day work, they will not engage in learning. Those at
the 200 level do not relate well to intense theory and
broad leadership concepts.
Conflict management, staff assignments, delegation,
team building, generational diversity, assertiveness, com-
munication, ethics, and patient satisfaction are topics
that most individuals at the 200 level can quickly learn
about and apply. The 200-level curriculum is a total of
24 hours. It consists of one 8-hour class per month over
the course of 3 months. Thus, this curriculum is available
four times a year.
The 300 level is for assistant nurse managers. It con-
sists of one 8-hour class per month over the course of 12
months. This level builds on the curriculum offered at
the 200 level. Individuals begin learning responsibilities
associated with this level of leadership through didactic
education, interaction, and role-playing. Staff develop-
ment, empowerment, leadership qualities, budgeting
and finance, regulation, progressive discipline, physician
relations, performance improvement, and cultural diver-
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sity are some of the topics addressed. The focus is on
leadership skills affecting the day-to-day functioning of
units. A team project that addresses identified issues on a
unit-based level, which is presented to upper-level lead-
ership, is required.
Level 400 is for nurse managers and assistant nurse
managers targeted for promotion to nurse manager.
The curriculum builds on previous curricula and also
incorporates skills that allow leaders to broaden their
understanding of the scope of leadership and effectively
interact with other departments and disciplines. Didac-
tic methodologies, role-playing, team games, hands-on
experiences, mentoring, and interactive discussions are
used. Advanced communication skills, team building,
various leadership styles and approaches, advanced
budgetary and finance techniques, advanced staff de-
velopment skills, change management, retention and
recruitment skills, and skills for rapidly responding
to the changing health care environment are taught.
Again, team projects that address issues affecting the
system, which are presented to upper-level leadership,
are required. These projects may cross disciplines or
units.
Level 500 is for directors. At this level, the scope of
leadership education is broad. Change management,
strategic management, performance improvement, men-
toring, and up-to-the-minute changes in health care are
addressed.
Level 600 is for executives. Areas of focus include
health care delivery, regulation, performance improve-
ment, and finance. At levels 500 and 600, workshops and
self-study packets are used for the busy executives.
Teaching
Most educators quickly realize that they cannot
teach leadership at all of the levels. At the author’s hos-
pital, all current leaders are responsible for developing
new leaders, regardless of discipline. Leaders are re-
quired to participate in an established speakers’ bureau
to share their knowledge and help new leaders learn
skills needed to be effective. Experts in each area (e.g.,
finance, executive leadership, strategic management,
or human resources) develop and teach courses to the
nursing leadership staff. This requires a time commit-
ment from some of the organization’s busiest individu-
als. These experts help strengthen overall leadership in
the organization.
Advanced classes at the 500 and 600 levels often re-
quire outside consultants, programs, or speakers. These
classes are sensitive to strategic goals of the organiza-
tion. They encompass national or global changes in
health care that immediately impact the organization.
The Journal of Continuing Education in Nursing · March 2009 · Vol 40, No 3
Evaluation
Continual evaluation of the educational process is
planned to ensure that the learning experience results
in established learning outcomes. The main purpose
of evaluation is to gain understanding of the impact of
student education and to improve the leaders’ learning
(Billings & Halstead, 2009). In leadership development,
projects and demonstrations are some of the methods
of evaluation. Indicators of retention, staff satisfaction,
and attainment of strategic goals are used to determine
the effectiveness of the program and its impact on the
organization.
Outcomes
The nursing leadership development program, in place
for less than 24 months, is beginning to demonstrate
measurable outcomes. The biggest impact to date has
related to nursing retention rates. Although leadership
development is not the only entity addressing retention
at the organization, training in retention methodologies
is the driving force at the unit level. During the past year,
the organization has experienced a 4% overall improve-
ment in retention and as much as a 24% improvement in
retention in selected units.
There is also a larger pool of nursing staff available
for promotion to higher-level positions. Promotion on
the basis of seniority or favoritism has been replaced by
promotion on the basis of participation in the leader-
ship program. Upper-level management staff frequently
contact nursing leadership development staff to inquire
about such participation before making hiring decisions.
The program has led to a baseline standard for leadership
education and ability.
The focus of leadership development is metrics-
driven. Therefore, the leadership team, including the
informal leaders of the Nurse Practice Councils, is ex-
periencing an increased awareness of the impact of its
decisions and actions in relation to patient safety and
outcomes. By allowing them to monitor progress, staff
can quantify the impact of their patient care decisions.
Through projects completed at the 300 and 400 levels,
nursing leadership is able to implement and monitor
new ideas affecting not only patient care but also staff
satisfaction.
Conclusion
Leadership development is a dynamic, ever-chang-
ing process directed at improving leaders and their
organizations. Leadership development is not a rapid
process; it takes time to build and implement a core
curriculum. Several years may pass before leadership
development outcomes are realized in an organiza-
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key points
Nursing Leadership Development
Swearingen, S. (2009). A Journey to Leadership: Designing
a Nursing Leadership Development Program. The Journal of
Continuing Education in Nursing, 40(3), 107-112.
1 Nursing does not consistently develop nursing leaders and
many nursing leaders fail due to lack of leadership knowledge.
2 Nursing leadership has a direct impact on retention and
recruitment of the nursing work force, the delivery of quality
patient care, and the financial stability of a health care organi-
zation.
3 Individual health care organizations can institute nursing
leadership programs that will develop their nursing leadership
talent.
tion. There is no time like the present to start a journey
to leadership.
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The Journal of Continuing Education in Nursing · March 2009 · Vol 40, No 3
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