Bette Case Di Leonardi remembers one nurse manager she encountered at a major urban medical center early in her career. The head nurse ran the unit with such a tight hand she terrified everyone who worked for her. “The staff were fearful and nearly trembling when they walked past her,” Di Leonardi said.

But her tough leadership style worked. They were so afraid of their boss that they worked hard and the care provided in the unit was terrific, she said.

That management approach would not be well-received today, though. It would erode morale and make it difficult to retain nurses, said Di Leonardi, now a nursing professional development consultant based in Chicago. The concept of a healthy workplace now is the antithesis of what she experienced as a young nurse, but nurse managers still set the tone. The keys to effective management are interpersonal cooperation, good communication, and a focus on education.

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Setting the tone

A 2017 Press Ganey Nursing Special Report that examined nurse and patient experience surveys found that nurse leaders have a substantial influence on the quality of the work environment and on safety, quality, and patient outcomes. Effective leadership at the top can improve all of these areas.

“Nurse managers set the tone for how effective and efficient the employees and staff will be,” said Seun Ross, director of nursing practice and work environment at the American Nurses Association. “Nurses represent the largest subgroup of health care professionals, and they provide the most care, which places them at a prime position to affect outcomes.”

According to researchers, factors nurse leaders can control and which have the greatest influence on nursing outcomes were autonomy and professional development. Patient outcomes were more influenced by appropriate staffing and teamwork.


Nurse managers have a direct impact on the quality of care provided by staff nurses, Ross said. They shape how each nurse feels, which affects burnout, turnover, and patient satisfaction. Consequently, it is important to foster qualities such as teamwork, accountability and good communication.

“I truly believe the biggest thing you can do [as a nurse manager] is to be a great mentor and have skills as a good listener and good communicator,” Ross said. “A nurse manager has to be professional and supportive and speak up for staff, because they recognize it if you don’t. And you can’t just sit and delegate, but you have to get out there and get your hands dirty.”

One of the strategies identified in the Press Ganey report as a way to drive improvement is the unit huddle. “One nurse manager described creating a huddle board that nurses on all of the shifts contribute to on a daily basis to identify small issues before they become big ones,” the report stated. “All of the nurses on the unit are encouraged to place idea cards with proposed solutions on the board as well.”

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Another term for autonomy is transformational leadership, which Di Leonardi describes as the “leader getting out of the way.” In fact, she thinks that the term manager in the nurse manager title may send the wrong message. Managers keep staff in line, but leaders empower staff. “This encourages autonomy and the nurses to step up and function and think beyond the direct care they are providing that day,” she said.

All nurses can be asked to help with things such as practice improvement or rounding or better use of the white board. When managers fail to seek involvement from the staff, their solutions are rarely those that take into account the whole group.

Good leadership is oriented toward the future, Di Leonardi said. Instead of just ensuring there are enough supplies, a good leader looks at how those supplies impact patient outcomes.

Professional development

Professional development can come in many forms, not just in continuing education hours. Because the patient care environment is driven largely by metrics, an important development opportunity is data tracking to help staff improve front-line work. There is no way to know, for instance, if a dialysis center is seeing the number of patients it should in a day or the number of line infections if no one tracks those data. Nurse managers are in the best position to do that, as staff nurses are focused on patient care. If data suggest that targets are not being met, a good nurse manager would consult with staff nurses to understand why.

Appropriate staffing

Nurse managers spend much of their time on staffing: They are always scrambling to staff the next shift. “Even though some managers are good at staffing and proud of the fact that they can create and fill schedules, the staffing burden can suck a lot of the joy out of the job,” Di Leonardi said. 

Leadership support

Physicians can play a role in supporting the work of nurse managers in clinic or hospital setting. One of the most important, according to Ross, is to understand that interprofessional collaboration is the quickest path to quality care. “We have to remember we are all in the same business and recognize that collaboration is vital to nurse leaders’ role,” she said. “They are usually out there on the unit more than the physicians.”

Everyone needs to be involved in patient care, including patients and their families. A physician leader and nurse leader should work as a team to convey the expectations and desired outcomes, Ross said. “They need to be having meaningful conversations with their staff instead of just pushing information out,” she said.