Discussion 4

Preparing nurse leaders for 2020

CAROL HUSTON M S N , M P A , D P A , F A A N 1,2

1President, Sigma Theta Tau International, Indianapolis, IN and 2Professor, School of Nursing, California State University Chico, Chico, CA, USA

Introduction

Planning for the future is difficult, even when environ-

ments are relatively static. When environments are

dynamic, the challenges multiply exponentially. Unfor-

tunately, few environments have been more unpredict-

able in the 21st century than health care. �The healthcare system is in chaos, as is much of the business

world. Traditional management solutions no longer

apply and a lack of strong leadership in healthcare

Correspondence

Carol Huston

10 Via Flora Ct.

Chico

CA 95973

USA

E-mail: [email protected]

H U S T O N C . (2008) Journal of Nursing Management 16, 905–911

Preparing nurse leaders for 2020

Aim: This article highlights eight leadership competencies likely to be an essential part of the nurse leader�s repertoire in 2020. Background: Planning for the future is difficult, even when environments are

relatively static. When environments are dynamic, the challenges multiply

exponentially. Unfortunately, few environments have been more unpredictable in

the 21st century than health care. The healthcare system is in chaos, as is much of

the business world. It is critical then that contemporary nursing and healthcare

leaders identify skill sets that will be needed by nurse leaders in 2020 and begin now

to create the educational models and management development programs necessary

to assure these skills are present.

Results: Essential nurse leader competencies for 2020 include: (i) A global perspective

or mindset regarding healthcare and professional nursing issues. (ii) Technology skills

which facilitate mobility and portability of relationships, interactions, and operational

processes. (iii) Expert decision-making skills rooted in empirical science. (iv) The

ability to create organization cultures that permeate quality healthcare and patient/

worker safety. (v) Understanding and appropriately intervening in political processes.

(vi) Highly developed collaborative and team building skills. (vii) The ability to bal-

ance authenticity and performance expectations. (viii) Being able to envision and

proactively adapt to a healthcare system characterized by rapid change and chaos.

Conclusions: Nursing education programmes and healthcare organizations must be

begin now to prepare nurses to be effective leaders in 2020. This will require the formal

education and training that are a part of most management development programmes

as well as a development of appropriate attitudes through social learning. Proactive

succession planning will also be key to having nurse leaders who can respond effec-

tively to the new challenges and opportunities that will be presented to them in 2020.

Keywords: future, leadership, nurse leadership competencies, leadership succession, management, year 2020

Accepted for publication: 2 July 2008

Journal of Nursing Management, 2008, 16, 905–911

DOI: 10.1111/j.1365-2834.2008.00942.x ª 2008 The Author. Journal compilation ª 2008 Blackwell Publishing Ltd 905

systems has limited the innovation needed to create

solutions to the new and complex problems that the

future will bring� (Marquis & Huston 2009, p. 146). It is critical then that contemporary nursing and

healthcare leaders identify the skills which will be nee-

ded by nurse leaders in 2020 and begin now to create

the educational models and management development

programmes necessary to assure these competencies are

present. This article presents eight leadership

competencies likely to be an essential part of the nurse

leader�s repertoire in 2020 (see Table 1).

A global perspective or mindset

The first competency needed by nurse leaders in 2020 is

a global perspective or mindset about healthcare and

professional nursing issues. Gupta et al. (2008, para 2)

define a global mindset as �one that combines an openness to and awareness of diversity across cultures

and markets with a propensity and ability to synthesize

across this diversity� and argue that developing a global mindset which recognizes and bridges such cultural

differences is essential to the success of any organiza-

tion. The benefit of a global mindset to the nurse

executive is that it allows him or her to proactively

identify and respond to emerging global healthcare and

nursing trends which potentially impact national,

regional or even local healthcare planning.

Indeed, Huston (2008, para 3 & 4) suggests that:

�One only has to look at the headlines to realize most healthcare and nursing issues must now be

viewed from a global perspective. The threat of

pandemics and epidemics such as Acquired

Immunodeficiency Syndrome (AIDS), Severe

Acute Respiratory Syndrome (SARS), drug resis-

tant tuberculosis, poliomyelitis, West Nile virus,

and bird flu, combined with a world increasingly

characterized by global travel, reminds us that the

health threats faced by any one country are

ultimately faced by all countries. In addition,

many professional nursing issues are now recog-

nized as global issues. There has never been a

greater urgency to establish international stan-

dards for nursing education or to identify global

standards or competencies for the novice nurse,

than right now. In addition, the current global

nursing shortage has resulted in the unprecedented

trans-national migration of nurses�,

leading to complaints of �brain drain� from donor countries and an increased risk of unethical, if not

illegal, employment practices for foreign nurses in

their host country, as a result of the lack of

regulatory oversight.

Huston (2008) also suggests:

�It is readily apparent that no one country has all the answers to the worldwide health care dilem-

mas we face today, including abuse of women and

children; care of people with HIV or AIDS; hunger

and lack of access to clean drinking water; the

multiplicity of ethical issues facing nurses and

other health care providers, as well as nations; and

health care worker shortages�.

The eight United Nations Millennium Development

Goals, which range from �eradicating extreme poverty and hunger to halting the spread of HIV/AIDS and pro-

viding universal primary education, all by the target date

of 2015, form a blueprint for all the world�s countries and leading development institutions� (United Nations 2008, para 1). Working together and sharing technologies,

strategies and successes worldwide will be an important

part of addressing these global health care dilemmas.

A working knowledge of technology

A second competency required by nurse leaders in 2020

is the ability to integrate technology which facilitates

mobility and portability of relationships, interactions

and operational processes. Electronic health records

(EHRs), clinical decision support (CDS) and biometrics

are examples of such technology, as all will continue to

impact not only what healthcare data are collected, but

how they are used, communicated and stored.

In January 2004, US President George Bush set a goal

that most Americans would have an EHR by 2014

(Office of the Assistant Secretary of the Defense (Health

Affairs) and the TRICARE Management Activity

2008). Similarly, Canada Health Infoway predicts that

Table 1 Essential nurse leader competencies for 2020

A global perspective or mindset regarding healthcare and professional nursing issues.

Technology skills which facilitate mobility and portability of relationships, interactions, and operational processes.

Expert decision-making skills rooted in empirical science. The ability to create organization cultures that permeate quality healthcare and patient/worker safety.

Understanding and appropriately intervening in political processes. Highly developed collaborative and team building skills. The ability to balance authenticity and performance expectations. Being able to envision and proactively adapt to a healthcare system characterized by rapid change and chaos.

C. Huston

906 ª 2008 The Author. Journal compilation ª 2008 Blackwell Publishing Ltd, Journal of Nursing Management, 16, 905–911

50% of Canadians will be able to access their own

EHRs by 2009 (Pooley 2006). Indeed, most developed

countries are actively moving towards the establishment

and implementation of EHRs. Australia has proposed a

strategy known as �Health Connect�, to facilitate the adoption of common standards by all e-health systems

in the Australian, State and Territory Governments

(Health Connect 2006). Czernowalow (2005) identified

the testing of EHRs at 15 State Hospitals in Africa�s Northern Cape, Western Cape and the Free State as of

2005 and reported that the Department of Health had

tasked the State IT Agency to initiate national

implementation of the system. The National Health

Service in the United Kingdom (UK) began an EHR

system in 2005 and has developed a national system to

transfer records directly and securely from one general

practitioner (GP) to another. More than 100 000

patients in 4000 GP practices in the UK are now using

this system (GP2GP 2008).

The process, however, to make such system wide

changes is not easy. Nor is it cheap. A lack of funding,

debates about who �owns� the data in the system and the challenges of getting computers to �talk to each other� will exist for some time to come (Pooley 2006).

In addition, �clinical decision support� (CDS), defined broadly as �a clinical system, application or process that helps health professionals make clinical decisions to

enhance patient care� (Healthcare Information and Management Systems Society 2008, para 1), will likely

be commonplace by 2020, giving providers the promise

of access at the point of care to cutting edge research,

best practices and decision-making support to improve

patient care. For example, Isabel Health, an online

diagnosis decision support application, �combats diagnosis error by reminding clinicians of potential

diagnoses. After users input free-text symptoms, Isabel

searches published literature for possible diagnoses,

with relevance attached. Isabel also provides access to

annotated images for visual confirmation as well as

suggestions for next steps, and can integrate with a

hospital EMR� (The Advisory Board Company 2006). Biometrics, �the science of identifying people through

physical characteristics – fingerprint, handprint, retinal

scan, voice recognition and facial structure� (Huston 2006), will increasingly be used as a technology to

safeguard client data by 2020. Andrews (2006) suggests

there are as many as 15 000 users for one customer in

healthcare and that 45 000 to 50 000 caregivers use

fingerprint technology on a regular basis. Indeed, fin-

gerprint scanning is the most commonly used biometric

technology in healthcare today, although Andrews

suggests that the use of handprints, retinal scans, facial

geometry and dynamic signatures will increase in the

future.

Expert decision-making skills

A third competency essential for 21st century nurse

leaders is expert decision-making, rooted in empirical

science. Marquis and Huston (2009, p. 1) suggest that

�decision making is often thought to be synonymous with management and is one of the criteria on which man-

agement expertise is judged. Indeed, the quality of the

decisions leader-managers make is the factor that often

weighs most heavily in their success or failure�. Using systematic, scientific approaches to problem solving does

increase the likelihood of making quality decisions,

although the role of intuition as an adjunct to quality

decision-making should not be overlooked. In addi-

tion, decision-making based on empirical science and

research-based, best practices also increases the likeli-

hood that decisions made will achieve the desired outcome.

Yet, Camillus (2008) warns that decision-making in

complex environments will only become more difficult

in the future, despite gathering additional data, defining

issues more clearly and breaking dilemmas down into

smaller problems. This is because problems faced by

organizational leaders are often �wicked� – meaning that they have innumerable causes, they are tough to

describe and there is no right answer. �Not only do conventional processes fail to tackle wicked problems,

but they may exacerbate situations by generating

undesirable consequences� (p. 100). One strategy nurse leaders of the future may increas-

ingly use to address wicked problems and improve the

quality of their decision-making is the use of commer-

cially purchased �expert networks� – communities of top thinkers, managers and scientists – to help them make

decisions (Saint-Amand 2008). Such network panels are

typically made up of researchers, healthcare profession-

als, attorneys and industry executives. Camillus (2008)

also recommends involving stakeholders in brainstorm-

ing sessions when wicked problems emerge, so that an

appropriate strategy can be developed and to better align

decision-making throughout the organization.

In addition, management science has produced many

tools to help decision makers make better and more

objective decisions. For example, Mind Tools Ltd

(2008) identifies a number of decision-making tools

including �Six Thinking Hats� (developed by Edward de Bono), Pareto analysis, paired comparison analysis, grid

analysis, decision trees, force field analysis and

cost-benefit analysis, just to name a few. Marquis and

Huston (2009) warn, however, that most decision-

Preparing nurse leaders for 2020

ª 2008 The Author. Journal compilation ª 2008 Blackwell Publishing Ltd, Journal of Nursing Management, 16, 905–911 907

making tools are subject to human error, and many do

not adequately consider the human element. Their

judicious use is therefore advised.

Prioritizing quality and safety

A fourth leadership competency for nurse leaders in 2020

is creating organizational cultures that recognize quality

healthcare and patient/worker safety as paramount. Bob

King, founder and CEO of GOAL/QPC, a non-profit

company directed at continuous improvement, quality

and organizational transformation, suggests that

healthcare is running 10 to 20 years behind in applying

the quality technology that other industries have

embraced successfully (iSix Sigma Europe 2008). King

also suggests that most healthcare organizations are still

unprepared for the cost squeeze coming in the next

3–5 years related to improving the quality of health care.

Indeed, a plethora of studies exist which suggest the

current healthcare system continues to be riddled with

errors and that patient and worker safety are compro-

mised. Some experts suggest this is occurring because

the health care industry has historically been comfort-

able striving for three sigma processes (all data points

fall within three standard deviations) in terms of

healthcare quality, instead of six (Huston 2006). �Sigma� is a statistical measurement reflecting how well a

product or process is performing. Higher sigma values

indicate better performance, while lower values indicate

a greater number of defects per unit. By achieving six

sigma, the failure rate is minimized to 3.4 defects

(errors) per million opportunities or a 99.9996%

success rate (Lanham & Maxson-Cooper 2003).

Experts also suggest that current quality problems are

exacerbated by organizational cultures which focus on

blame instead of identifying how and why such errors are

made, and then addressing the processes which increase

the likelihood of errors occurring. Stumpf (2007, p. 61)

agrees, arguing that safety aspects of care should be

discussed at every opportunity: �on rounds, at department meetings, in discussions with administrators, and in

teaching residents and medical students�. In addition, Stumpf suggests that creating or supporting protocols

and guidelines and improving communication among all

members of the healthcare care will reduce the chance of

errors occurring. Similarly, Jessee (2006) suggests that an

organizational climate must be created in which safety is

an integral part of day-to-day operations, that adequate

resources must be devoted to patient safety and that

organizational policies must be in pace to support patient

safety. White (2006) suggests that organization leaders in

the 21st century will be those that lead in identifying and

adopting innovative safety and quality improvement

approaches.

Being politically astute

A fifth competency for nurse leaders in 2020 is under-

standing and being able to appropriately intervene in

political processes. Blass and Ferris (2007, p. 6),

incorporating a number of definitions, define political

skill as �managing interactions with others in influential ways that lead to organization goal accomplishment

amid rapidly changing contexts�. The politically skilled individual is focused outward (toward others) and is

able to maintain a balance on accountability to others

as well as self. Marquis and Huston (2009) define

political skill as the art of using legitimate power wisely

and suggest that it requires clear decision-making,

assertiveness, accountability and the willingness to

express one�s own views. It also requires being proactive rather than reactive and demands decisiveness.

Because politics is a part of every organization, nurse

leaders must have a clear understanding of the politics in

the organization where they work. Nurse executives often

lose hard-earned power because they make political mis-

takes. Marquis and Huston (2009) suggest that the most

important strategy is to learn to �read the environment� through observation, listening, reading, detachment and

analysis. This allows the nurse leader to understand rela-

tionships and communication within the organization as

well as informal power structures. Blass and Ferris (2007)

agree, arguing that politically skilled leaders not only

accurately interpret different social situations at work,

they know how to act in these situations and do so in a

manner that does not appear to be self-serving.

Being politically skilled can also promote leadership

development in subordinates. As leaders gain political

skill, they become role models for their followers. This in

turn becomes an informal indoctrination and socializa-

tion process whereby more empowered and politically

astute leaders can be created (Blass and Ferris 2007). �By understanding how organizational politics are passed

along through social learning and mentor relationships,

and reinforced through organizational structures, lead-

ers can more effectively understand political behaviors,

the changing nature of organizational contexts, and the

complex dynamics that are reflected in the development

of leader reputations� (Blass and Ferris, p. 16).

Collaborative and team building skills

A sixth competency essential to nurse leaders in 2020 is

highly developed collaborative and team building skills.

C. Huston

908 ª 2008 The Author. Journal compilation ª 2008 Blackwell Publishing Ltd, Journal of Nursing Management, 16, 905–911

Scott (2006) contends that a paradigm shift took place

early in the 21st century, with a transition from �indus- trial age leadership� to �relationship age leadership�. Industrial age leadership focused on traditional hierarchy

management structures, skill acquisition, competition

and control. Relationship age leadership focuses

primarily on the relationship between the leader and his/

her followers, on discerning common purpose and

working together cooperatively (Scott).

Marquis and Huston (2009) suggest, however, that

contemporary healthcare leaders can not and must not

focus solely on relationship building, as assuring

productivity and achieving desired outcomes are essential

to organizational success. Similarly, while building teams

and collaborative relationships was identified as one of

four critical leadership competencies by the Center for

the Health Professions at the University of California, San

Francisco, the development of vision (purpose) and the

task to implement that vision (process) were identified in

a survey of nurse leaders as more important than

relationship building (people) (O�Neil et al. 2008). The key then appears to lie in being able to integrate the

priorities of both the industrial age and relationship

age paradigms.

The other reality is that creating positive and produc-

tive working relationships is often very difficult. The

healthcare team in 2020 will increasingly be character-

ized by highly educated, multidisciplinary experts. While

this would appear to ease the leadership challenges of

managing such a team, Gratton and Erickson (2007, p.

102) suggest such challenges actually increase, as the

greater the proportion of experts a team has, the more

likely it is to disintegrate into a non-productive conflict or

stalemate. This occurs because teams of experts are �less likely-absent other influences – to share knowledge

freely, to learn from one another, to shift workloads

flexibly to break up unexpected bottlenecks, to help one

another complete jobs and meet deadlines, and to share

resources – in other words, to collaborate� (p. 102). Gratton and Erickson (2007) contend that leaders can

counteract this, at least in part, by demonstrating a

commitment to collaboration, role modelling highly

collaborative behaviour themselves, and by creating a

sense of community as a result of mentoring, resolving

conflicts appropriately and communicating clearly.

Nurse leaders in the 21st century will also likely have to

coordinate decentralized decision-making involving

multiple stakeholders including boards. A study by

Mastal et al. (2007) of 73 hospital leaders across the

United States found significant differences in the

perceptions of Chief Nursing Officers (CNOs) regarding

leader�s abilities to manage quality of care in hospitals

compared with those of board chairs and Chief Executive

Officers (CEOs). For instance, CNOs perceived board

members to have only moderate engagement in initiatives

about quality of care, whereas CEOs and board chairs

gave higher ratings to board members� abilities to integrate planning for quality with overall strategic

planning. The authors concluded that CNOs play an

important role in influencing board members and helping

them to integrate quality goals with key business goals.

Balancing authenticity and performance expectations

The seventh competency essential for nurse leaders in

2020 is the ability to balance authenticity with perfor-

mance expectations. Authentic leaders are those who

are true to themselves and their values and act accord-

ingly. Stanley (2006, p. 132) calls this phenomenon

�congruent leadership�, and defines it as �a match (congruence) between the activities, actions, and deeds

of the leader and the leader�s values, principles, and beliefs�. Authentic or congruent leadership differs from more traditional transformational leadership theories

which suggest that the leader�s vision or goals are often influenced by external forces and that there must be at

least some �buy-in� of that vision by followers. �In authentic leadership, it is the leader�s principles and their conviction to act accordingly that inspires

followers� (Marquis & Huston 2009, p. 58). In 2005, the American Association of Critical-Care

Nurses released a landmark publication identifying

authentic leadership as one of the six standards neces-

sary to establish and sustain healthy work environments

in healthcare (Shirey 2006a). Authentic leadership was

described as the �glue� needed to hold together a healthy work environment. George (2007) concurs, suggesting

that 21st century organizations can not develop

sustained growth without authenticity in leadership.

Kerfoot (2006, para 1) also agrees, suggesting that �the leadership traits of the person in charge works either as

a magnet to attract, retain, and inspire, or as a force that

repels� as �people hunger for personalized leadership that speaks to their hearts and inspires them to do things

they didn�t know they were capable of accomplishing�. Yet, there is little doubt that nurse leaders experience

intrapersonal values conflicts between what they believe

to be morally appropriate and a need to deliver results

in a healthcare system, increasingly characterized by

pay for performance and rewarded by cost contain-

ment. Indeed, a survey by O�Neil et al. (2008) found that funding and budgeting were identified as the

greatest leadership challenge by nurse executives. In

Preparing nurse leaders for 2020

ª 2008 The Author. Journal compilation ª 2008 Blackwell Publishing Ltd, Journal of Nursing Management, 16, 905–911 909

contrast, it was ranked at the bottom of the top 5 by

non-nursing leaders assessing what they saw as the most

critical leadership challenge facing nurses in senior

leadership roles. This dichotomy points out the personal

conflict nurse executives may face in attempting to meet

the differing expectations and priorities of organiza-

tional stakeholders. George (2007) suggests that leaders

should be honest with themselves in acknowledging a

temptation to cut corners in pursuit of short-term

profits but must resist that temptation and hold

devotion to customers at least as important as devotion

to stakeholders.

In addition, nurse leaders should realize that becom-

ing an authentic leader is a process that occurs over time

and requires self-discovery, self-improvement, reflection

and renewal. It is attained not through self-proclama-

tion, but by validation from the leader�s followers (Shirey 2006b).

Coping effectively with change

The final leadership competency discussed here, for

nurses in 2020, and perhaps, the most important, is

being visionary and proactive in response to a health-

care system, increasingly characterized by rapid change

and chaos. Marquis and Huston (2009) suggest that

most 21st century healthcare organizations find

themselves undergoing continual change directed at

organizational restructuring, quality improvement and

employee retention. Linda Hill, an expert in change and

leadership development, concurs, suggesting that

�change is so rapid that one leader can�t hope to keep abreast of all developments, much less be responsible

for the innovation needed to keep ahead of them� (Hemp 2008, p. 123 ). Such profound change is not easy

as all major change brings feelings of achievement and

pride as well as loss and stress.

Porter-O�Grady (2003) agrees, noting that the skills necessary to move reticent groups should not be under-

stated. The leader must use developmental, political and

relational expertise to ensure that needed change is not

sabotaged. Burritt (2005, p. 482) also concurs, suggesting

that, �putting an organization on a positive, healthier course is about leadership that focuses on re-energizing

and empowering a workforce. It is about restoring

people�s confidence in themselves and inspiring them to embrace and initiate change�.

Contemporary nurse leaders then must be visionary in

identifying where change is needed in the organization

and they must be flexible in adapting to change they have

directly initiated or by which they have been indirectly

affected (Marquis & Huston 2009). For example,

Malloch & Porter-O�Grady (2005) suggest that the future will increasingly call for a more fluid, flexible and

mobile work environment, which requires an entirely

innovative set of interactions and relationships as well as

the leadership necessary to create them. Increasingly,

skills related to complexity, conflict, multi-focal work

realities, individual accountability, vulnerability and

virtual workplaces will require transformed constructs

and shifting foundations for defining leadership and

expressing it. Leaders who understand these emerging

realities and who can adapt accordingly will continue to

thrive in this changing work dynamic. Leaders who do

not, will simply cease to be effective (Sigma Theta Tau

International 2005). Blass and Ferris (2007, p. 5) agree,

suggesting that �appropriate responses to rapidly chang- ing contexts cannot possibly be scripted. Therefore,

leaders are needed who can flexibly adapt to and deal

effectively with this ambiguity and change�.

Conclusions

The year 2020 is only 12 years away and inadequate

numbers of nurses have the skills that will be needed to

lead in an increasingly complex healthcare environ-

ment, characterized by competing demands and stake-

holders, rapid change, an ever increasing reliance on

technology and wicked problems. Hill suggests that

cadres of globally savvy executives do not currently

exist and warns that many organizations fail to view

talented people as potential leaders (Hemp 2008 ). She

suggests this occurs because �demographic invisibles� – �people who, because of their gender, ethnicity, nationality, or even age, don�t have access to the tools – the social networks, the fast-track training courses, the

stretch assignments – that can prepare them for posi-

tions of authority and influence� (p. 125). Hill also suggests that other potential leaders are missed as they

are viewed as �stylistic invisibles� – individuals who do not fit the conventional image of a leader, as they do not

exhibit take charge, direction setting behavior (p. 125).

Clearly, then nursing education programmes and

healthcare organizations must be more open minded

about who the profession�s future leaders might be and begin now to prepare nurses to be effective leaders in

2020. This will require the formal education and training

that are a part of most management development

programmes as well as a development of appropriate

attitudes through social learning (Marquis & Huston

2009). Proactive succession planning is the key to having

nurse leaders who can respond effectively to the new

challenges and opportunities that will be presented to

them in 2020.

C. Huston

910 ª 2008 The Author. Journal compilation ª 2008 Blackwell Publishing Ltd, Journal of Nursing Management, 16, 905–911

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