Nursing Leadership: The Differences Between Nurse Executives, Administrators, and Managers

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As their careers progress, nurse practitioners have the opportunity to advance into leadership roles. These leadership positions can range from managing a unit to serving as the chief medical officer of a healthcare organization. Because nurse practitioners uniquely bridge the gap between nursing and medicine, they are often called upon to fill roles traditionally held by either one of those professions.

This article discusses the specialized knowledge, job duties, and certifications available for nurse practitioners interested in leadership positions. The article also profiles three nurses serving in unique leadership roles.

Specialized Knowledge of Leaders in Nursing

Nurse practitioners in leadership positions must demonstrate expertise in domain areas outside their medical specialization. Leaders in the healthcare setting require knowledge of human resources, informatics, healthcare finance and economics, quality improvement, team coordination, interprofessional communication, organizational behavior, and health policy. The table below lists core knowledge areas of nurse practitioner leaders.

Knowledge Area Scope
Business and Finance
  • Knowledge of marketing, business planning and strategic planning
  • Development and analysis of financial management processes for an organization’s capital, budget, and accounting systems
Governance
  • Analysis of the organizational structure and with delineating responsibility and accountability at all levels of the organization
  • Implementation of policies and procedures for the governance process
Health Systems
  • Understanding of managed care models, healthcare trends, ancillary services, and care providers
Technology & Information Management
  • Management of clinical information systems such as assessing how current technologies and major innovations are changing the way providers manage and use information
  • Implementation of technology into the care setting
Human Resources
  • Assessing the need for and the supply of professional staff and other personnel
  • Can include the recruitment, selection, training, compensation and evaluation of such personnel and how to examine ways of evaluating productivity and accountability for results
Policy and Regulations
  • Interpreting the impact of government regulations and law on the organization.
  • Identifying the need for an developing new regulations and laws
  • Investigating, monitoring, documenting, and enforcing existing statutes
  • Maintaining communication and cooperation with both public and private organizations
Ethics
  • Developing procedures to ensure the needs of professional staff are met
  • Disseminating codes of professional conduct
  • Understanding the implications of ethical decisions
  • Providing procedures to monitor standards of behavior within the organization
  • Determining, maintaining and monitoring accountability procedures
Quality
  • Evaluating organizational accountability by developing quality improvement programs
  • Possessing a deep understanding of quality assessment and assurance philosophies.
This table was adapted from the American College of Healthcare Executives Job Analysis Study and Ten Core Knowledge Areas of Healthcare Executives

Job Opportunities in Nursing Leadership

Job duties of nurse practitioners in leadership roles vary depending on the type and setting of the position. Generally, these nurse practitioners manage other clinicians, develop and maintain relationships with other executives, plan and implement strategic operational initiatives of their organization, serve as an ethical role model. These nurse practitioners can be employed by clinics, hospitals, health departments, insurance companies, and technology companies.

Recruiters generally contact candidates directly for leadership roles, so they will want to ensure their LinkedIn profiles are up to date and demonstrate previous leadership experience. Aspiring nurse leaders can also ask current managers for more leadership opportunities to help pave the way for advancement.

A quick Internet search revealed a job opening for “Chief Nurse Practitioner Officer” at a hospital in New York. The position requires at least a master’s degree but prefers a doctor of nursing practice (DNP) degree. Duties listed on the job description include:

  • Supervises and coordinates a team of primary care nurse practitioners
  • Develops, recommends and participates in the formulation of procedures and protocols for medical providers
  • Conducts clinical reviews and participates in responses to patient complaints, quality management issues, and risk management requests
  • Reviews and recommends changes regarding the utilization of personnel and proposes staffing patterns
  • Conducts quality improvement studies quarterly and reports through the quality improvement structure
  • Identifies, analyzes and makes recommendations to resolve service problems, duplication of tasks or operational issues.

Salaries for nurse practitioners in leadership positions also vary depending on the level and setting of the position. Typically, nurse practitioners can expect these salaries to be higher than their clinical salaries and for the salary to increase as he or she moves up in the organization or oversees more people. Of note, the skyrocketing salaries of healthcare executives has come under scrutiny.

Exemplary Nurse Leaders

Certifications: Nurse Executive vs Administrator vs Manager

While a leadership certification is usually not necessary to qualify for a management, administrative, or executive position, it can help demonstrate one’s expertise to employers. The remainder of this article discusses these certifications in depth.

The nursing profession provides four different “leadership” certifications, which vary in education requirements and certifying body. Notably, the American College of Healthcare Executives also offers a certification applicable to nurse practitioners interested in leadership.

Certifications sought by nurse practitioners interested in holding leadership roles include:

  1. Nurse Executive & Nurse Executive Advanced (NE-BC and NEA-BC)
  2. Certified in Executive Nursing Practice (CENP)
  3. Certified Nurse Manager and Leader (CNML)
  4. Clinical Nurse Leader (CNL)
  5. Fellow of the American College of Healthcare Executives (FACHE)
Credential & Certifying Body Education Requirements Description Knowledge Expertise

Nurse Executive (NE-BC)

American Nurses Credentialing Center

Bachelor’s degree or higher

A nurse leader responsible for managing the daily operations of a unit or service line
Structures and processes, professional practice, leadership, and knowledge management

Nurse Executive Advanced (NEA-BC)

American Nurses Credentialing Center

Master’s degree or higher
Same as above
Structures and processes, exemplary professional practices, transformational leadership, and new knowledge and practice applications

Certified in Executive Nursing Practice (CENP)

American Organization of Nurse Executives

Master’s degree or higher
A nurse leader working at the executive level in their organization
Communication and relationship-building, knowledge of the healthcare environment, leadership, professionalism, and business skills

Certified Nurse Manager and Leader (CNML)

American Organization of Nurse Executives

Diploma or higher
A nurse leader serving in any healthcare-specific managerial role
Financial management, human resources management, performance improvement, and strategic management and technology

Clinical Nurse Leader (CNL)

American Association of Colleges of Nursing

Graduates from a master’s or post-master’s CNL program
A nurse leader who still provides direct patient care
Care coordination, outcomes measurement, transitions of care, interprofessional communication, team leadership, risk assessment, implementation of best practices, and quality improvement

Fellow of the American College of Healthcare Executives (FACHE)

American College of Healthcare Executives

Master’s degree or higher
Any healthcare professional who serves in executive management roles
Business, finance, governance and organizational structure, healthcare, healthcare technology, human resources, laws and regulation, management and leadership, professional ethics, and quality and performance improvement

Nurse Executive & Nurse Executive Advanced (NE-BC and NEA-BC)

The nurse executive certification is awarded by the American Nurses Credentialing Center (ANCC). This certification was previously called nurse administrator, and it is tailored toward the nurse responsible for managing the daily operations of a unit or service line. To be eligible for the nurse executive certification, one must:

  1. Hold a current, active registered nurse license within a state or territory of the United States or the professional, legally recognized equivalent in another country
  2. Have a bachelor’s degree or higher in nursing
  3. Have held a mid-level administrative or higher position or a faculty position teaching nursing administration for at least 24 months in the previous five years
  4. Have completed 30 hours of continuing education in nursing administration within the last three years (requirement waived for those who hold a master’s degree in nursing administration)

The certification requires applicants to pass an exam, which provides a valid and reliable assessment of the entry-level clinical knowledge and skills required of a nurse executive. The initial application and certification fee is $270 for members of the American Nurses Association and $395 for non-members.

The certification exam consists of 175 multiple choice questions, 150 of which are scored. The test evaluates a candidate’s knowledge in four domains of executive practice: structures and processes, professional practice, leadership, and knowledge management. The ANCC provides both a detailed exam content outline as well as sample questions. If one meets the eligibility criteria listed above and passes the exam, he or she will earn the Nurse Executive-Board Certified credential (NE-BC).

The ANCC also offers the credential Nurse Executive, Advanced (NEA-BC). The eligibility criteria for this credential is the same except a candidate must hold either a master’s degree or higher in nursing or a bachelor’s degree in nursing and a master’s degree in another field. The exam for the advanced certification is similar in structure but covers different domains of executive practice: structure and processes, exemplary professional practices, transformational leadership, and new knowledge and practice applications. The ANCC provides both a detailed exam content outline as well as sample questions for this certification as well.

To prepare the the certification exam, the ANCC recommends the following books:

  • Nurse Executive Review and Resource Manual
  • Nursing Administration: Scope and Standards of Practice
  • Contemporary Nursing: Issues, Trends, and Management
  • Legal and Ethical Issues in Nursing
  • Leadership Roles and Management Functions in Nursing

Certified in Executive Nursing Practice (CENP)

The American Organization of Nurse Executives (AONE) awards the Executive Nursing Practice certification, which is tailored for nurse leaders working at the executive level in their organization. Eligibility criteria for this certification includes:

  1. A current, valid, unrestricted license as a registered nurse (RN)
  2. A master’s degree or higher in nursing plus two years of experience in an executive nursing role, or a bachelor’s degree in nursing plus four years of experience in an executive nursing role

This certification also requires applicants to pass an exam. This exam has 175 multiple choice questions, 150 of which are scored. It covers five core topics: communication and relationship-building, knowledge of the healthcare environment, leadership, professionalism, and business skills. A detailed outline and sample questions can be found starting on page 22 of the AONE Certified in Executive Nursing Practice Examination Handbook.

The application costs $325 for an AONE member and $450 for a non-member. If one meets the eligibility criteria and passes the exam, her or she will be awarded the CENP credential.

In preparation for this exam, the AONE recommends a review of the following books:

  1. Nursing Administration: Scope and Standards of Practice
  2. Leadership and Management in Nursing
  3. Crucial Conversations: Tools for Talking When Stakes are High
  4. Quantum Leadership: Advancing Innovation, Transforming Healthcare
  5. Evidence-Based Practice in Nursing & Healthcare: A Guide to Best Practice
  6. Financial Management for Nurse Managers and Executives

Certified Nurse Manager and Leader (CNML)

The AONE also awards the Nurse Manager and Leader certification, which is designed for those nurses in the managerial role. The AONE describes this certification as the “industry-recognized certification that demonstrates knowledge of the essential elements of nursing management and leadership…a certificate to showcase your management expertise and share your credentials across the nursing leadership community.”

Eligibility criteria for this certification include having a current, valid, unrestricted registered nurse license and one of the following:

  1. A diploma or associate’s degree in nursing plus 5,200 hours of experience in a nurse manager role
  2. A non-nursing bachelor’s degree plus 3,120 hours of experience in a nurse manager role
  3. A bachelor’s degree or higher in nursing plus 2,080 hours of experiences in a nurse manager role

Just like the CENP, this certification requires applicants to pass a multiple-choice exam. The exam includes 115 questions, 100 of which are scored. Topics covered included in the exam are financial management, human resources management, performance improvement, and strategic management and technology. A detailed outline and sample questions can be found in the the AONE Certified Nurse Manager and Leader Examination Handbook. The application costs $300 for AONE members and $450 for non-members.

In preparation for this exam, the AONE recommends the following books:

  • Budgeting Concepts for Nurse Managers
  • Human Resource Management
  • From Novice to Expert: Excellence and Power in Clinical Nursing Practice
  • Project Planning and Management
  • Organizational Behavior, Theory, and Design in Healthcare

Clinical Nurse Leader (CNL)

The American Association of Colleges of Nursing (AACN) awards the Clinical Nurse Leader (CNL) certification, which is tailored toward a clinical leader (i.e. one who is at the point-of-care) focusing specifically on care coordination, outcomes measurement, transitions of care, interprofessional communication, team leadership, risk assessment, implementation of best practices, and quality improvement.

Eligibility criteria for this certification can be found on page nine of the CNL Certification Guide and includes the following:

  1. Graduate of an accredited CNL master’s or post-master’s education program or a student in their last term of a CNL education program
  2. A current and active, unrestricted professional registered nurse license

To earn the certification, a candidate must also pass a 140 question multiple-choice exam. The test covers three key topic areas: nursing leadership, clinical outcomes management, and care environment management. The 2016 Job Analysis Summary published by the AACN contains a detailed outline of content that is covered on the exam. Candidates can also purchase a practice test for $50 from the AACN website.

In preparation for this exam, the AACN recommends the following books:

  • Clinical Nurse Leader Certification Review, 2nd Edition
  • Policy & Politics in Nursing and Healthcare
  • Quality by Design: A Clinical Microsystems Approach
  • Lilienfeld’s Foundations of Epidemiology
  • Essentials of Nursing Informatics, 6th Edition

Fellow of the American College of Healthcare Executives

The American College of Healthcare Executives (ACHE) awards the Fellow of the American College of Healthcare Executives (FACHE) credential, which is tailored toward any healthcare discipline (including nurse practitioners) who serve in executive management roles.

Eligibility criteria for this credential includes:

  1. Current ACHE member with three years tenure as a full member, faculty associate, or international associate (student members excluded)
  2. Master’s degree or other post-bachelor’s degree
  3. Currently holds an executive healthcare management position with a minimum of five years of executive healthcare management experience
  4. Proof of 36 hours of healthcare-related continuing education within the last three years
  5. Two examples of community/civic activities AND two examples of healthcare-related activities within the last three years
  6. Two references: one fellow reference (must be a structured interview) and one from a senior-level healthcare executive

In addition to meeting the eligibility criteria, to become a certified FACHE, a candidate must pass the Board of Governors Exam. This exam includes 230 multiple-choice questions, 200 of which are scored. It covers 10 core knowledge areas, including business, finance, governance and organizational structure, healthcare, healthcare technology, human resources, laws and regulation, management and leadership, professional ethics, and quality and performance improvement. The exam registration fee is $200. The ACHE offers both a Complete Reference Manual and a practice exam with answer key.

In preparation for the exam, the ACHE recommends the following textbooks:

  • Practical Governance
  • Human Resources in Healthcare
  • Managing Health Services Organizations and Systems
  • Essentials of Healthcare Finance
  • Applying Quality Management in Healthcare: A Systems Approach
  • Understanding the U.S. Health Services System
  • Contemporary Issues in Healthcare Law and Ethics
Dr. Melissa DeCapua, DNP, PMHNP-BC

Dr. Melissa DeCapua, DNP, PMHNP-BC

Author

Melissa DeCapua is a board-certified psychiatric nurse practitioner who graduated from Vanderbilt University. She has a background in child and adolescent psychiatry as well as psychosomatic medicine. Uniquely, she also possesses a bachelor’s degree in studio arts, which she uses to enhance patient care, promote the nursing profession, and solve complex problems. Melissa currently works as the Healthcare Strategist at a Seattle-based health information technology company where she guides product development by combining her clinical background and creative thinking. She is a strong advocate for empowering nurses, and she fiercely believes that nurses should play a pivotal role in shaping modern health care. For more about Melissa, check out her blog www.melissadecapua.com and follow her on Twitter @melissadecapua.