Health systems are asking nurse managers to oversee 24/7 units while balancing staffing, budgets, quality, length-of-stay goals and the needs of dozens of employees. Some are now confronting another question: How do they persuade nurses to want the job?
At Greenville, N.C.-based ECU Health, managers may have anywhere from 30 to 80 direct reports, with responsibility for annual evaluations and development conversations on top of day-to-day operations. Joshua Crocker, vice president of the HR center of excellence at ECU Health, likens the job to running a business within a business.
“They’re tasked with the day-to-day operations of that unit, from staffing to whatever the issues of the day are with the patients or anything else, to the business of the operation,” Mr. Crocker told Becker’s. “They have productivity measures and targets. They have goals as it relates to things like length of stay and all the metrics they’re tasked with being in charge of. It is essentially a mini-CEO of that unit.”
The 2025 American Organization for Nursing Leadership “Nursing Leadership Insight Study” of 2,992 nurse leaders found 23% intended to leave their positions and another 23% said they might. A separate AONL and Laudio analysis found the average annual nurse manager organizational exit rate to be 7.5%, while manager departures were associated with declines in nurse retention on their units.
Several leaders interviewed by Becker’s said their succession pipelines remain healthy, and AONL CEO Claire Zangerle, DNP, RN, described the national decline in interest in nurse manager positions as modest. But systems seeing fewer nurses raise their hands for management are changing what the job asks and how they prepare nurses for it, weighing the trade-offs nurses make when deciding whether to leave the bedside, including compensation, schedules, workload, preparation and how much authority they will actually have to lead.
Bedside pay, schedules compete with management
Some systems are seeing that hesitation early, in how few nurses express interest in leadership at all.
Crystal Kohanke, executive vice president and chief people officer at Little Rock-based Arkansas Children’s, said a recent survey of more than 60 new-graduate nurses found only three were interested in leadership. Nurses have told the system that managing people looks difficult, bedside earning potential may be greater and the additional responsibility may not be worth the trade-off.
“We are learning that this is not only a readiness problem,” Ms. Kohanke told Becker’s. “It is a value-proposition problem. The role must offer a reasonable balance of compensation, workload, flexibility, support and accountability.”
Smaller hospitals are weighing the same trade-offs with fewer resources to offset them. Tom McCauley, chief human resources officer of Aspen Valley Health in Aspen, Colo., said the organization has raised pay for management positions, though compensation has not resolved the other factors nurses consider. At an organization with roughly 650 employees, becoming a manager also does not necessarily mean leaving bedside work behind.
“I would think it’d be more attractive than it is. We are bumping up the pay rates of those management positions, but I think there are other factors that weigh in,” Mr. McCauley said. “So it’s got to be the right combination of expanded responsibilities, increased upside and better compensation, along with matching it with the right time in your life to be doing that.”
“We’re a smaller hospital, so we do have a lot more player-coaches. You can’t totally step away from the bedside, because if someone calls in sick, you’re likely filling that shift,” he said. “That’s probably another reason why people may be apprehensive, because they’re genuinely wired to serve others, and their altruistic motives of wanting to treat patients go against that, or they’re afraid of missing that, and they often do.”
Aspen Valley worked with an outside consultant in late 2025 to define six leadership competencies and is using 2026 to build a program around them for a 2027 launch. The organization plans to reach potential leaders earlier through a new emerging-leader group that includes supervisors, leads, lab section leads and charge nurses. Across its C-suite, directors, managers and emerging leaders, Aspen Valley expects the program to reach 150 to 200 employees.
At larger systems, the calculation nurses are making comes down to specifics. At ECU Health, which employs about 3,000 nurses, Mr. Crocker said compensation is one of the most tangible factors nurses weigh because bedside earnings have increased significantly in recent years.
“Compensation is certainly a big factor. We know the market rate for nurses has grown exponentially in the last several years, and so the amount of money that can be made at the bedside, with things like shift differentials, incentives and overtime, when you package all that together, can be fairly lucrative compared to a straight salary in a nursing leadership position,” he said.
The schedule can make the trade-off more difficult for nurses accustomed to working three 12-hour shifts, particularly when a management position brings a traditional workweek along with greater responsibility outside regular hours.
“The other thing that’s maybe not so tangible is the work-life balance conversation,” Mr. Crocker said. “A lot of nurses today like to do their shifts. If they work three [12-hour shifts], they want to do their three 12s and then have that balance to take the rest of the time with family or whatever they want to do in their personal life. I think we’re seeing a struggle with that, because in a nursing leadership role, the expectation is generally a 40- to 45-hour workweek, and you’re on call really at all times.”
Mr. Crocker said ECU Health is seeing a smaller overall pool of nurses interested in pursuing management, instead of one particular leadership title becoming significantly harder to fill.
What health systems are taking off managers’ plates
The workload nurses see when considering management is one reason systems are examining what responsibilities need to remain with the nurse manager. Nurse manager expectations have increased without corresponding support, according to a February report from Vizient and Kaufman Hall.
“Nurse managers get a lot of things piled onto their plate, but they don’t get things taken off of their plate necessarily,” Dr. Zangerle said. “And the complexity of the role is what’s really making it a little more challenging, and the requirement to have higher level competency beyond ‘you’re a great clinician’ is also making it complex.”
Managers themselves have identified a similar tension between the work they find meaningful and the responsibilities that consume their time. In a McKinsey & Co. survey of 1,301 nurses, managers ranked resolving conflicts and performing corrective actions, handling incident reports, injuries and complaints and reaching out to staff to fill workforce gaps among their most frustrating daily activities. Their most satisfying tasks centered on people management, including daily huddles, multidisciplinary unit rounds and staff meetings.
Dr. Zangerle said systems looking to make the role more sustainable should examine both managers’ span of control and responsibilities that can be automated, delegated or reassigned. The AONL does not recommend a single maximum number of direct reports, instead looking at factors including staffing models, unit acuity, manager experience and whether managers have support from positions such as unit clerks or assistant nurse managers.
Supply counts, payroll, scheduling and HR coordination are among the responsibilities systems can examine to determine whether they need to remain with the nurse manager.
“It’s really more those clerical tasks that sometimes get piled on nurse managers that have to be done, and they’re important to be done,” Dr. Zangerle said. “How can you take those things away from a nurse manager and give them to somebody else, or automate them, or get a technology solution, so that they can be freed up, much like we’re trying to do for our staff nurses in virtual nursing?”
Charlotte, N.C.-based Advocate Health has already redesigned parts of the job around those questions. The system spent 18 months asking nurse managers what they were doing that they should not be doing, what they liked doing and what was consuming their time. It ultimately standardized job descriptions and scopes across assistant managers, managers and directors and created a manager relief program so managers would not have to assume responsibility for a second unit after a colleague’s departure. Advocate has seen nurse manager turnover decline and staffing levels stabilize since making the changes, Jane Dus, DNP, RN, senior vice president and chief nursing officer of the system’s Midwest region, previously told Becker’s.
Arkansas Children’s has also examined managers’ scope, establishing a general nursing span-of-control standard of 30 to 35 direct reports while accounting for acuity, turnover and team experience. The system has centralized portions of nursing staffing to reduce the time managers spend filling shifts.
ECU Health’s work has included rethinking performance management because annual evaluations alone can create significant work for managers overseeing 30 to 80 employees. Sara Lilley, vice president of HR talent management, said the system has involved nursing leaders in examining how the process could be streamlined without sacrificing meaningful feedback.
“What can we do to make that process more streamlined, to be more cognizant of the timelines we’re giving them, knowing that they could have anywhere from 30 to 80 direct reports that they have to do an evaluation for?” Ms. Lilley said. “How do we make our performance management process in a way that our nursing managers are getting meaningful feedback and taking the time to sit down and have those meaningful development conversations with their nurses?”
Building interest before a job opens
Along with examining workload and span of control, health systems are giving nurses earlier exposure to leadership and broadening the experience they consider when identifying potential managers.
Arkansas Children’s, for example, allows charge nurse, preceptor and project leadership experience to stand in for formal management experience when evaluating candidates. Its eight-month Manager Leadership Academy combines formal learning, mentoring, shadowing and peer collaboration.
ECU Health’s 12-month Aspiring Nurse Leader program is similarly designed to expose nurses to leadership before they make the transition. The program is open to nurses with a nursing degree who have been with the organization at least a year and combines educational sessions, rotations and shadowing with nurse leaders across the system and individualized career development planning. Fifty-four percent of graduates have received a professional promotion, according to Ms. Lilley.
The system also offers its broader Leadership Journeys curriculum across the workforce, but Ms. Lilley said ECU Health has found value in development designed specifically around the demands nurses encounter when they become leaders.
“My recommendation would be to look to stand up a leadership development program that is tailored to and specific to nursing leadership and all of the uniqueness that comes with being a nursing leader, putting that focus on not just leadership development but leadership development in nursing roles,” she said. “I think my director of development would say shadowing, project work, anything that can get the nurses real-life exposure to what it’s like to be a nursing leader would definitely be my number one recommendation.”
Pittsburgh-based Allegheny Health Network is taking a similar approach by preparing nurses for management before a vacancy forces the transition. Chief Nurse Executive Ashley Carlucci, DNP, RN, said Allegheny wants nurses to learn how to lead before they are placed in a manager position.
“We want to make sure that you’re set up for success instead of failure,” Dr. Carlucci said. “We tend, in general and nationally, to have the nurse leader position open and you get thrown into it. [Nurses might] feel like there’s barely any orientation. We wouldn’t throw a new grad RN into the bedside without giving them the tools to be successful. So we’re doing the same thing in that thought process for a nurse manager.”
Through a center of nursing excellence, AHN makes leadership coursework available to nurses in both formal and informal leadership positions. Leaders identify nurses already demonstrating leadership at the bedside, while nurses who express interest themselves can be paired with mentors. Dr. Carlucci said that exposure also gives nurses an opportunity to decide leadership is not the right path without treating that decision as a failure.
Supporting managers through the first 18 months
At AHN, that preparation continues after nurses move into management, particularly as new managers adjust to the responsibilities and learn how to set boundaries while leading in a 24/7 environment.
Dr. Carlucci said the network sees a fairly predictable progression: New managers begin growing comfortable around six months, can feel overwhelmed around eight months and generally settle into their roles again around 18 months. During that period, AHN reinforces delegation, helps managers determine which meetings require their attendance and which can go to staff and encourages them to set limits on their availability.
“You tend to take a new leadership role, you’re usually going from staff to the manager role. You want people to like you. You’re overly available, and we are in a 24/7 world, and they will use it,” she said. “We give our leaders those tools to say it’s OK to set boundaries.”
Dr. Carlucci said AHN also watches managers’ spans of control because the number of direct reports can grow beyond what allows leaders to provide employees with the level of support they want to give.
“It can very easily get out of control, where a nurse manager has 120 direct reports, which is not really realistic for them to give what they want to give,” she said.
For organizations that do not have the resources to build extensive leadership programs, Dr. Carlucci pointed to mentorship and structured opportunities for new managers to connect with peers as an accessible starting point.
“They tend to feel, as a new manager, a little like they’re on their own,” she said. “So setting up those kinds of meetings and formalizing that, again, can be used with very limited resources. It’s your people that you’re tapping into.”
Giving unit leaders access to senior leadership
At Somerville, Mass.-based Mass General Brigham, efforts to develop future nurse leaders are tied to the health system’s quality structure. Chief Quality Officer Rachel Sisodia, MD, said MGB historically had a fragmented nursing structure organized largely hospital by hospital, without a common management line, and is working toward a systemwide pipeline that gives nurses a more visible career trajectory.
The system’s high-reliability organization model gives unit leaders defined metrics and regular access to senior leadership. About 60% of units are participating in HRO rounds, with a goal of reaching all units by the end of the year, according to Dr. Sisodia.
She said attracting nurses into leadership also requires connecting the work to the reason many entered nursing in the first place: patient care.
“No good nurse wants to take a job where they’re like, ‘Oh, you’re just a measurement monkey, or you’re just trying to appease rankings or whatever,'” she said. “You have to make the job speak to their values, which all the nurses I know, their values are patient care.”
Under the model, unit nurse leaders present to senior leadership monthly. They are accountable for their results but also have an opportunity to raise operational barriers affecting their teams and ask executives for resources to address them. Dr. Sisodia said giving unit leaders both accountability for results and the ability to raise barriers directly with senior executives can make the role more meaningful.
“My experience has been that the people who are going to ultimately be good leaders, whether they’re nurses, physicians, whoever, they’re hungry for that ability to be held to account and demonstrate their competence in front of people. They’re also highly motivated by being able to affect change for the people that report to them,” Dr. Sisodia said. “No one wants to be a leader in those scenarios where you have no agency.”
The structure also allows MGB to identify potential leaders at the unit level while showing nurses a progression from unit nurse director to associate chief nurse, hospital chief nurse and system chief nursing executive.
Rethinking what the job asks
Across the system leaders interviewed by Becker’s, leadership development is closely tied to a broader examination of what nurses see when they consider becoming managers: the workload and number of direct reports, what they can earn at the bedside, how much of their time will be spent on administrative work and whether the role will give them greater ability to improve care.
“We’ve learned, probably like a lot of organizations have, that promoting the best nurse or best clinician doesn’t always equate to the next best leader for us,” Mr. Crocker said.
ECU Health also sees a financial case for keeping strong managers in place, according to Mr. Crocker, who said units with stable leadership have more consistent engagement and turnover results. The system treats manager vacancies, whether planned or unplanned, as a high priority to fill.
Dr. Zangerle said strengthening the pipeline requires health systems to examine the role nurses are being asked to take on, including the work managers are expected to do once they accept it.
“I would tell them to take a critical look at their operating model, redesign the role of the manager so that they can do the work that you hire them to do, and that it make leadership worthy of choice,” she said. “And I think the way to do that is to listen to nurse managers and their lived experiences, and have an open mind around redesigning the role.”
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