What the Research Says About New Managers in Healthcare, and What Organizations Can Do About It

Most healthcare organizations promote from within. A strong nurse becomes a nurse manager. A skilled biller becomes a revenue cycle supervisor. A reliable medical assistant becomes a front-office lead. It’s a reasonable practice, and in a tight labor market it’s often the only practical one.

The problem is what happens next. DDI’s Frontline Leader Project found that only 10% of first-time managers felt prepared for the transition into leadership, and 84% described it as stressful. The Center for Creative Leadership reports that nearly 60% of new managers received no training at all when they moved into their first leadership role. Widely cited industry estimates put new-manager failure rates at roughly 40% within the first 18 months.

I spent two decades in healthcare workforce and leadership development before founding Wildbrush Collective, and these numbers match what I saw across hospitals, health centers, and rural systems: organizations invest heavily in identifying who to promote and very little in preparing them once promoted. This article summarizes what the research shows about where new managers struggle, what those struggles cost, and what the evidence says effective development requires.

Where new managers struggle

The research identifies a consistent set of difficulties in the first 18 months, regardless of department or clinical background.

Difficult conversations, feedback, and accountability. DDI identifies the inability to hold difficult performance conversations as the single biggest weakness of frontline managers. This is compounded in promote-from-within environments, where the new manager is now responsible for evaluating former peers. Avoidance follows, and with it perceptions of favoritism and erosion of team accountability.

The transition itself. Linda Hill’s longitudinal research at Harvard, which followed new managers through their first year, found the shift from individual contributor to manager is a fundamental change in professional identity, and one most people underestimate. In healthcare this is sharpened by the fact that promotion criteria are typically clinical or technical excellence, the exact skills the new role asks them to spend less time using.

Operational and financial literacy. New managers inherit schedules, budgets, productivity

reports, and dashboards they have often never seen. AONL identifies FTE budget management and interpreting productivity data as core nurse-manager competencies that new leaders typically lack on day one.

Compliance anxiety. New supervisors consistently report uncertainty about documentation, protected conversations, and what they can legally say or do. The result is hesitation on performance issues at precisely the stage when early intervention matters most.

Isolation and burnout. Capterra’s survey of middle managers found 71% report feeling overwhelmed, stressed, or burned out, and more than 40% of managers with under two years of experience were actively looking for another job. SHRM has described the new middle manager position as the loneliest role in the organization.

What it costs

Gallup’s research across 2.5 million work units found that the manager accounts for approximately 70% of the variance in team engagement. In healthcare settings, that variance translates directly into retention, patient experience, and operational stability.

The healthcare-specific data is worth reviewing closely:

• AONL’s longitudinal research found 45% of nurse managers considering leaving their positions, with burnout and work-life balance as primary drivers. Nurse manager departures are associated with measurable declines in RN retention on their units, and NSI Nursing Solutions places the average cost of a single bedside RN departure at just over $60,000.
• MGMA reported 40% annual turnover among front-office staff and 33% among clinical support and business operations staff in medical practices. These teams are typically supervised by first-time managers, and these managers receive the least leadership development of any group despite direct revenue-cycle consequences.
• DDI found that 57% of employees have left a job specifically because of their manager.

For community health centers, the retention math is especially direct. NACHC’s workforce research found that 86% of health centers report being unable to offer competitive salaries, and financial opportunity elsewhere is the most common reason staff leave. When compensation is constrained, the quality of frontline management becomes one of the few retention levers an organization fully controls.

What effective development requires

The training-transfer and adult-learning literature is unusually consistent on what distinguishes development that changes behavior from development that doesn’t. Five findings stand out.

1. Spaced delivery outperforms single events. Decades of research on spaced learning and retrieval practice show that content distributed over weeks or months, with structured recall and application, produces substantially better retention and behavior change than a one- or two-day workshop. Single-event training reliably shows strong satisfaction scores and weak behavior change.

2. Application between sessions is where the learning happens. The transfer literature is clear that knowledge acquisition alone does not change management behavior. Programs that require participants to apply skills on the job between sessions (a real feedback conversation, a real delegation decision) and then debrief the results show meaningfully stronger outcomes.

3. Cohort-based formats improve both completion and wellbeing. CCL’s research found participants in social, cohort-based programs persisted significantly further than self-paced learners. For new managers specifically, peer cohorts also address the documented isolation that contributes to early attrition.

4. The participant’s own supervisor is the strongest predictor of transfer. Research on training transfer finds that active supervisor support, including reinforcing new behaviors and adjusting expectations during the learning period, roughly triples the likelihood that training changes on-the-job behavior. An unsupportive supervisor largely negates program quality. Organizations evaluating development programs should ask how the program engages participants’ managers, because the evidence says this variable outweighs most curriculum decisions.

5. Timing and context matter. Development delivered at or near the transition outperforms development delivered later, after habits have formed; the first months in role are the highest-risk and highest-leverage period. Content built for healthcare realities such as spans of control, 24/7 accountability, credentialing and regulatory load, and staffing shortages transfers better than generic corporate material that participants must translate on their own.

Two additional points deserve mention. First, the evidence supports virtual delivery: controlled comparisons of physician leadership training found virtual programs achieved knowledge and skill gains comparable to in-person formats, which makes well-designed virtual cohorts a credible option for multi-site systems and geographically dispersed health centers. Second, skills training alone is insufficient. The research consistently shows that the persistent behaviors (feedback avoidance, reluctance to delegate, overwork) are rooted in the identity transition Hill documented, and they respond to coaching, peer support, and

structured reflection alongside skill instruction. Effective programs address both the mechanics of management and the transition into the role itself.

The bottom line

The first 18 months of a manager’s tenure is when they are most likely to fail, most receptive to development, and most consequential to the teams they lead. The research gives healthcare organizations a clear specification for what works: development that begins near the transition, is spaced over time, is cohort-based, requires on-the-job application, engages participants’ supervisors, and is built for healthcare context. Organizations that meet that specification are making one of the highest-leverage workforce investments available to them. Organizations that promote strong clinicians and technicians without it are absorbing the costs documented above, in turnover, engagement, and operational performance, whether or not those costs appear on a training budget line.

References

AONL Foundation & Joslin Insight. (2022). Longitudinal Nursing Leadership Insight Study, Part Four. American Organization for Nursing Leadership. https://www.aonl.org/resources/nursing-leadership-survey

AONL Foundation & Joslin Insight. (2023). Longitudinal Nursing Leadership Insight Study, Fifth Report. American Organization for Nursing Leadership. https://www.aonl.org/resources/nursing-leadership-survey

Baldwin, T. T., & Ford, J. K. (1988). Transfer of training: A review and directions for future research. Personnel Psychology, 41(1), 63–105.

Blume, B. D., Ford, J. K., Baldwin, T. T., & Huang, J. L. (2010). Transfer of training: A meta- analytic review. Journal of Management, 36(4), 1065–1105.

Capterra. (2023). Middle Manager Survey. https://www.capterra.com/resources/middle- manager-burnout-strategies/

Center for Creative Leadership; Gentry, W. A. (2016). Be the Boss Everyone Wants to Work For: A Guide for New Leaders. Berrett-Koehler Publishers. (Source of CCL first-time manager research, including training and effectiveness findings.)

Cepeda, N. J., Pashler, H., Vul, E., Wixted, J. T., & Rohrer, D. (2006). Distributed practice in verbal recall tasks: A review and quantitative synthesis. Psychological Bulletin, 132(3), 354– 380.

Comparing virtual vs in-person immersive leadership training for physicians. (2023). Journal

of Healthcare Leadership, 15, 139–151. https://doi.org/10.2147/JHL.S411091

DDI (Development Dimensions International). (2019). Frontline Leader Project. https://www.ddi.com/research/frontline-leader-project

Gallup. (2015). State of the American Manager: Analytics and Advice for Leaders. Gallup, Inc.

Hill, L. A. (2003). Becoming a Manager: How New Managers Master the Challenges of Leadership (2nd ed.). Harvard Business School Press.

Immersive leadership training for physicians: Comparing retrospective pre- and post-test virtual vs in-person 6-month follow-up of learning. (2024). Journal of Healthcare Leadership, 16. https://doi.org/10.2147/JHL.S455105

MGMA (Medical Group Management Association). (2023). MGMA DataDive Practice Operations: Restoring Balance to Patient Access and Medical Practice Operations. https://www.mgma.com/data-report-practice-operations-2023

NACHC (National Association of Community Health Centers). (2022). Current State of the Health Center Workforce: Pandemic Challenges and Policy Solutions to Strengthen the Workforce of the Future.

NACHC (National Association of Community Health Centers). (2024). Health center workforce survey findings on recruitment and compensation.

NSI Nursing Solutions. (2024). 2024 NSI National Health Care Retention & RN Staffing Report.

SHRM (Society for Human Resource Management). Commentary on middle-manager isolation. https://www.shrm.org

Anna Smith, MHA, CPTM, is the founder of Wildbrush Collective, a boutique leadership institute in Missoula, Montana, serving healthcare organizations nationally. To discuss what this research means for your organization, schedule a conversation.