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Nurse managers’ insights regarding their role highlight the need for practice changes
Applied Nursing Research 30 (2016) 98–103
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Applied Nursing Research journal homepage: www.elsevier.com/locate/apnr
Nurse managers’ insights regarding their role highlight the need for practice changes Linda Weaver Moore, PhD, RN, CNS, CNL ⁎, Cynthia Sublett, PhD, RN, CNL 1, Cathy Leahy, MSN, MEd, CNL Xavier University School of Nursing, 3800 Victory Parkway, Cincinnati, OH 45207
a r t i c l e
i n f o
Article history: Received 21 August 2015 Revised 6 November 2015 Accepted 8 November 2015 Available online xxxx Keywords: Nurse manager Retention Recruitment Leadership development Succession planning
a b s t r a c t Aim: The purpose of this study was to understand the insights of nurse managers regarding the nurse manager role. Background: Nurse managers are vital to the success of healthcare organizations. Vacancy rates of nurse manager positions are on the rise. Recruiting and retaining qualified individuals for these positions requires an understanding of the perceptions of nurse managers regarding the role and the issues embedded in the role. Methods: A descriptive, qualitative investigation was conducted. Data were analyzed using content analysis. Findings: Although desired, role orientation, mentorship, and a strong foundational knowledge, were often lacking. Personal attributes viewed as important for success in the role included seeking opportunities and intentional selfgrowth. Lessons learned while in the role included the art of managing role demands and that comfort comes with time. Conclusion: Concerns regarding the preparation for, introduction to, and support in the nurse manager role highlight the need for practice changes. © 2015 Elsevier Inc. All rights reserved.
The role of nurse manager is often demanding and sometimes daunting in today’s ever evolving healthcare arena. Nurse managers have been described as being the “key interface between patients, nursing staff, medical staff, other clinical and ancillary staff, and hospital administration,” as they manage both human and capital resources (DeCampli, Kirby, & Baldwin, 2010, p. 132). They are vital to the success of healthcare organizations, influencing profitability, nurse retention, and the overall organizational environment (Cowden, Cummings, & Profetto-McGrath, 2011; Gray, 2012; Shirey, McDaniel, Ebright, Fisher, & Doebbeling, 2010). Considering the complexities of the current healthcare system, the role of nurse manager is generally considered one of the most valuable, yet challenging in any healthcare organization. Concerns regarding vacancy rates of nurse manager positions are on the rise. According to the 2006 Aging Workforce Survey, of 978 nurse leaders, approximately 55% are planning to retire between 2011 and 2020 (Hodes Healthcare Division, 2006). In addition, the pool of qualified applicants from which to draw may be limited considering the fact that members of Generation X may find the challenges confronting nurse managers such as a lack of upward mobility, the need to be available at all times, and the inflexibility of organizations to be unappealing and out of alignment with their views of professional success and personal fulfilment (Keys, 2014). Replacing a workforce of individuals with long careers in organizational management is a formidable task
⁎ Corresponding author. Tel.: +1 513 745 1008. E-mail addresses: [email protected] (L.W. Moore), [email protected] (C. Sublett). 1 Tel.: +1 513 745 4333. http://dx.doi.org/10.1016/j.apnr.2015.11.006 0897-1897/© 2015 Elsevier Inc. All rights reserved.
and requires a clear understanding of the issues that nurse managers face and the perceptions that nurse managers hold regarding the role. The purpose of this article is to present findings from a qualitative study that examined the perceptions of nurse managers regarding the nurse manager role. Insights gleaned highlight the need for practice changes. Attending to the voices of those who walk the walk is imperative if well qualified individuals are to be recruited, retained, and satisfied in the nurse manager role and if the role is to remain vital in future healthcare organizations. 1. Background As the healthcare system has been redesigned over the past three decades, so has the role of nurse manager. Today the role is more complex as increasing demands and broader responsibilities have been added to the job description (Shirey, Ebright, & McDaniel, 2008). Nurse managers must attend to both leadership and management responsibilities (McCallin & Frankson, 2010), including responsibilities such as staffing, establishing goals and objectives for the unit, formulating standards of care, managing budgets and quality improvement activities, as well as, hiring, orienting, and evaluating staff (Richmond, Book, Hicks, Pimpinella, & Jenner, 2009). As healthcare systems continue to evolve, the expectations of nurse managers will continue to be more expansive and require even newer and enhanced levels of skills (Aiken & Harper-Harrison, 2012). Because of the complexity of the role and the potential for role overload (McCallin & Frankson, 2010), role stress and burnout have been noted (Shirey et al., 2008; Zwink et al., 2013).
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Nurse managers are key to the creation of a healthy and successful work environment (Shirey, 2006). Staff nurses in Magnet hospitals have noted nurse manager support as 1 of 8 essentials of a healthy work environment (Schmalenberg & Kramer, 2009). Nurse managers often set the tone for the workplace and can greatly impact staff nurse satisfaction and retention (Cowden et al., 2011; Shirey, 2006; Shirey et al., 2008). Organizational productivity and profitability have also been noted to be influenced by the level of nurse manager engagement (Gray, 2012). Literature suggests that thoughtful recruitment of individuals to the role of nurse manager has been lacking. Nurse managers have been selected based on clinical expertise rather than leadership and management potential (Fennimore & Wolf, 2011; McCallin & Frankson, 2010). There is the expectation that the nurse who does well clinically will also do well in management, but, expert clinicians often become management novices (McCallin & Frankson, 2010). Pressure to fill longvacant manager positions may also increase the risk that an underprepared nurse from the ranks will be called upon to fill the position (Espinoza, Lopez-Saldana, & Stonestreet, 2009). Therefore, nurse managers often lack the needed preparation and leadership skills to step into the role (Fennimore & Wolf, 2011) and learn to manage through a trial and error approach, with much learning about leadership occurring after an individual undertakes the role (Paliadelis, Cruickshank, & Sheridan, 2007). Orientation and socialization to the role may also be minimal. While nurse managers have reported a steep learning curve coming into the role (Cziraki, McKey, Peachey, Baxter, & Flaherty, 2014), few orientation programs are specifically designed for new nurse managers (O’Neil, Morjikian, & Cherner, 2008). Nurse managers have noted the need for not only early socialization and development in the role, but also sustained activities that would continue to promote growth (Mackoff & Triolo, 2008). Researchers who have examined trends in healthcare caution that unless there is organizational commitment to development of leadership, including development of nurse managers, the future of healthcare organizations may be at risk (O’Neil et al., 2008). Two recent studies explored the perceptions of nurse managers regarding what attracted them to the role and what retained them in the role (Cziraki et al., 2014; Zwink et al., 2013). In one study, 20 nurse managers offered the following reasons for their attraction to the role: a desire to effect a change, natural career progression, and encouragement by colleagues. Reasons found for staying in the role included peer collaboration and the ability to make positive changes (Zwink et al., 2013). Findings from a study of 11 nurse managers suggested that they were attracted to the role because they perceived the work as meaningful and saw the role as providing an opportunity for advancement. Nurse managers remained in the role because of a passion for their specialties, the accomplishments of staff, and their ability to continue to grow (Cziraki et al., 2014). Scholars have concluded that the nurse manager role has been understudied noting that further research is needed to determine strategies for supporting nurse managers (Cziraki et al., 2014). Findings presented in this article add to the body of knowledge regarding the perceptions of nurse managers regarding the nurse manager role. Findings also highlight the need for changes in practice if the role is to remain vital and sustainable for healthcare organizations in the future. 2. Methods Data presented in this article are part of a larger data set from a study focused on maintaining healthy work environments and the part nurse managers play in creating those environments. Data for this article derived from questions designed to elicit information regarding nurse managers’ perceptions of the role. This study was a descriptive, qualitative investigation. Semi-structured, researcher-participant interviews allowed for sufficient structure to elicit thick, rich descriptions from the managers regarding their experiences, but flexible enough for
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researchers to probe deeper when further clarification of their stories was needed. 2.1. Participants Participants sought for the study were individuals who held the title of nurse manager or a similar title with middle management duties such as 24 hour fiscal, quality and human resources responsibilities for at least one department or nursing unit within an acute care facility. Individuals were recruited who had been in the role for at least 1 year. The researchers desired to include nurse managers who were a “good fit” for the role. “Good fit” was loosely defined by the researchers to be nurse managers who had staff that seemed satisfied and respected the nurse manager’s leadership. Having worked with many nurse managers and their nursing staff over several years while serving as faculty guiding students through clinical rotations, the researchers were familiar with nurse managers who seemed to be a “good fit” for the role. Although selecting “good fit” managers was loosely defined and based on anecdotal information, it provided the researchers with some parameters in selecting nurse managers who seemed well suited to the role. The expectation was individuals who served in the role for at least a year and who were a “good fit” for the role would be accustomed to and thriving in the role and could provide rich descriptions. Eighteen potential participants were recruited via email with information regarding the study and were requested to respond to the researchers if they were interested in participating. If no response was received, a follow-up email was sent after 48 hours. Of the 18 potential participants recruited, 13 agreed to be interviewed. Of the 13 participants, all were employed in large, urban Midwestern acute care organizations. Five different healthcare organizations were represented. The age range of participants was from 30 to 64 years (mean [SD], 48.9 [9.51] years). The number of years participants were employed in the nurse manager role ranged from 1 to 32 years (mean [SD], 10.38 [9.43] years). Eleven participants (85%) were female, while 2 participants (15%) were male. For 7 participants (54%) a baccalaureate was the highest educational degree held, while 6 participants (46%) held master’s degrees. The participants’ places of employment represented a number of specialties including: medical-surgical units, intensive care units, emergency room, and operating room. 2.2. Data collection After receiving institutional review board approval from the researchers’ affiliated university, recruitment emails were sent to potential participants outlining the study. Individuals were asked to respond back to the researchers if they were interested in participating. Once participants agreed to be involved, a date and time for the researcherparticipant interview was established. All interviews were conducted over a 4 month period during non-work hours and at locations away from the participant’s work setting. Two researchers conducted 4 interviews each and the third researcher conducted five interviews. Interview questions, developed by the researchers, were broad in nature and designed to assist participants in telling their personal experiences of living the nurse manager role. In addition, questions were asked that focused on the health of the nurse manager’s work environment and nurse relationships. For the purposes of this article, only data focused on the perceptions of nurse managers regarding the role are reported. Written consent was obtained prior to each interview. Interviews lasted between 60 to 90 minutes and were audio tape recorded and later transcribed. Transcriptions were verified for accuracy. 2.3. Data analysis Transcripts of the interviews were analyzed using a conventional content analysis approach. By using this approach, researchers allowed categories and names for categories to emerge from the data rather than
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using preconceived categories (Hsieh & Shannon, 2005). The three researchers independently read each transcript several times to immerse themselves in the data and gain a sense of the data as a whole. Each researcher read each interview carefully word by word, capturing all data that pertained to the nurse manager role and highlighted key words and phrases from the data. Main ideas were then identified from the key words and phrases and labeled without interpretation. Together, researchers clustered similar ideas, and through the use of interpretation and the movement of ideas to a higher level of abstraction, categories emerged that were representative of the clustered group. In addition, throughout the data analysis process, careful tracking was maintained regarding the number of participants represented within each category, allowing for frequency counts to be determined. Scholars have suggested that content analysis allows for data to be analyzed qualitatively and, at the same time, provides an opportunity to quantify the data (Vaismoradi, Turunen, & Bondas, 2013). While greater frequency may simply represent the participants’ willingness to talk more openly about one topic than another, a greater frequency can indicate greater importance and, with caution, be viewed as representative of a higher level of significance (Vaismoradi et al., 2013). To enhance the rigor of the study, several measures were taken by the researchers. Researchers were skilled with qualitative data analysis, having conducted several previous qualitative investigations. Researchers analyzed data independently and, then came together, and through discussion and constantly returning to the data, reached agreement regarding the findings. An audit trail was maintained throughout and findings were linked directly back to the data. After the review of transcripts, researchers sought clarification from participants of any areas of the transcripts that appeared unclear. Some participants also contacted the researchers after their interview when, upon reflection, they believed something they said needed clarification. Finally, as noted by Krippendorff (2004), one way to determine the quality of findings is whether new understandings regarding the studied phenomenon are uncovered that can inform practice. Findings from this study provide a better understanding of nurse managers’ insights regarding the role and highlight areas for needed practice changes. 3. Results The findings presented highlight the perceptions of participants regarding the nurse manager role. The participants’ descriptions focused on four overarching topics including: their path to becoming a nurse manager, what they ‘wished for’ as a manager to help them grow, personal attributes that they believed contributed to their success, and lessons learned. Categories that emerged from the data for each topic are presented as well as the frequency percentages, signifying the number of participants represented within that category. Because of the rich detail of the descriptions, the percentages are greater than 100% for each topic.
just knew that the role was right for them. These participants actively sought out the role, voicing aspirations for upward mobility to those already in leadership positions. One participant stated, “I expressed to my manager that I was looking for some additional ways to grow,” while another commented, “I had significant leadership experience in another field and I approached the director and said, ‘would you consider looking at my years of leadership experience in another area’.” However, six participants (46%) told of being approached by others and more passively accepting the role. One commented that she “fell into” the role while another talked of being “pushed” into the role. One participant stated, “I walked into the ICU where I worked and someone said to me, ‘oh we heard you’re going to apply for the nurse manager job.’ I said, ‘me?’ ‘No way,’ and I thought about it. I met with my boss and I talked it through with her. I talked it through with my husband and I actually went back and said, ‘I don’t think it’s for me.’ Then I slept on it a couple of days and I thought I do want to do it and I went back and I said, ‘I do want to interview.’” The idea that others could see leadership potential in the participants, even when they themselves had not considered the possibility, is also evidenced in this statement, “I was walking past my boss and she said, ‘hey come in here a minute’ and it was the beginning of the end. I didn’t know if I was going to like the nurse manager position.” Nine participants’ (69%) descriptions revealed the category, “climbing the leadership ladder.” These participants told of how, prior to being formally appointed as a nurse manager, they served in various leadership positions such as nurse preceptor, charge nurse, and shift supervisor. One participant described how the nurse manager role seemed like the next step and commented, “I did such a good job as charge nurse running the department so they thought it would be a natural progression.” Another commented on how a previous leadership role had helped to prepare her stating, “the charge nurse role probably prepared me the best because of all the interdisciplinary interactions and in terms of being a resource to help facilitate the flow and the care of patients.” Twelve participants shared thoughts regarding their orientation to the role. While three of the twelve participants (25%) related a positive experience that involved “many resources” and “wonderful opportunities,” the much more common experience that emerged from their stories was one of trial by fire (9 participants, 75%). Participants’ comments exemplified the difficulties experienced with statements such as, “the orientation was essentially non-existent…it was shocking to me…they turned me loose and said you’re in charge. Call me if you need me.” Similarly, one participant stated, “It was pretty horrible… I learned a lot the hard way.” Other comments that highlight this time of trial included, “there was a lot of learn on the fly,” “I was thrown into the position with a week’s orientation,” and “I learned everything on my own and, for a while, I didn’t know what I didn’t know.” Comments by some participants reflected the emotional toll their negative role introduction had on them. One said, “I struggled for years,” while others commented, “it was very hard on me,” and “it’s still a tremendous sore spot.”
3.1. Path to becoming 3.2. Growth in the role Participants described their journey to becoming a nurse manager. Four categories emerged from the data including: “paid dues,” “actively seeking-passively accepting,” “climbing the leadership ladder,” and “trial by fire.” Thirteen participants (100%) explained how they had paid dues, each working as staff nurses prior to becoming a manager. The years that participants worked as bedside nurses ranged from two to 22 years. None of the participants came directly from their basic educational studies to the manager role. They spoke of how they believed their nurses valued the fact that, as managers, they had previously walked in the shoes of a nurse and could “do the job” they were asking of their staff. As the participants spoke about how they came to consider the nurse manager role, some told of actively seeking the role while others told of passively accepting the role. Seven participants (54%) shared that they
Participants shared their thoughts regarding what they wished they had available to them to help them grow in the role. Two categories emerged from the data including, “someone to walk alongside” and “a stronger foundational knowledge from which to draw.” Nine participants’ (69%) descriptions revealed a hunger for more formal mentorship or coaches to “walk alongside” guiding them and supporting them. Many spoke of how mentorship was missing for both individuals new to the role and those with more experience. One participant noted how, for novice managers, “assigned” mentors would be helpful to “go to with all the questions.” Other participants noted that bosses can serve as wonderful mentors but time constraints often get in the way. One participant stated, “I would love it if my immediate boss would be able to have the time to truly mentor and foster me more formally … I
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would like it because she has great knowledge, great experience… We’re both so busy. We just don’t have the opportunity.” Even those with years of managerial experience desired mentorship, but often found it was not a reality. One participant with 16 years in the manager role noted, “Being mentored or coached does not exist as a leader …We do not network well and we do not support each other well. There’s really not the opportunity to do it. It’s not so much that we don’t want to … the environment does not exist for that to happen. I think we fail ourselves miserably.” This desire for mentorship was also noted in the comments of another participant with 10 years of managerial experience, “I still need to be mentored even though I’ve been doing this for quite some time, sometimes I think that gets lost.” A “stronger foundational knowledge from which to draw” emerged in the accounts of seven participants (54%) as something they wished they had available to them. Participants desired a stronger foundation in areas including budgeting, finance, relationship building, and performance evaluations. Some participants believed that more structured orientation programs specifically for managers could ease some knowledge deficits. One participant stated, “I stumbled upon the fact that our employee files weren’t how they should be, but nobody told me that … It would also be nice if there were a little bit more guidance when evaluations were due. It was kind of like, ‘Your evaluations are coming due in July. Go!’ Maybe classes or maybe even just, ‘hey, why don’t you sit in on this evaluation. This is the criteria we’re looking for.” Some participants’ comments indicated that while certain topics are addressed in occasional classes, more in-depth information is desired. One noted, “Probably at least 50% of my day is working around HR issues with staff … you get a class about it. There are guides, but the guides are not always real specific.” Other comments suggested that real-life situations rarely play out as depicted in class. “They talk broad strokes in class but not actually down to the nitty gritty like those uncomfortable conversations…they talk broad strokes but that’s never how the conversation goes. Employees never respond like the person on the video does!” 3.3. Personal attributes essential to the role As the participants shared their stories the personal attributes that they believed were essential to their success in the role of nurse manager became apparent. Two categories emerged: “valuing, seeking and seizing opportunities” and “intentional self-growth.” Ten participants’ stories (77%) revealed the importance of “valuing, seeking, and seizing opportunities” throughout their careers. One participant spoke about being part of a team who created a new nursing unit and her experience of being the manager of that unit. She noted, “I knew that was not a very frequently occurring opportunity, to be able to create something from scratch and wow it’s been the greatest part of my career by far.” Another talked about how she responds when seeing things that need improvement and noted, “I’m more of a glass half full than a glass half empty person … when I look at something, I think this isn’t bad, it’s just an opportunity and we can fix it.” Another’s comments also spoke to the importance of looking for and grabbing opportunities as she stated, “Opportunities sometimes come calling to me like this role … I saw this role and thought I’m called to do that. It’s definitely seizing those opportunities.” Nine participants (69%) made comments that supported the category of “intentional self-growth.” Comments included: “I have an inquisitiveness of always wanting to know why,” “I’ve gone to classes to work on my weaknesses,” and “I taught myself … I’m still learning.” One participant discussed how she watched other leaders and said, “I’m pretty diligent about picking out characteristics that I want to emulate and working towards that end.” Another reflected her intention toward self-growth commenting, “I’ve invited people to mentor me…I ask a lot of questions … being open to feedback … I have that selfawareness to say, ‘What can I do better? What are some areas that I can develop that will help me as a leader?’”’
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3.4. Lessons learned Although participants were not specifically asked to address lessons learned over their years as a nurse manager, all 13 participants’ (100%) narratives were threaded with insights gained with experience. Two categories emerged from their accounts regarding lessons learned including “the art of managing role demands” and “comfort in the role comes with time.” Seven participants (54%) spoke of learning “the art of managing role demands.” Some demands came with role implementation while others were on a more personal level such as the recognition and maintenance of boundaries. One commented, “I had problems drawing boundaries with the staff. On days when I wasn’t on call, I’d get tons of calls at home but I’d feel guilty not answering them. Or, the unit would call me even though it wasn’t my call day, I’d be like, ‘okay, I’m not going to answer it’ and then I’d call back 30 minutes later because I had to make sure everything was OK.” Another noted the personal demands stating, “There is not good work-life balance if you want to be a good manager…the demands are way higher than they should be.” Still others spoke of always being on the outside of the unit group. One noted, I’m not everybody’s best friend,” while another commented, “there’s a lot of manager exclusion.” There were many comments regarding the demands involved with role implementation. Comments like: “sometimes you are spread so thin,” “you don’t have all the authority and autonomy that your staff think you have,” “I still need my job…I have to decide the hills to die on…where I am going to push the envelope,” and “the support and resources are not there for us anymore” attest to role implementation demands. The participants were passionate as they discussed the difficulties of being a “middle” manager. One described feeling “squeezed” while another spoke of being “tossed” between the “responsibilities of budget and outcomes and Joint Commission review.” Similarly, one addressed the discomfort of being between staff and the organization when decisions are being made: “you support what the hospital decides…a difficult position is trying to sell things to your staff and you’re thinking I’m not sure about that.” Finally, one summarized this challenge, “It is the toughest position on the planet. There is no one between you and the staff. There is no one between you and the patient. There is no one between you and the family and there is no one between you and the administration. It’s very, very, very, very, very challenging when you’re extremely busy and overloaded and you just feel like you want to pull your hair out…it’s fun when it works, but it’s tough.” The category, “comfort in the role comes with time,” emerged as seven participants (54%) discussed how adjusting to the role did not happen immediately upon stepping into the role. One participant spoke of “learning to relax a little bit … most things aren’t life and death.” Another said,” I found myself changing because I always thought I have to think of a solution right now … that was a change in me … I don’t feel like I have to solve the issues. I don’t have to know everything about everything … I’ve loosened up the reins and now I say, ‘here folks, you’re smart people, you can figure this out’.” Another added, “I grew into being a better manager…it took a couple of years for me to feel comfortable in that new skin … I never really grasped the concept that I was the boss … I was one of them … I finally got that I could be the boss, still be a nice person and still be all those things. It was better … I felt comfortable in my new skin.” 3.5. Discussion and practice implications Findings from this study highlight the need for practice changes if nurse managers are to thrive in the role and the role is to be sustained. The finding that only 54% of participants readily recognized their leadership potential and “knew” the manager role was meant for them is of concern. Even when encouraged to take on the role, 46% remained reluctant, perhaps indicating they did not recognize leadership potential
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in themselves. This finding suggests the need for better identification and cultivation of staff nurses who possess leadership qualities and serves as the basis for several practice recommendations. First, simulation assessment centers, often used by healthcare organizations to determine nursing practice capabilities, can be used to create reality based simulations in which managerial skills and abilities can also be identified. Some suggest that simulation training allows for development of managerial skills at a fast pace and is therefore ideal for identifying and educating emergent managers (Salas, Wildman, & Piccolo, 2009). In addition, nurse managers, as front-line leaders, are ideally situated to continually assess leadership potential in their staff. Once leadership potential is identified, managers can provide opportunities for emergent leaders to “try on” the role for short stints under the direction of the expert nurse manager. Identifying nurses who demonstrate leadership attributes and helping them grow their leadership potential are important initial steps in cultivating managers for the future. These actions can contribute to the development of leadership succession plans, plans that are often non-existent in healthcare organizations (Titzer, Phillips, Tooley, Hall, & Shirey, 2013). Identifying and cultivating leadership potential is crucial when considering predicted managerial vacancies (Hodes Healthcare Division, 2006). The finding that 75% of participants had negative role orientation experiences is alarming, but parallels the reports of others (DeCampli et al., 2010; Espinoza et al., 2009). Participants spoke of having limited orientation, orientation “not as good as” the orientation offered to new graduates. Participants’ accounts of learning “on the fly” and “being thrown into the position” and the descriptions of the emotional toll that such experiences had on the participants speak to the need for practice change and serve as the foundation for practice recommendations. More standardized orientation programs specifically targeted for new nurse managers should be designed and offered. These programs should parallel those developed for new graduates and take place over several months, with experienced nurse managers serving as formally assigned preceptors, guiding new managers in the role. Orientations should be competency based addressing topics that focus on the five competency domains relevant to all healthcare managers including communication and relationship management, professionalism, leadership, knowledge of the healthcare system, and business skills and knowledge (Stefl, 2008). Emergent managers should work toward achieving competencies in these areas under the guidance of expert managers. Educational workshops that focus on specific topics such as budgets, finance, performance evaluations, and relationship building, areas identified by participants in this study as areas where knowledge was lacking, should be emphasized. The finding that 69% of participants desired to be mentored and coached in the role is of interest. Although others have noted the importance of mentorship to those new to the role (Cziraki et al., 2014; DeCampli et al., 2010), a somewhat surprising finding was that participants well-seasoned in the role also desired mentorship. Participants with 9, 10, and 16 years of experience voiced their wish to have another person walk alongside. As noted by one participant, “I still need to be mentored…I think that gets lost.” Often there is an assumption that expert managers have determined how to appropriately navigate in the role and require minimal, if any, guidance from others. The finding that managers with all levels of expertise desire mentorship provides the basis for the practice recommendation that organizations work to provide opportunities for managers to meet, socialize, and develop mentoring and coaching networks that will continue well beyond the first year in the role. Finally, findings from this study support the work of others who have noted the complexity and stressful nature of the nurse manager role (Shirey et al., 2008). Participants spoke of having to address the demands of the role, both personal and those encountered during role implementation. Participants told of feeling “guilty” if not attending to the role responsibilities on a 24-7 basis and of not having a “good work-life balance.” They spoke of being “spread thin.” Because both leadership
and management responsibilities are now enveloped in the nurse manager role, it is a difficult and challenging role to fulfill. Therefore, practice change is recommended. Organizations should consider possible ways to transform the role. One creative strategy is the use of the comanaging model. With this model two full time employees are assigned to the manager role rather than one. The co-manager model has been shown to decrease turnover and increase personal empowerment among nurse managers (Shirey et al., 2008). Creative and flexible strategies are essential if future generations of nurses are to be drawn to this pivotal role in healthcare. 4. Conclusion The role of nurse manager is a demanding but essential role in today’s ever changing healthcare arena. Understanding the insights of nurse managers regarding the role is imperative if strategies are to be developed to address their concerns and to enable recruitment and retention of qualified individuals to the role. Findings from this study indicate the need for better identification and cultivation of future managers, development of orientation programs targeted specifically for new managers, establishment of more formalized networking groups for both novice and expert managers, and the development of new and creative models for transforming the challenging nurse manager role. Supporting those who are currently fulfilling the role and those who come to the role in the future is crucial if the nurse manager role is to remain vital and sustained in healthcare organizations. Acknowledgement The authors would like to acknowledge the Omicron Chapter of Sigma Theta Tau for its financial support of this research. Conflicts of interest: none. References Aiken, L. C., & Harper-Harrison, A. (2012). Is there a fast track to new nurse manager preparation? Nursing Management, 43, 11–14. Cowden, T., Cummings, G., & Profetto-McGrath, J. (2011). Leadership practices and staff nurses’ intent to stay: A systematic review. Journal of Nursing Management, 19, 461–477. Cziraki, K., McKey, C., Peachey, G., Baxter, P., & Flaherty, B. (2014). Factors that facilitate Registered Nurses in their first-line nurse manager role. Journal of Nursing Management, 22, 1005–1014. DeCampli, P., Kirby, K. K., & Baldwin, C. (2010). Beyond the classroom to coaching: Preparing new nurse managers. Critical Care Nursing Quarterly, 33, 132–137. Espinoza, D. C., Lopez-Saldana, A., & Stonestreet, J. S. (2009). The pivotal role of the nurse manager in healthy workplaces: Implications for training and development. Critical Care Nursing Quarterly, 32, 327–334. Fennimore, L., & Wolf, G. (2011). Nurse manager leadership development: Leveraging the evidence and system-level support. Journal of Nursing Administration, 41, 204–210. Gray, L. R. (2012). Nurse manager engagement: A concept analysis. Nursing Forum, 47, 193–199. Hodes Healthcare Division (2006). The 2006 Aging Workforce Study. Atlanta: The Bernard Hodes Group. Hsieh, H., & Shannon, S. E. (2005). Three approaches to qualitative content analysis. Qualitative Health Research, 15, 1277–1288. Keys, Y. (2014). Looking ahead to our next generation of nurse leaders: Generation X nurse managers. Journal of Nursing Management, 22, 97–105. Krippendorff, K. (2004). Content analysis: An introduction to its methodology (2nd ed.). London: Sage. Mackoff, B., & Triolo, P. K. (2008). Why do nurse managers stay? Building a model of engagement. Part 2. Cultures of engagement. Journal of Nursing Administration, 38, 166–171. McCallin, A. M., & Frankson, C. (2010). The role of the charge nurse manager: A descriptive exploratory study. Journal of Nursing Management, 18, 319–325. O’Neil, E., Morjikian, R., & Cherner, D. (2008). Developing nursing leaders: An overview of trends and programs. Journal of Nursing Administration, 38, 178–183. Paliadelis, P., Cruickshank, M., & Sheridan, A. (2007). Caring for each other: How do nurse managers ‘manage’ their role? Journal of Nursing Management, 15, 830–837. Richmond, P. A., Book, K., Hicks, M., Pimpinella, A., & Jenner, C. A. (2009). C.O.M.E. be a nurse manager. Nursing Management, 40, 52–54. Salas, E., Wildman, J. L., & Piccolo, R. F. (2009). Using simulation-based training to enhance management education. Academy of Management Learning and Education, 8(4), 559–573. Schmalenberg, C., & Kramer, M. (2009). Nurse manager support: How do staff nurses define it? Critical Care Nurse, 29, 61–69.
L.W. Moore et al. / Applied Nursing Research 30 (2016) 98–103 Shirey, M. R. (2006). Authentic leaders: Creating healthy work environments for nursing practice. American Journal of Critical Care, 15, 256–267. Shirey, M. R., Ebright, P. R., & McDaniel, A. M. (2008). Sleepless in America: Nurse managers cope with stress and complexity. Journal of Nursing Administration, 38, 125–131. Shirey, M. R., McDaniel, A. M., Ebright, P. R., Fisher, M. L., & Doebbeling, B. N. (2010). Understanding nurse manager stress and work complexity. Journal of Nursing Administration, 40, 82–91. Stefl, M. E. (2008). Common competencies for all healthcare managers: The Healthcare Leadership Alliance Model. Journal of Healthcare Management, 53, 360–374.
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Titzer, J., Phillips, T., Tooley, S., Hall, N., & Shirey, M. (2013). Nurse manager succession planning: A synthesis of the evidence. Journal of Nursing Management, 21, 971–979. Vaismoradi, M., Turunen, H., & Bondas, T. (2013). Content analysis and thematic analysis: Implications for conducting a qualitative descriptive study. Nursing and Health Sciences, 15, 398–405. Zwink, J. E., Dzialo, M., Fink, R. M., Oman, K. S., Shiskowsky, K., Waite, K., ... Le-Lazar, J. T. (2013). Nurse manager perceptions of role satisfaction and retention at an academic Medical Center. Journal of Nursing Administration, 43, 135–141.
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Applied Nursing Research journal homepage: www.elsevier.com/locate/apnr
Nurse managers’ insights regarding their role highlight the need for practice changes Linda Weaver Moore, PhD, RN, CNS, CNL ⁎, Cynthia Sublett, PhD, RN, CNL 1, Cathy Leahy, MSN, MEd, CNL Xavier University School of Nursing, 3800 Victory Parkway, Cincinnati, OH 45207
a r t i c l e
i n f o
Article history: Received 21 August 2015 Revised 6 November 2015 Accepted 8 November 2015 Available online xxxx Keywords: Nurse manager Retention Recruitment Leadership development Succession planning
a b s t r a c t Aim: The purpose of this study was to understand the insights of nurse managers regarding the nurse manager role. Background: Nurse managers are vital to the success of healthcare organizations. Vacancy rates of nurse manager positions are on the rise. Recruiting and retaining qualified individuals for these positions requires an understanding of the perceptions of nurse managers regarding the role and the issues embedded in the role. Methods: A descriptive, qualitative investigation was conducted. Data were analyzed using content analysis. Findings: Although desired, role orientation, mentorship, and a strong foundational knowledge, were often lacking. Personal attributes viewed as important for success in the role included seeking opportunities and intentional selfgrowth. Lessons learned while in the role included the art of managing role demands and that comfort comes with time. Conclusion: Concerns regarding the preparation for, introduction to, and support in the nurse manager role highlight the need for practice changes. © 2015 Elsevier Inc. All rights reserved.
The role of nurse manager is often demanding and sometimes daunting in today’s ever evolving healthcare arena. Nurse managers have been described as being the “key interface between patients, nursing staff, medical staff, other clinical and ancillary staff, and hospital administration,” as they manage both human and capital resources (DeCampli, Kirby, & Baldwin, 2010, p. 132). They are vital to the success of healthcare organizations, influencing profitability, nurse retention, and the overall organizational environment (Cowden, Cummings, & Profetto-McGrath, 2011; Gray, 2012; Shirey, McDaniel, Ebright, Fisher, & Doebbeling, 2010). Considering the complexities of the current healthcare system, the role of nurse manager is generally considered one of the most valuable, yet challenging in any healthcare organization. Concerns regarding vacancy rates of nurse manager positions are on the rise. According to the 2006 Aging Workforce Survey, of 978 nurse leaders, approximately 55% are planning to retire between 2011 and 2020 (Hodes Healthcare Division, 2006). In addition, the pool of qualified applicants from which to draw may be limited considering the fact that members of Generation X may find the challenges confronting nurse managers such as a lack of upward mobility, the need to be available at all times, and the inflexibility of organizations to be unappealing and out of alignment with their views of professional success and personal fulfilment (Keys, 2014). Replacing a workforce of individuals with long careers in organizational management is a formidable task
⁎ Corresponding author. Tel.: +1 513 745 1008. E-mail addresses: [email protected] (L.W. Moore), [email protected] (C. Sublett). 1 Tel.: +1 513 745 4333. http://dx.doi.org/10.1016/j.apnr.2015.11.006 0897-1897/© 2015 Elsevier Inc. All rights reserved.
and requires a clear understanding of the issues that nurse managers face and the perceptions that nurse managers hold regarding the role. The purpose of this article is to present findings from a qualitative study that examined the perceptions of nurse managers regarding the nurse manager role. Insights gleaned highlight the need for practice changes. Attending to the voices of those who walk the walk is imperative if well qualified individuals are to be recruited, retained, and satisfied in the nurse manager role and if the role is to remain vital in future healthcare organizations. 1. Background As the healthcare system has been redesigned over the past three decades, so has the role of nurse manager. Today the role is more complex as increasing demands and broader responsibilities have been added to the job description (Shirey, Ebright, & McDaniel, 2008). Nurse managers must attend to both leadership and management responsibilities (McCallin & Frankson, 2010), including responsibilities such as staffing, establishing goals and objectives for the unit, formulating standards of care, managing budgets and quality improvement activities, as well as, hiring, orienting, and evaluating staff (Richmond, Book, Hicks, Pimpinella, & Jenner, 2009). As healthcare systems continue to evolve, the expectations of nurse managers will continue to be more expansive and require even newer and enhanced levels of skills (Aiken & Harper-Harrison, 2012). Because of the complexity of the role and the potential for role overload (McCallin & Frankson, 2010), role stress and burnout have been noted (Shirey et al., 2008; Zwink et al., 2013).
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Nurse managers are key to the creation of a healthy and successful work environment (Shirey, 2006). Staff nurses in Magnet hospitals have noted nurse manager support as 1 of 8 essentials of a healthy work environment (Schmalenberg & Kramer, 2009). Nurse managers often set the tone for the workplace and can greatly impact staff nurse satisfaction and retention (Cowden et al., 2011; Shirey, 2006; Shirey et al., 2008). Organizational productivity and profitability have also been noted to be influenced by the level of nurse manager engagement (Gray, 2012). Literature suggests that thoughtful recruitment of individuals to the role of nurse manager has been lacking. Nurse managers have been selected based on clinical expertise rather than leadership and management potential (Fennimore & Wolf, 2011; McCallin & Frankson, 2010). There is the expectation that the nurse who does well clinically will also do well in management, but, expert clinicians often become management novices (McCallin & Frankson, 2010). Pressure to fill longvacant manager positions may also increase the risk that an underprepared nurse from the ranks will be called upon to fill the position (Espinoza, Lopez-Saldana, & Stonestreet, 2009). Therefore, nurse managers often lack the needed preparation and leadership skills to step into the role (Fennimore & Wolf, 2011) and learn to manage through a trial and error approach, with much learning about leadership occurring after an individual undertakes the role (Paliadelis, Cruickshank, & Sheridan, 2007). Orientation and socialization to the role may also be minimal. While nurse managers have reported a steep learning curve coming into the role (Cziraki, McKey, Peachey, Baxter, & Flaherty, 2014), few orientation programs are specifically designed for new nurse managers (O’Neil, Morjikian, & Cherner, 2008). Nurse managers have noted the need for not only early socialization and development in the role, but also sustained activities that would continue to promote growth (Mackoff & Triolo, 2008). Researchers who have examined trends in healthcare caution that unless there is organizational commitment to development of leadership, including development of nurse managers, the future of healthcare organizations may be at risk (O’Neil et al., 2008). Two recent studies explored the perceptions of nurse managers regarding what attracted them to the role and what retained them in the role (Cziraki et al., 2014; Zwink et al., 2013). In one study, 20 nurse managers offered the following reasons for their attraction to the role: a desire to effect a change, natural career progression, and encouragement by colleagues. Reasons found for staying in the role included peer collaboration and the ability to make positive changes (Zwink et al., 2013). Findings from a study of 11 nurse managers suggested that they were attracted to the role because they perceived the work as meaningful and saw the role as providing an opportunity for advancement. Nurse managers remained in the role because of a passion for their specialties, the accomplishments of staff, and their ability to continue to grow (Cziraki et al., 2014). Scholars have concluded that the nurse manager role has been understudied noting that further research is needed to determine strategies for supporting nurse managers (Cziraki et al., 2014). Findings presented in this article add to the body of knowledge regarding the perceptions of nurse managers regarding the nurse manager role. Findings also highlight the need for changes in practice if the role is to remain vital and sustainable for healthcare organizations in the future. 2. Methods Data presented in this article are part of a larger data set from a study focused on maintaining healthy work environments and the part nurse managers play in creating those environments. Data for this article derived from questions designed to elicit information regarding nurse managers’ perceptions of the role. This study was a descriptive, qualitative investigation. Semi-structured, researcher-participant interviews allowed for sufficient structure to elicit thick, rich descriptions from the managers regarding their experiences, but flexible enough for
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researchers to probe deeper when further clarification of their stories was needed. 2.1. Participants Participants sought for the study were individuals who held the title of nurse manager or a similar title with middle management duties such as 24 hour fiscal, quality and human resources responsibilities for at least one department or nursing unit within an acute care facility. Individuals were recruited who had been in the role for at least 1 year. The researchers desired to include nurse managers who were a “good fit” for the role. “Good fit” was loosely defined by the researchers to be nurse managers who had staff that seemed satisfied and respected the nurse manager’s leadership. Having worked with many nurse managers and their nursing staff over several years while serving as faculty guiding students through clinical rotations, the researchers were familiar with nurse managers who seemed to be a “good fit” for the role. Although selecting “good fit” managers was loosely defined and based on anecdotal information, it provided the researchers with some parameters in selecting nurse managers who seemed well suited to the role. The expectation was individuals who served in the role for at least a year and who were a “good fit” for the role would be accustomed to and thriving in the role and could provide rich descriptions. Eighteen potential participants were recruited via email with information regarding the study and were requested to respond to the researchers if they were interested in participating. If no response was received, a follow-up email was sent after 48 hours. Of the 18 potential participants recruited, 13 agreed to be interviewed. Of the 13 participants, all were employed in large, urban Midwestern acute care organizations. Five different healthcare organizations were represented. The age range of participants was from 30 to 64 years (mean [SD], 48.9 [9.51] years). The number of years participants were employed in the nurse manager role ranged from 1 to 32 years (mean [SD], 10.38 [9.43] years). Eleven participants (85%) were female, while 2 participants (15%) were male. For 7 participants (54%) a baccalaureate was the highest educational degree held, while 6 participants (46%) held master’s degrees. The participants’ places of employment represented a number of specialties including: medical-surgical units, intensive care units, emergency room, and operating room. 2.2. Data collection After receiving institutional review board approval from the researchers’ affiliated university, recruitment emails were sent to potential participants outlining the study. Individuals were asked to respond back to the researchers if they were interested in participating. Once participants agreed to be involved, a date and time for the researcherparticipant interview was established. All interviews were conducted over a 4 month period during non-work hours and at locations away from the participant’s work setting. Two researchers conducted 4 interviews each and the third researcher conducted five interviews. Interview questions, developed by the researchers, were broad in nature and designed to assist participants in telling their personal experiences of living the nurse manager role. In addition, questions were asked that focused on the health of the nurse manager’s work environment and nurse relationships. For the purposes of this article, only data focused on the perceptions of nurse managers regarding the role are reported. Written consent was obtained prior to each interview. Interviews lasted between 60 to 90 minutes and were audio tape recorded and later transcribed. Transcriptions were verified for accuracy. 2.3. Data analysis Transcripts of the interviews were analyzed using a conventional content analysis approach. By using this approach, researchers allowed categories and names for categories to emerge from the data rather than
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using preconceived categories (Hsieh & Shannon, 2005). The three researchers independently read each transcript several times to immerse themselves in the data and gain a sense of the data as a whole. Each researcher read each interview carefully word by word, capturing all data that pertained to the nurse manager role and highlighted key words and phrases from the data. Main ideas were then identified from the key words and phrases and labeled without interpretation. Together, researchers clustered similar ideas, and through the use of interpretation and the movement of ideas to a higher level of abstraction, categories emerged that were representative of the clustered group. In addition, throughout the data analysis process, careful tracking was maintained regarding the number of participants represented within each category, allowing for frequency counts to be determined. Scholars have suggested that content analysis allows for data to be analyzed qualitatively and, at the same time, provides an opportunity to quantify the data (Vaismoradi, Turunen, & Bondas, 2013). While greater frequency may simply represent the participants’ willingness to talk more openly about one topic than another, a greater frequency can indicate greater importance and, with caution, be viewed as representative of a higher level of significance (Vaismoradi et al., 2013). To enhance the rigor of the study, several measures were taken by the researchers. Researchers were skilled with qualitative data analysis, having conducted several previous qualitative investigations. Researchers analyzed data independently and, then came together, and through discussion and constantly returning to the data, reached agreement regarding the findings. An audit trail was maintained throughout and findings were linked directly back to the data. After the review of transcripts, researchers sought clarification from participants of any areas of the transcripts that appeared unclear. Some participants also contacted the researchers after their interview when, upon reflection, they believed something they said needed clarification. Finally, as noted by Krippendorff (2004), one way to determine the quality of findings is whether new understandings regarding the studied phenomenon are uncovered that can inform practice. Findings from this study provide a better understanding of nurse managers’ insights regarding the role and highlight areas for needed practice changes. 3. Results The findings presented highlight the perceptions of participants regarding the nurse manager role. The participants’ descriptions focused on four overarching topics including: their path to becoming a nurse manager, what they ‘wished for’ as a manager to help them grow, personal attributes that they believed contributed to their success, and lessons learned. Categories that emerged from the data for each topic are presented as well as the frequency percentages, signifying the number of participants represented within that category. Because of the rich detail of the descriptions, the percentages are greater than 100% for each topic.
just knew that the role was right for them. These participants actively sought out the role, voicing aspirations for upward mobility to those already in leadership positions. One participant stated, “I expressed to my manager that I was looking for some additional ways to grow,” while another commented, “I had significant leadership experience in another field and I approached the director and said, ‘would you consider looking at my years of leadership experience in another area’.” However, six participants (46%) told of being approached by others and more passively accepting the role. One commented that she “fell into” the role while another talked of being “pushed” into the role. One participant stated, “I walked into the ICU where I worked and someone said to me, ‘oh we heard you’re going to apply for the nurse manager job.’ I said, ‘me?’ ‘No way,’ and I thought about it. I met with my boss and I talked it through with her. I talked it through with my husband and I actually went back and said, ‘I don’t think it’s for me.’ Then I slept on it a couple of days and I thought I do want to do it and I went back and I said, ‘I do want to interview.’” The idea that others could see leadership potential in the participants, even when they themselves had not considered the possibility, is also evidenced in this statement, “I was walking past my boss and she said, ‘hey come in here a minute’ and it was the beginning of the end. I didn’t know if I was going to like the nurse manager position.” Nine participants’ (69%) descriptions revealed the category, “climbing the leadership ladder.” These participants told of how, prior to being formally appointed as a nurse manager, they served in various leadership positions such as nurse preceptor, charge nurse, and shift supervisor. One participant described how the nurse manager role seemed like the next step and commented, “I did such a good job as charge nurse running the department so they thought it would be a natural progression.” Another commented on how a previous leadership role had helped to prepare her stating, “the charge nurse role probably prepared me the best because of all the interdisciplinary interactions and in terms of being a resource to help facilitate the flow and the care of patients.” Twelve participants shared thoughts regarding their orientation to the role. While three of the twelve participants (25%) related a positive experience that involved “many resources” and “wonderful opportunities,” the much more common experience that emerged from their stories was one of trial by fire (9 participants, 75%). Participants’ comments exemplified the difficulties experienced with statements such as, “the orientation was essentially non-existent…it was shocking to me…they turned me loose and said you’re in charge. Call me if you need me.” Similarly, one participant stated, “It was pretty horrible… I learned a lot the hard way.” Other comments that highlight this time of trial included, “there was a lot of learn on the fly,” “I was thrown into the position with a week’s orientation,” and “I learned everything on my own and, for a while, I didn’t know what I didn’t know.” Comments by some participants reflected the emotional toll their negative role introduction had on them. One said, “I struggled for years,” while others commented, “it was very hard on me,” and “it’s still a tremendous sore spot.”
3.1. Path to becoming 3.2. Growth in the role Participants described their journey to becoming a nurse manager. Four categories emerged from the data including: “paid dues,” “actively seeking-passively accepting,” “climbing the leadership ladder,” and “trial by fire.” Thirteen participants (100%) explained how they had paid dues, each working as staff nurses prior to becoming a manager. The years that participants worked as bedside nurses ranged from two to 22 years. None of the participants came directly from their basic educational studies to the manager role. They spoke of how they believed their nurses valued the fact that, as managers, they had previously walked in the shoes of a nurse and could “do the job” they were asking of their staff. As the participants spoke about how they came to consider the nurse manager role, some told of actively seeking the role while others told of passively accepting the role. Seven participants (54%) shared that they
Participants shared their thoughts regarding what they wished they had available to them to help them grow in the role. Two categories emerged from the data including, “someone to walk alongside” and “a stronger foundational knowledge from which to draw.” Nine participants’ (69%) descriptions revealed a hunger for more formal mentorship or coaches to “walk alongside” guiding them and supporting them. Many spoke of how mentorship was missing for both individuals new to the role and those with more experience. One participant noted how, for novice managers, “assigned” mentors would be helpful to “go to with all the questions.” Other participants noted that bosses can serve as wonderful mentors but time constraints often get in the way. One participant stated, “I would love it if my immediate boss would be able to have the time to truly mentor and foster me more formally … I
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would like it because she has great knowledge, great experience… We’re both so busy. We just don’t have the opportunity.” Even those with years of managerial experience desired mentorship, but often found it was not a reality. One participant with 16 years in the manager role noted, “Being mentored or coached does not exist as a leader …We do not network well and we do not support each other well. There’s really not the opportunity to do it. It’s not so much that we don’t want to … the environment does not exist for that to happen. I think we fail ourselves miserably.” This desire for mentorship was also noted in the comments of another participant with 10 years of managerial experience, “I still need to be mentored even though I’ve been doing this for quite some time, sometimes I think that gets lost.” A “stronger foundational knowledge from which to draw” emerged in the accounts of seven participants (54%) as something they wished they had available to them. Participants desired a stronger foundation in areas including budgeting, finance, relationship building, and performance evaluations. Some participants believed that more structured orientation programs specifically for managers could ease some knowledge deficits. One participant stated, “I stumbled upon the fact that our employee files weren’t how they should be, but nobody told me that … It would also be nice if there were a little bit more guidance when evaluations were due. It was kind of like, ‘Your evaluations are coming due in July. Go!’ Maybe classes or maybe even just, ‘hey, why don’t you sit in on this evaluation. This is the criteria we’re looking for.” Some participants’ comments indicated that while certain topics are addressed in occasional classes, more in-depth information is desired. One noted, “Probably at least 50% of my day is working around HR issues with staff … you get a class about it. There are guides, but the guides are not always real specific.” Other comments suggested that real-life situations rarely play out as depicted in class. “They talk broad strokes in class but not actually down to the nitty gritty like those uncomfortable conversations…they talk broad strokes but that’s never how the conversation goes. Employees never respond like the person on the video does!” 3.3. Personal attributes essential to the role As the participants shared their stories the personal attributes that they believed were essential to their success in the role of nurse manager became apparent. Two categories emerged: “valuing, seeking and seizing opportunities” and “intentional self-growth.” Ten participants’ stories (77%) revealed the importance of “valuing, seeking, and seizing opportunities” throughout their careers. One participant spoke about being part of a team who created a new nursing unit and her experience of being the manager of that unit. She noted, “I knew that was not a very frequently occurring opportunity, to be able to create something from scratch and wow it’s been the greatest part of my career by far.” Another talked about how she responds when seeing things that need improvement and noted, “I’m more of a glass half full than a glass half empty person … when I look at something, I think this isn’t bad, it’s just an opportunity and we can fix it.” Another’s comments also spoke to the importance of looking for and grabbing opportunities as she stated, “Opportunities sometimes come calling to me like this role … I saw this role and thought I’m called to do that. It’s definitely seizing those opportunities.” Nine participants (69%) made comments that supported the category of “intentional self-growth.” Comments included: “I have an inquisitiveness of always wanting to know why,” “I’ve gone to classes to work on my weaknesses,” and “I taught myself … I’m still learning.” One participant discussed how she watched other leaders and said, “I’m pretty diligent about picking out characteristics that I want to emulate and working towards that end.” Another reflected her intention toward self-growth commenting, “I’ve invited people to mentor me…I ask a lot of questions … being open to feedback … I have that selfawareness to say, ‘What can I do better? What are some areas that I can develop that will help me as a leader?’”’
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3.4. Lessons learned Although participants were not specifically asked to address lessons learned over their years as a nurse manager, all 13 participants’ (100%) narratives were threaded with insights gained with experience. Two categories emerged from their accounts regarding lessons learned including “the art of managing role demands” and “comfort in the role comes with time.” Seven participants (54%) spoke of learning “the art of managing role demands.” Some demands came with role implementation while others were on a more personal level such as the recognition and maintenance of boundaries. One commented, “I had problems drawing boundaries with the staff. On days when I wasn’t on call, I’d get tons of calls at home but I’d feel guilty not answering them. Or, the unit would call me even though it wasn’t my call day, I’d be like, ‘okay, I’m not going to answer it’ and then I’d call back 30 minutes later because I had to make sure everything was OK.” Another noted the personal demands stating, “There is not good work-life balance if you want to be a good manager…the demands are way higher than they should be.” Still others spoke of always being on the outside of the unit group. One noted, I’m not everybody’s best friend,” while another commented, “there’s a lot of manager exclusion.” There were many comments regarding the demands involved with role implementation. Comments like: “sometimes you are spread so thin,” “you don’t have all the authority and autonomy that your staff think you have,” “I still need my job…I have to decide the hills to die on…where I am going to push the envelope,” and “the support and resources are not there for us anymore” attest to role implementation demands. The participants were passionate as they discussed the difficulties of being a “middle” manager. One described feeling “squeezed” while another spoke of being “tossed” between the “responsibilities of budget and outcomes and Joint Commission review.” Similarly, one addressed the discomfort of being between staff and the organization when decisions are being made: “you support what the hospital decides…a difficult position is trying to sell things to your staff and you’re thinking I’m not sure about that.” Finally, one summarized this challenge, “It is the toughest position on the planet. There is no one between you and the staff. There is no one between you and the patient. There is no one between you and the family and there is no one between you and the administration. It’s very, very, very, very, very challenging when you’re extremely busy and overloaded and you just feel like you want to pull your hair out…it’s fun when it works, but it’s tough.” The category, “comfort in the role comes with time,” emerged as seven participants (54%) discussed how adjusting to the role did not happen immediately upon stepping into the role. One participant spoke of “learning to relax a little bit … most things aren’t life and death.” Another said,” I found myself changing because I always thought I have to think of a solution right now … that was a change in me … I don’t feel like I have to solve the issues. I don’t have to know everything about everything … I’ve loosened up the reins and now I say, ‘here folks, you’re smart people, you can figure this out’.” Another added, “I grew into being a better manager…it took a couple of years for me to feel comfortable in that new skin … I never really grasped the concept that I was the boss … I was one of them … I finally got that I could be the boss, still be a nice person and still be all those things. It was better … I felt comfortable in my new skin.” 3.5. Discussion and practice implications Findings from this study highlight the need for practice changes if nurse managers are to thrive in the role and the role is to be sustained. The finding that only 54% of participants readily recognized their leadership potential and “knew” the manager role was meant for them is of concern. Even when encouraged to take on the role, 46% remained reluctant, perhaps indicating they did not recognize leadership potential
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in themselves. This finding suggests the need for better identification and cultivation of staff nurses who possess leadership qualities and serves as the basis for several practice recommendations. First, simulation assessment centers, often used by healthcare organizations to determine nursing practice capabilities, can be used to create reality based simulations in which managerial skills and abilities can also be identified. Some suggest that simulation training allows for development of managerial skills at a fast pace and is therefore ideal for identifying and educating emergent managers (Salas, Wildman, & Piccolo, 2009). In addition, nurse managers, as front-line leaders, are ideally situated to continually assess leadership potential in their staff. Once leadership potential is identified, managers can provide opportunities for emergent leaders to “try on” the role for short stints under the direction of the expert nurse manager. Identifying nurses who demonstrate leadership attributes and helping them grow their leadership potential are important initial steps in cultivating managers for the future. These actions can contribute to the development of leadership succession plans, plans that are often non-existent in healthcare organizations (Titzer, Phillips, Tooley, Hall, & Shirey, 2013). Identifying and cultivating leadership potential is crucial when considering predicted managerial vacancies (Hodes Healthcare Division, 2006). The finding that 75% of participants had negative role orientation experiences is alarming, but parallels the reports of others (DeCampli et al., 2010; Espinoza et al., 2009). Participants spoke of having limited orientation, orientation “not as good as” the orientation offered to new graduates. Participants’ accounts of learning “on the fly” and “being thrown into the position” and the descriptions of the emotional toll that such experiences had on the participants speak to the need for practice change and serve as the foundation for practice recommendations. More standardized orientation programs specifically targeted for new nurse managers should be designed and offered. These programs should parallel those developed for new graduates and take place over several months, with experienced nurse managers serving as formally assigned preceptors, guiding new managers in the role. Orientations should be competency based addressing topics that focus on the five competency domains relevant to all healthcare managers including communication and relationship management, professionalism, leadership, knowledge of the healthcare system, and business skills and knowledge (Stefl, 2008). Emergent managers should work toward achieving competencies in these areas under the guidance of expert managers. Educational workshops that focus on specific topics such as budgets, finance, performance evaluations, and relationship building, areas identified by participants in this study as areas where knowledge was lacking, should be emphasized. The finding that 69% of participants desired to be mentored and coached in the role is of interest. Although others have noted the importance of mentorship to those new to the role (Cziraki et al., 2014; DeCampli et al., 2010), a somewhat surprising finding was that participants well-seasoned in the role also desired mentorship. Participants with 9, 10, and 16 years of experience voiced their wish to have another person walk alongside. As noted by one participant, “I still need to be mentored…I think that gets lost.” Often there is an assumption that expert managers have determined how to appropriately navigate in the role and require minimal, if any, guidance from others. The finding that managers with all levels of expertise desire mentorship provides the basis for the practice recommendation that organizations work to provide opportunities for managers to meet, socialize, and develop mentoring and coaching networks that will continue well beyond the first year in the role. Finally, findings from this study support the work of others who have noted the complexity and stressful nature of the nurse manager role (Shirey et al., 2008). Participants spoke of having to address the demands of the role, both personal and those encountered during role implementation. Participants told of feeling “guilty” if not attending to the role responsibilities on a 24-7 basis and of not having a “good work-life balance.” They spoke of being “spread thin.” Because both leadership
and management responsibilities are now enveloped in the nurse manager role, it is a difficult and challenging role to fulfill. Therefore, practice change is recommended. Organizations should consider possible ways to transform the role. One creative strategy is the use of the comanaging model. With this model two full time employees are assigned to the manager role rather than one. The co-manager model has been shown to decrease turnover and increase personal empowerment among nurse managers (Shirey et al., 2008). Creative and flexible strategies are essential if future generations of nurses are to be drawn to this pivotal role in healthcare. 4. Conclusion The role of nurse manager is a demanding but essential role in today’s ever changing healthcare arena. Understanding the insights of nurse managers regarding the role is imperative if strategies are to be developed to address their concerns and to enable recruitment and retention of qualified individuals to the role. Findings from this study indicate the need for better identification and cultivation of future managers, development of orientation programs targeted specifically for new managers, establishment of more formalized networking groups for both novice and expert managers, and the development of new and creative models for transforming the challenging nurse manager role. Supporting those who are currently fulfilling the role and those who come to the role in the future is crucial if the nurse manager role is to remain vital and sustained in healthcare organizations. Acknowledgement The authors would like to acknowledge the Omicron Chapter of Sigma Theta Tau for its financial support of this research. Conflicts of interest: none. References Aiken, L. C., & Harper-Harrison, A. (2012). Is there a fast track to new nurse manager preparation? Nursing Management, 43, 11–14. Cowden, T., Cummings, G., & Profetto-McGrath, J. (2011). Leadership practices and staff nurses’ intent to stay: A systematic review. Journal of Nursing Management, 19, 461–477. Cziraki, K., McKey, C., Peachey, G., Baxter, P., & Flaherty, B. (2014). Factors that facilitate Registered Nurses in their first-line nurse manager role. Journal of Nursing Management, 22, 1005–1014. DeCampli, P., Kirby, K. K., & Baldwin, C. (2010). Beyond the classroom to coaching: Preparing new nurse managers. Critical Care Nursing Quarterly, 33, 132–137. Espinoza, D. C., Lopez-Saldana, A., & Stonestreet, J. S. (2009). The pivotal role of the nurse manager in healthy workplaces: Implications for training and development. Critical Care Nursing Quarterly, 32, 327–334. Fennimore, L., & Wolf, G. (2011). Nurse manager leadership development: Leveraging the evidence and system-level support. Journal of Nursing Administration, 41, 204–210. Gray, L. R. (2012). Nurse manager engagement: A concept analysis. Nursing Forum, 47, 193–199. Hodes Healthcare Division (2006). The 2006 Aging Workforce Study. Atlanta: The Bernard Hodes Group. Hsieh, H., & Shannon, S. E. (2005). Three approaches to qualitative content analysis. Qualitative Health Research, 15, 1277–1288. Keys, Y. (2014). Looking ahead to our next generation of nurse leaders: Generation X nurse managers. Journal of Nursing Management, 22, 97–105. Krippendorff, K. (2004). Content analysis: An introduction to its methodology (2nd ed.). London: Sage. Mackoff, B., & Triolo, P. K. (2008). Why do nurse managers stay? Building a model of engagement. Part 2. Cultures of engagement. Journal of Nursing Administration, 38, 166–171. McCallin, A. M., & Frankson, C. (2010). The role of the charge nurse manager: A descriptive exploratory study. Journal of Nursing Management, 18, 319–325. O’Neil, E., Morjikian, R., & Cherner, D. (2008). Developing nursing leaders: An overview of trends and programs. Journal of Nursing Administration, 38, 178–183. Paliadelis, P., Cruickshank, M., & Sheridan, A. (2007). Caring for each other: How do nurse managers ‘manage’ their role? Journal of Nursing Management, 15, 830–837. Richmond, P. A., Book, K., Hicks, M., Pimpinella, A., & Jenner, C. A. (2009). C.O.M.E. be a nurse manager. Nursing Management, 40, 52–54. Salas, E., Wildman, J. L., & Piccolo, R. F. (2009). Using simulation-based training to enhance management education. Academy of Management Learning and Education, 8(4), 559–573. Schmalenberg, C., & Kramer, M. (2009). Nurse manager support: How do staff nurses define it? Critical Care Nurse, 29, 61–69.
L.W. Moore et al. / Applied Nursing Research 30 (2016) 98–103 Shirey, M. R. (2006). Authentic leaders: Creating healthy work environments for nursing practice. American Journal of Critical Care, 15, 256–267. Shirey, M. R., Ebright, P. R., & McDaniel, A. M. (2008). Sleepless in America: Nurse managers cope with stress and complexity. Journal of Nursing Administration, 38, 125–131. Shirey, M. R., McDaniel, A. M., Ebright, P. R., Fisher, M. L., & Doebbeling, B. N. (2010). Understanding nurse manager stress and work complexity. Journal of Nursing Administration, 40, 82–91. Stefl, M. E. (2008). Common competencies for all healthcare managers: The Healthcare Leadership Alliance Model. Journal of Healthcare Management, 53, 360–374.
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Titzer, J., Phillips, T., Tooley, S., Hall, N., & Shirey, M. (2013). Nurse manager succession planning: A synthesis of the evidence. Journal of Nursing Management, 21, 971–979. Vaismoradi, M., Turunen, H., & Bondas, T. (2013). Content analysis and thematic analysis: Implications for conducting a qualitative descriptive study. Nursing and Health Sciences, 15, 398–405. Zwink, J. E., Dzialo, M., Fink, R. M., Oman, K. S., Shiskowsky, K., Waite, K., ... Le-Lazar, J. T. (2013). Nurse manager perceptions of role satisfaction and retention at an academic Medical Center. Journal of Nursing Administration, 43, 135–141.