In the face of healthcare reform, hospitals struggle to find ways of providing safer, better quality care using fewer resources. Since a hospital's nursing staff is its largest and most costly resource, many organizations spend much of their time and energy trying to maximize the productivity of frontline nurses. Inescapably, these organizations are drawn to the role of the frontline nurse manager, who's the fulcrum on which staff engagement, productivity, quality outcomes, and positive experiences rest.1-6
Delivery of the highest quality and safest care begins with retaining experienced nurses.7 Nurse managers are widely accepted as the most influential force in staff satisfaction and retention because of their role in work environments.1,5 Responsibilities once performed by nurse directors have now been integrated into the nurse manager's scope of practice. Indeed, within clinical units, the nurse manager is a consistent presence, uniquely positioned with a front-row view of the intricacies of nurse-patient, nurse-physician, and nurse-interdisciplinary team dynamics. Nurse managers are expected to oversee the daily demands of unit operations while developing an environment that fosters nursing excellence and promotes an engaged nursing staff.4 Nurse managers are also the vital link between senior executives and direct care nurses.
Keeping all this in mind, two critical findings from the literature must be considered: direct care nurses tend to leave an organization because of their managers, and managers who feel supported by their organizations reciprocate this support with their staffs.8 Balancing these dynamics and fostering a healthy work environment requires a rare blend of talent, knowledge, and skills. Given the pressures and complexities of today's healthcare environment, taking on the ever-expanding role of the nurse manager is a challenging endeavor. Moreover, in a system where demand frequently outpaces financial and human resources, hospital and quality performance is widely scrutinized and patient outcomes are considered a direct reflection of a nurse manager's effectiveness in fulfilling the role. Given the impact of the nurse manager on retention, satisfaction, productivity, and outcomes, organizations are wise to seek ways to better understand this critical role and foster an organizational climate that develops, engages, and empowers nurse managers.4,9
Not enough time
The complexity of the nurse manager role coupled with the sheer number and variety of responsibilities raises the question of whether the frontline nurse manager role is configured unrealistically.1 Research has characterized the frontline nurse manager role as frustrating, overwhelming, and demanding.6 Not surprisingly, attracting leaders to these positions is becoming more difficult.10 However, if organizations hope to weather a growing nursing shortage, they must be committed to understanding the role, reconfiguring it for success, and finding ways to support, protect, and rejuvenate leaders who are responsible for managing their most precious resources.
The role of the nurse manager is now widely recognized as one of the most overburdened roles in healthcare.8,11,12 Not having enough time to complete work, being torn in multiple directions, excessive committee meetings, and numerous daily interruptions increase the stress and complexity of a nurse manager's job.7 Organizational red tape, interpersonal conflict, changing regulatory requirements, multiple simultaneous hospital initiatives, and system inefficiencies are also factors that increase job stress.7 Being an experienced sensor, or someone who's able to perceive developing issues, requires the nurse manager to spend an adequate amount of time on the unit in order to nip problems in the bud.1
Managers, faced with unrealistic expectations, found that they spent only 25% of their time on what they felt was an important part of their job. The additional 75% of their time was spent on other obligations and duties, referred to as the "invisible work" of the nurse manager because it's often difficult to define and/or quantify.1 Other studies found that the desired role, identified by nurse managers, was one that allowed the manager to prioritize tasks, develop day-to-day work, and have time for his or her staff. Resource allocation seemed to occupy most of the nurse managers' time, with supervision of personnel and staff development activities also consuming a large portion of time and attention.13-16
The literature also indicates that nurse managers are plagued by human resource issues; they experience increasing emphasis on acquiring, using, and mastering new technology; they must manage change; cope with increasing spans of control; and must often fill in as frontline nurses when their units are short staffed.17 Further, new managers are often promoted from within direct care nurse ranks, given limited formal training, and are then expected to "hit the ground running."3,18
Although these new managers may bring key skills such as communication, planning, organization, prioritization, and documentation to the role, they often lack skills in managing and leading, which require formal education and training.17 Given the importance of nurse managers in creating a healthy work environment for all staff, it's imperative for senior leadership to understand the nurse manager's role, appreciate the difficulties they face, and create more realistic role expectations.3,19
Focusing on managers
Over the last 5 years, our organization has experienced a high turnover of nurse managers. In keeping with trends in the industry, the role of the manager at this 861-bed academic medical center has continued to expand. The study we conducted was designed to develop a clearer understanding of nurse managers' current responsibilities within the organization. Specifically, the study examined nurse managers' perceptions of: the frequency of performing specific key responsibilities of their role, level of importance of these responsibilities, and levels of expertise in meeting the expectations of the role.
Using current literature and the Health Care Advisory Board's Nurse Manager Job Analysis and Activity Audit, a 40-item tool was developed to address these questions.1,3,13,14,20 A draft of the tool was shared with members of the Nurse Manager Council to ensure that it included a realistic list of nurse manager responsibilities. Based on feedback from council members, the final tool included 3 demographic questions and 40 questions specific to the nurse manager role. Items were related to the nurse manager's responsibilities in the following categories: clinical, recruiting, staffing and scheduling, managing current staff, unit operations, finance, staff development, quality/safety, and hospital-wide initiatives.
To measure the frequency that the managers spent their time performing these responsibilities, a 6-point Likert scale was developed: 1-never, 2-seldom, 3-about half the time, 4-usually, 5-always, 6-delegated. The nurse managers' perceptions of the importance of job responsibilities were measured using a 3-point Likert scale: 1-unimportant, 2-moderately important, and 3-very important. Level of expertise was based on Benner's Novice to Expert Model, using a 5-point Likert scale: 1-novice, 2-advanced beginner, 3-competent, 4-proficient, 5-expert.18 For the analysis, the frequency scale was collapsed into three categories: seldom, never, delegated; about half the time; and usually/always. Level of expertise was also collapsed into three categories: novice/advanced beginner, competent, and proficient/expert.
Institutional Review Board approval was obtained before the start of the study. A list of current nurse managers was obtained from Human Resources, and a descriptor was defined for nurse managers: an RN holding a nurse manager title with 24-hour accountability for an inpatient clinical unit. An e-mail was sent to 34 managers fitting the description. They were invited to participate in the study anonymously via a survey link in the e-mail.
The results are in...
The sample included 29 nurse managers (76% response rate). Forty percent (12) of the participants had less than 5 years experience as a nurse manager. Eighty-three percent (25) had two or fewer assistant nurse managers working with them, and 40% (12) were responsible for more than 75 full-time equivalents (FTEs).
Participants were asked to indicate the frequency they spent time on specific job responsibilities. More than three quarters of the respondents indicated that they usually/always spent time rounding on a unit and disseminating urgent, mandatory communications (76%); reviewing performance evaluations (79%); ensuring compliance with regulatory standards (79%); developing and implementing process improvement plans (79%); networking and relationship building with physicians (76%); dealing with process glitches, departmental, interdepartmental, or ancillary problems (79%); attending and facilitating unit meetings/councils (79%); and reviewing and analyzing financial reports (83%).
Addressing patient satisfaction issues/complaints and conducting patient satisfaction rounds were identified as very important by 97% of the respondents. Ninety-three percent stated that indirect patient care, talking with patients and families, reviewing the schedule daily, and checking census were very important, whereas 90% felt that calling in staff members and dealing with staffing emergencies, monitoring staffing/flexing staff volume, and ensuring compliance with regulatory agency standards were very important. Eighty-three percent of the respondents indicated that coaching staff while rounding, resolving staff conflicts, and reviewing and analyzing financial reports were very important.
The tasks the managers spent most of their time on and those felt to be most important were quite different, suggesting that managers aren't spending the majority of their time on responsibilities they feel are the most important. (See Table 1.)
Overall, the respondents indicated their level of expertise as proficient/expert. Only 38% (11) of the managers reported their level of expertise as proficient/expert in participation in hospital-sponsored community initiatives; 41% (12) viewed themselves as proficient/expert in analysis of financial reports, and 48% (14) in identification of variances.
There were notable differences between nurse managers with less than 5 years and those with more than 5 years of manager experience. (See Table 2.) Generally, less experienced managers spent more time mentoring charge nurses, providing indirect patient care, rounding on the unit, talking to patients and families, and spending time meeting with senior executives and nursing leaders. Managers with more than 5 years of experience spent the majority of their time preparing and delivering disciplinary action and spent less than half the amount of time of less experienced managers on mentoring charge nurses, rounding and meeting with senior executives and nursing leadership, reviewing resumes, and participating in recruiting activities.
Managers with more than 5 years of experience indicated proficiency/expertise in dealing with unit supplies and medications, attending and facilitating unit meetings, addressing compliance with regulatory agency standards, and disseminating urgent mandatory communications. These seasoned managers also indicated more expertise in the review of new equipment, products, and technology; participation in hospital-wide committee or task force meetings; and performing general office/clerical duties.
Restructuring old roles
The findings of this study confirm the complexity and variety of responsibilities of nurse managers. They spend their time on numerous activities to meet expectations of the role, including managing both the administrative and clinical activities of their units.3,7,10 If managers are expected to perform all the duties currently assigned to the role, organizations must structure education, training, and support systems for these leaders to equip them with the skills needed to be successful managers. Alternatively, organizations may need to consider a more realistic configuration of this frontline leadership role.
This study found that inexperienced managers spent more time with their leaders, perhaps needing their guidance and direction. Those with less experience also spent more time on their units, mentoring their direct reports and rounding with patients and families. Being visible and accessible to staff members is a perceived priority of this group.
The responsibility of meeting with senior leaders was also important for the less experienced nurse managers. The more traditional roles of discipline and performance appraisals were considered important by more mature leaders. The experienced leaders also felt they had mastered the routines of supply management, chairing meetings, ensuring compliance with regulatory standards, and facilitating/attending meetings with their leaders and peers.
Variations related to the experience levels of managers call attention to the need to ensure that leadership development opportunities meet the requirements of new, emerging nurse managers, as well as seasoned leaders. Competency-based orientation plans, new manager orientations, leadership training, coaches, and peer support are critical to the success of all nurse managers. Managers should be provided with the support needed to be successful. Ready access to education and clinical specialists, assistant nurse manager support, and expert clerical assistance are critical.
Continuing the transformation
This study had several limitations. The sample was small and restricted to one organization. Also, the study didn't ask respondents for a breakdown equal to 100% of the actual time spent on tasks-it would've been beneficial to quantify the amount of time top responsibilities took in minutes/hours. Finally, the demographic data were limited to years of experience (less than or more than 5), number of FTEs (less than or greater than 75), and the number of assistant nurse managers (0 to 2 or greater than 2). Additional data on educational preparation, certification, prior nursing or leadership experiences, and level of clerical support would've provided more insight into the nurse managers' actual experience. Further research, qualitative and quantitative, will be beneficial in exploring the complex responsibilities that managers are expected to juggle.
The findings of this study have important implications for reconfiguring the nurse manager's role to meet the challenges of today's healthcare environment. Nurse managers need additional secretarial support, a business line liaison, restructuring of orientation, and meeting-free schedule blocks during designated times for unit huddles. Implementing these strategies can assist managers with their complex and diverse role responsibilities, which will not only benefit nursing staff, but also the organization as a whole.
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