What Factors Encourage Nurse Managers to Keep Working and Do An Excellent Job?
Researchers interviewed 30 nurse managers at six medical centers from May to August 2007 to elicit "signature" individual and organizational factors that encourage engagement among nurse managers, that is, job longevity and excellence in job performance.
- Engaged nurse managers exhibit 10 signature behaviors. For example:
- Focusing on purpose, outcomes and big-picture thinking about self, team and organization.
- Finding gratification in developing others, and offer opportunities for autonomy and freedom.
- Conveying excitement about staff, colleagues and leadership, and dedication to patient care and the organization.
- Five signature elements of organizational culture contribute to the longevity and excellence in job performance of nurse managers. Among them:
- Creating opportunities for educational mobility, and encourages learning through risk-taking.
- Conveying esteem for nursing through responsiveness to the viewpoints and decision-making of nurse managers.
- Communicating its mission and values with clarity, and aligns its goals and values with those of individuals.
The Robert Wood Johnson Foundation (RWJF) supported this project with $71,863 in solicited funding from December 2005 through August 2007.
In their dual roles as both clinicians and administrators, nurse managers are essential to recruiting and retaining other nurses and to developing a positive work environment. However, mid-level nurse managers often feel overwhelmed by their responsibilities, sense little support from their institutions and have high turnover rates, according to a 2001 article in the Journal of Nursing Administration. The results are job vacancies and a projected vacuum in nursing leadership in the United States.
Existing studies have asked why nurse managers leave their jobs. Few have asked why nurse managers stay, that is, why do some become engaged and display outstanding performance and job longevity?
RWJF has been addressing the nursing shortage not only through developing nursing faculty (a necessary step to increase capacity for training additional nurses), but through projects and programs to retain nurses, such as:
- Transforming Care at the Bedside, a program to create, test and spread prototype hospital nursing unit-level strategies to improve the work environment and quality of care.
Barbara L. Mackoff, Ed.D., a Seattle-based educator and author, and Pamela Triolo, R.N., Ph.D., chief nursing officer at the University of Pittsburgh Medical Center, sought to elicit "signature behaviors" in individuals and organizations that lead to engaged nurse managers. The researchers aimed to develop a model that organizations could follow to foster engagement within their own nurse mid-manager cohort with engagement defined as job longevity and excellence in job performance.
"Signature behaviors" is a term adapted from the work of Lynda Gratton and Sumantra Ghoshol that denotes the values, characteristics, aspirations and interests of individuals and organizations. ("Beyond Best Practice," Sloan Management Review, 46(3): 4957, 2005. This article may be purchased online.)
To develop their model, the researchers created "The Nurse Manager Engagement Questionnaire," which they tested in a pilot group interview with five nurse managers at the University of Texas Medical Center in February 2006.
The researchers then used the questionnaire to conduct 30 hour-and-a-half, face-to-face interviews with nurse managers at six medical centers from May to August 2007. Supervisors at those institutions recommended nurse managers who had:
- Job longevity of five or more years in their current mid-management role.
- Been designated as outstanding by senior leadership.
The questionnaire used an "appreciative inquiry" approach. That is, the interviewers asked guided, open-ended questions designed to elicit participants' experiences and values. The researchers analyzed the resulting narratives to uncover signature factors that lead to successful long-term tenure among nurse middle managers.
The nurse managers interviewed worked at the following six medical centers:
- Cedars-Sinai Medical Center, Los Angeles
- Children's Memorial Hospital, Chicago
- University of Pittsburgh Medical Center/Shadyside, Pittsburgh
- Seton Medical Center, Austin, Texas
- New York University Medical Center, New York
- University of Washington Medical Center, Seattle
Mackoff and Triolo published four articles on the project, in the Gallup Management Journal, the Journal of Nursing Administration (2) and Nurse Leader. The investigators also fulfilled some 24 requests for information on their findings by distributing Project Report: Creating a Model of Nurse Manager Engagement, which they prepared for RWJF. (For more details, see the Bibliography.)
In their published articles and unpublished report to RWJF, the researchers cited findings in several key areas:
- Engaged nurse managers exhibit 10 signature behaviors, experiences, capabilities and attributes:
- Mission driven: they focus on purpose, outcomes and big-picture thinking about self, team and organization.
- Generativity: they find gratification and joy in developing others and creating a legacy, and they offer opportunities for autonomy and freedom.
- Ardor: they convey excitement about staff, colleagues and leadership, and dedication to patient care and the organization.
- Identification: they savor their part in the accomplishments and success of their staff.
- Boundary clarity: they create strong connections with others without losing a sense of self.
- Reflection: they examine and learn from experience, and observe the effect of their behavior on others.
- Self-regulation: they manage their emotions, cultivate patience and practice restraint and perseverance.
- Attunement: they display regard for individuals, and their contributions to the organization, understand diverse perspectives and set aside assumptions to learn from others.
- Change agility: they challenge process through innovation, and welcome and initiate change through learning.
- Affirmative framework: they use an optimistic, explanatory style, generate positive expectations and model resilient behavior.
- Five signature elements of organizational culture contribute to the longevity and excellence in job performance of nurse managers. These include:
- A learning culture: the organization creates opportunities for educational mobility, encourages learning through risk-taking and offers information and resources.
- A culture of regard: the organization conveys esteem for nursing through responsiveness to the viewpoints and decision-making of nurse managers, empowers nursing practice and facilitates goal attainment.
- A culture of meaning: the organization communicates its mission and values with clarity, and aligns its goals and values with those of individuals.
- A generative culture: the organization leadership is available and approachable, and provides mentors for the next generation.
- A culture of excellence: the organization communicates high standards, and cultivates pride in its accomplishments and reputation.
- Organizations can foster the future engagement of nurse managers by relying on six key elements:
- Socialization and education for staff nurses who are becoming nurse managers: expand the time and scope of first-year orientation for nurse managers to include both "nitty-gritty" concerns (such as payroll) and leadership challenges.
- Designated mentorship: rely on an "orientation through buddy system," assigning mentors or preceptors to new nurse managers.
- Strong physician/nurse relationships: cultivate colleagueship between nurse managers and physicians, hold physicians accountable for behavior in areas such as wait times and patient satisfaction and empower nurse managers to make decisions.
- Work/life balance: offer flexible schedules, incentives to avoid burnout, such as vouchers for dinner and on-campus child care, and time off for rejuvenation.
- Compensation: increase pay for staff nurses to avoid vacancies, and see salaries as a vehicle for showing regard for nursing and reducing stress.
- Reduction and division of workload: reduce the double clinical and administrative workload of nurse managers by assisting them with accreditation responsibilities and paperwork, and adding co-managers, business assistants and clinical instructors.
- Organizations can apply these findings and the resulting model in a number of arenas, according to project staff. Organizations can:
- Integrate the findings into graduate and continuing nurse education.
- Use them in the orientation and training of nurse managers.
- Factor them into interviewing and personnel decisions.
- Use them to create job descriptions and support nurse recruitment.
- Apply them to organizational self-study and development.
AFTER THE GRANT
Project director Mackoff is using the survey findings to develop a curriculum and practicum on nurse manager engagement.
GRANT DETAILS & CONTACT INFORMATION
Identifying Key Factors for the Creation of a Model of Nurse Middle Manager Engagement
Barbara L. Mackoff, Ed.D. (Seattle, WA)
Dates: December 2005 to August 2007
Barbara L. Mackoff, Ed.D.
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Mackoff BL and Triolo PK. "Line of Sight: The Crucible in Nurse Manager Engagement." Nurse Leader, 6(2): 2128, 2008.
Mackoff BL and Triolo PK. "Why Do Nurse Managers Stay? Building a Model of Engagement: Part 1, Dimensions of Engagement." Journal of Nursing Administration, 38(3): 118124, 2008. Abstract available online. Full text available to subscribers.
Mackoff B and Triolo PK. "How to Keep Great Nurse Managers: Two Researchers Studied the Best of the Best and Found What It Takes to Keep People in This Demanding Role Flourishing." Gallup Management Journal (an online journal, release date March 13, 2008). Available online to subscribers.
Mackoff BL and Triolo PK. "Why Do Nurse Managers Stay? Building a Model of Engagement: Part 2, Cultures of Engagement." Journal of Nursing Administration, 38(4): 166177, 2008. Abstract available online.
Mackoff BL and Triolo PK. "Why the Nursing Shortage Is a Chicken and Egg Problem (and How Engaged Middle Managers Are Part of the Solution)." Unpublished project report.
"The Nurse Manager Engagement Questionnaire," fielded MayAugust, 2007.
Report prepared by: James Wood
Reviewed by: Sandra Hackman
Reviewed by: Molly McKaughan
Program Officer: Michelle A. Larkin