The nurse manager role is pivotal in staff nurse satisfaction and retention, quality of patient care, and achieving organizational goals, which is why the decreasing numbers of qualified nurse managers in the acute care environment is of concern.

The American Organization of Nurse Executives (AONE) reported vacancy rates for nurse managers are on average as high as 8.3% nationwide. This fact is compounded by the intent of the largest group of nurse managers with long career and organizational experience and higher levels of organizational commitment to retire in about 10 years. Replacing this number of nurse managers is a daunting challenge that can only be met by understanding the issues involved and the viewpoint of the managers themselves.

What’s the problem?

The role of nurse managers relate to both management (mobilizing people and resources) and leadership (influence and vision), while they contend with a variety of role stressors and challenges. The widespread availability of personal communication devices lends a sense of being available 24-hours a day, 7 days a week without a break. Working in intense human relations situations 10-12 hours per day with an increasing span of control and dealing with complex issues typically outside of the manager’s control contributes to overall stress.

Nurse manager workplace demands include increasing numbers of direct reports, decreased resources, decreased clinical involvement, increased staff diversity, increased coordination across differing nursing units, issues with assistive personnel, changing regulatory requirements, and the need for new management skills coupled with the increasing complexity of hospitalized patients. The time consuming demands of staffing, however, have been reported to be the manager’s greatest challenge, precluding ability to be visible, build relationships with staff, and allow time to engage in those activities directly related to constructing a committed, retained staff.

What nurse managers say

Zastocki asked a group of 188 nurse managers to comment about their jobs. Many of the comments provided were related to challenges encountered in the work environment. Many of the nurse managers felt disempowered, inadequate, and ignored, resulting in widespread feelings of dissatisfaction and intent to leave. Here is a sample of some of their comments:

The role…must be re-evaluated given turnover rate and dissatisfaction. Nurse manager frustration is ignored. The position has become increasingly difficult to fill adding more stress and responsibility to those who are then asked to cover additional units.

I have learned my responsibilities through negative feedback. (I am) made (to) feel inadequate and unable to reach expectations. Rarely is any positive feedback given. With many staffing deficits, I have to work the unit to maintain patient safety. No allowances/exceptions for report deadlines are given. Nor is any assistance offered to complete reports. I am expected to work late (using personal time) without compensation. I am expected to work weekends, evenings and nights if an RN calls out and there is not other RN available for straight pay. At times the demands seem abusive … there’s no balance between work and family.

I do not believe the nurse executives understand the demands (of the nurse manager role). Manager satisfaction is much neglected; creative ideas to embrace and improve are ignored…

Mutual respect is absent. Example: suggestion presented to offer nurse managers a 10-hour day, having the assistant nurse manager cover on the fifth day. Managers do not work an 8-hour day. This compounds the many job responsibilities and decreases satisfaction. When this was suggested an immediate “NO” was the response, what a poor message.

Executives need to take note that the nurse manager role is the adhesive that holds the organization together, keeps goals in sight, drives patient care, advocates for staff, patients and families, and gets the least recognition for their contribution.

Lack of support and the demands of an increasingly regulated environment were other predominant themes in this group of nurse managers. Nurse managers are also saying:

Other departments seem to have more assistants than the nursing management team. I think the whole culture of nursing expects this level of management to “walk on water”, and do the impossible, with additional coverage of other units as a standard part of “other duties as assigned”.

What makes me want to leave this job is the fact that, with the ever-increasing demands of finances and regulatory requirements, there have been no additional resources added. It has gotten worse over the 20 years I have been in this job and at this point I seriously think about leaving this role.

As a nurse manager I feel I have no support… and there is no accountability for anyone’s actions.

Too many reporting statistics programs limit time to do important things like round with patients and staff meetings. As long as report are completed, doesn’t matter how other tasks are completed, usually meaning additional non paid work hours taking away from personal life. If could go back in time and change decision to become nurse manager, would not do it again.

What can be done to retain nurse managers?

Nurse manager studies on creating healthy workplaces suggest desirable components include a framework of shared leadership, participatory management, relationship building, development of nurse managers, evaluation of role expectations, and empowerment.

Predominant themes from Zastocki’s survey that are consistent with the review of the nursing literature are work-life balance, support, acknowledgement, opportunities growth with support for education, role expectations. Additional themes on the importance of the chief nurse executive role and the impact of tenure and employee benefits as investments in the organization were also consistent with the literature.

These findings are supported by the nurse manager engagement study by Mackoff and Triolo, which found six elements for future nurse manager engagement. These were:

• Work/life balance
• Strong physician/nurse relationships
• Socialization and education
• Designated mentorship
• Compensation to reflect contribution and diminish stress
• Reduction and division of workload.

Here is a summary of what nurse managers want, based on the Zastocki survey:

Work-life Balance

More time off

Variable scheduling

Flexibility in scheduling

Limits to being on-call

Support

Clerical support

No expectation for assuming secretarial duties such as distributing flyers and paperwork to staff

Budgetary advice and support

A charge RN without a clinical assignment on all shifts

Acknowledgement

Recognition of the difficulty of the role

Accountability from other departments

Respect from the CNO/Nursing Director

Compensation

Salary commensurate with job responsibilities

Greater tuition reimbursement

Leadership/Professionalism

Encouragement of creative solutions

Empowerment to make change

Autonomy

No micromanaging

Ability to make needed change

Creating healthy work environments requires a committed participative process for evaluating role options essential to nurse manager retention and recruitment. Personal resources, social support, and mentoring are combination strategies that take into consideration individual nurse manager needs for personal development and for the types of social/professional network(s) considered supportive. An immediate, low-cost hospital action may be hardiness training to provide emotional support to the nurse managers.

Nurse managers need to accept individual responsibility to seek resources that nurture their well-being. Options such as job sharing and separating clinical and administrative roles may work in some organizations. Strategies for stress management, role expectations and role redesign, and processes for creating healthy workplaces, need to be evaluated both in response to broader healthcare and workforce trends as well as within organizational culture and constraints. While recruiting new nurse managers is essential, it’s equally important to retain experienced nurse managers as part of the succession plan of the nurse executive.

Nurse executives need to reflect on those leadership behaviors that are viewed as more supportive by nurse managers and begin discussion on the predominant themes of work expectations, work-life balance, workload and role expectations, support, education and growth opportunities, acknowledgement and respect for contributions to the organization, and compensation. Beginning the discussion is the first step in acknowledging change must occur to retain committed and engaged nurse managers. This dialogue can provide the platform for succession planning and broader discussions with different age cohort nurses earlier in their careers who may consider nurse manager roles in the future. Succession planning is an immediate imperative; given the reported average age of the nurse manager is 45 years. Supporting discussion of creating healthy work environments can also establish a culture of support and a basis for long-term organizational change.

Time to act

Support, empowerment, and the ability to make change in a timely manner are essential to retaining the nurse manager. Empowerment should be evaluated as part of the organizational culture as an influence on nurse manager perceptions of control, support, and their ability to address role expectations and demands. Organizational leadership should develop an ongoing process and an environment where nurse managers participate in this creative process.

Succession planning that uses focus groups with potential nurse managers may prove helpful in evaluating job design, role expectations, and workload. Options such as job sharing or separating clinical and administrative roles require organizational assessment for organizational fit. Organizational support in creating healthy work environments and commitment to an ongoing process to continue to evaluate options and explore new models are essential to retention.

Educating hospital leadership concerning the critical nature of the nurse manager role, projected shortages, and the need for support for organizational change is a major challenge for the nurse executive in financially constrained hospitals. Developing opportunities for education, growth, and mentorship require assessment of the basic competency levels of nurse managers, support of academic achievement at the master’s degree level, horizontal growth opportunities, and ongoing continuing education, and supportive professional networking. The time for committing to action is now. Nursing leaders need to take ownership, perhaps albeit small incremental change initially, of creating the future environment. Focusing on the many circumstances outside of one’s control will result in a leadership crisis in the near future.

In a recent study, senior leaders were challenged to support nurse managers in the following ways:

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“know which leader behaviors make the difference and support managers in carrying them out; help the manager deal with polarities; help the manager set realistic boundaries; negotiate for a strong supportive role from Human Resources; remove organizational barriers to results; encourage managers to develop a supportive network; listen to what the managers tell you; and encourage managers to learn from each other…” (Manion, 2005; p. 54).

The nurse executives’ understanding of what is important to nurse managers individually, and collectively, remains a critical component in designing organizational strategies. Although many nurse managers are in later career stages, the recruitment of new managers requires strategic planning for organizational supports and individualized development plans with mentors for each manager.

The recent work of Mackoff and Triolo on nurse manager engagement provides a resource with suggested applications. Implementing strategies to manage work experiences at entry into the organization and at entry into the nurse manager position may prove more effective for enhanced affective commitment and perceived organizational support.

Deborah Zastocki RN, MEd, DNP, is president & CEO of Chilton Memorial Hospital in Pompton Plains, New Jersey. Cheryl Holly RN, EdD, is associate professor and director of the New Jersey Center for Evidence Based Practice and director of the DNP Program at the University of Medicine and Dentistry of New Jersey, School of Nursing in Newark.

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