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Nurse Manager Behaviors That RNs Perceive to Affect Their Job Satisfaction Rebecca A. Feather, PhD, RN, NE-BC, Patricia Ebright, PhD, RN, FAAN, and Tamilyn Bakas, PhD, RN, FAHA, FAAN Rebecca A. Feather, PhD, RN, NE-BC, is Assistant Professor, School of Nursing, Indiana University, Bloomington, IN; Patricia Ebright, PhD, RN, FAAN, is Associate Professor and Associate Dean for Graduate Programs, School of Nursing, Indiana University, Indianapolis, IN; and Tamilyn Bakas, PhD, RN, FAHA, FAAN, is Professor and PhD Program Coordinator, School of Nursing, Indiana University, Indianapolis, IN. Keywords Behavior, engagement, job satisfaction, manager Correspondence Rebecca A. Feather, PhD, RN, NE-BC, Indiana University School of Nursing, Bloomington, IN E-mail: [email protected]
Feather
Ebright
PURPOSE. Nurse manager behaviors and job satisfaction are commonly addressed in the literature; however, registered nurse (RN) perceptions of nurse manager behaviors provide a unique perspective that may inform future strategies designed to enhance RN job satisfaction. In this paper, the perceptions of RNs were explored through focus groups to learn the behaviors of nurse managers that most influence RNs’ job satisfaction. METHODS. Five focus groups were conducted through semi-structured interviews of a total of 28 RNs to provide data that were coded through qualitative content analysis for themes. FINDINGS. The findings provide nurse managers with data related to the perceptions of RNs and the behaviors of managers that influence job satisfaction. The findings identified two conceptual categories of RN perceptions of nurse manager behaviors: manager behaviors supportive of RNs (communication, respect, and feeling cared for) plus the RNs’ perceived disconnect of work issues from the manager’s role. CONCLUSION. Findings support past research in relation to the perceptions of RNs wanting to be respected, included in communication, and the need to feel cared for by nurse managers to have higher levels of job satisfaction.
Bakas
One of the biggest challenges for a healthcare facility today is not only recruitment of registered nurses (RNs) but also retention. This is especially true in the current healthcare reform environment, with the vast number of changes still to come as the Affordable Care Act moves into full swing between now and 2014 (Pfeifer, 2013). The U.S. Department of Labor, Bureau of Labor Statistics (2012) projects a need for 711,900 RNs by the year 2020, an increase of 26% since 2010.
A 2003 Institute of Medicine (IOM) report pointed out the urgent need for healthcare organizations to recruit and retain RNs in times of short supply (IOM, 2003). Due to the influx of patients entering the system with the expansion of Medicaid, as well as the mandated purchase of health insurance in 2014, it is vital for hospitals to recruit and retain as many RNs as possible (Pfeifer, 2013). Unfortunately, a study by Staiger, Auerbach, and Buerhaus (2012) projected that as the recession lifts and job recovery takes place, 125
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Nurse Manager Behaviors That RNs Perceive many RNs who entered the workforce due to the recession between 2005 and 2010 will likely leave at a time when they are needed the most. Projected shortages of RNs by 2015 will come as the demand for health care is sharply increasing (Staiger et al., 2012). Many RNs leave the workforce due to negative experiences with nurse managers (Taunton, Boyle, Woods, Hansen, & Bott, 1997). Further exploration of the importance of nurse manager behavior from the perspectives of RNs might provide valuable information needed to develop future strategies for retention. The purpose of this study was to explore nurse manager behaviors that RNs perceive as most influencing their job satisfaction.
R. A. Feather et al. Although researchers have reported that nurse managers play a vital role in creating the daily work environment and, therefore, have an effect on RN retention (Shirey, Ebright, & McDaniel, 2008), a review of the literature showed that a gap still exists in our understanding of the specific links between nurse manager behaviors and RN job satisfaction. This finding points to the importance of exploring nurse manager behaviors directly from the perceptions of the RNs employed by them. Identifying the RN perceptions of the managers’ own staff may lead to new strategies to enhance RN job satisfaction and, ultimately, improve RN retention in the workforce. Literature Review
Background Many factors influence retention of RNs, such as being part of the decision-making process and feeling respected by management (American Nurses Association, 2013). Although past research has provided evidence, there is an overall link between nurse manager behaviors and RN job satisfaction; RN perceptions of manager behavior in the current healthcare environment need to be revisited to provide updated research about why RNs leave or stay in their current positions. A past study on job satisfaction in 30 leading hospitals found that nearly 100% of the nurse participants reported the nurse manager as a factor in their decision to leave the organization (Taunton et al., 1997). Other studies, based on exit interviews with RNs, found that nurse manager behaviors were what most influenced staff nurses’ decisions to leave their positions (Kramer et al., 2007; Shobbrook & Fenton, 2002). A recent study cited in Forbes (Smith, 2012) found that RNs had the second highest unhappiness rate for their job in the United States. Nurses who responded to the survey cited poor compensation, lack of growth opportunities, and workplace culture as being the biggest factors in their dissatisfaction, along with difficult coworkers and managers. Another study surveying nurse attitudes and outlooks (Vital Signs, 2012) found “poor, unsupportive, unresponsive management” to be the top nurse dissatisfier (31% of those surveyed), along with “lack of respect and appreciation from management” (14% of those surveyed), rounding out the top five items leading to dissatisfaction in the workplace. Other dissatisfiers mentioned in the study were work overload/high patient-to-nurse ratios/long hours (31%), low compensation/pay cuts/no raises (15%), and inadequate staffing (15%). 126 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume 50, No. 2, April-June 2015
Nurse managers’ leadership behaviors have been identified as the factors most likely to improve job satisfaction and retention of hospital staff nurses (Andrews & Dziegielewski, 2005). A synthesis of the literature involving outcomes related to nurse manager behaviors and staff job satisfaction covering the time period from 1997 to 2008 revealed that research related to the “post-reconstruction” era of the early 1990s is limited. This era included changes within nursing management that involved elimination of a layer of middle managers in many healthcare organizations. Many of the changes that occurred during this period of time contributed to a nursing shortage (Boyle, Bott, Hansen, Woods, & Taunton, 1999). The literature from 2009 to 2012 does show continued research in the area of job satisfaction and the work environment, but no studies focused solely on RN perceptions. Furthermore, the more recent literature documents disagreement between RNs and nurse managers on what specific behaviors most influence the job satisfaction of staff nurses (Gormley, 2011; Stuenkel, Nguyen, & Cohen, 2007). In addition, the literature shows a lack of consistency in definitions of job satisfaction and in conclusions that could suggest specific management behaviors to promote job satisfaction in RNs. Several studies measured job satisfaction as a factor in the development of a nursing model (Cummings et al., 2008) or as supporting evidence for the value of the Magnet setting (Schmalenberg & Kramer, 2008), yet there is no consistent definition of job satisfaction in the nursing literature. Recent research by Lacey et al. (2011) described professional work satisfaction as being “closely related to the type of environment that promotes or enables professional practice” (p. 15).
Nurse Manager Behaviors That RNs Perceive
R. A. Feather et al. This definition is one that provides a description of job satisfaction that relates to perceptions of RNs and nurse manager behaviors that promote or hinder professional practice. However, most research indicates that data are not readily available about perceptions of RNs about nurse manager behaviors that directly affect the RNs’ job satisfaction. This study defines job satisfaction of the nurse as cognitive and affective reactions of what the employee wants to receive from their nursing manager compared with what is actually received while an individual is employed as an RN (Ma, Samuels, & Alexander, 2003). Methods A qualitative descriptive design was used to gather data describing nurse manager behaviors perceived by RNs as influencing the RNs’ job satisfaction. Qualitative descriptive studies offer a comprehensive summary and are the method of choice when straight descriptions of phenomena are desired (Sandelowski, 2000). Sample A sample of 28 RNs working in two communitybased hospitals in the Midwest participated in one of five focus groups. Inclusion criteria included hospitals with a minimum of 50 licensed beds and national accreditation. Each hospital had a retention rating that was well above the national average of 55% at the time of the study (American Health Care Association, 2010). Turnover for one facility was 5% and for the other, 6.6%. Both hospitals were Magnet certified and participated in the collection of the National Database of Nursing Quality Indicators (NDNQI) to evaluate nursing care, improve patient outcomes, and identify linkages between nurse staffing and patient outcomes at the unit level. While the NDNQI includes a section that measures job satisfaction, it focuses on the evaluation of the work environment as a whole and is not specific to staff nurse perceptions of nurse manager behaviors (Montalvo, 2007). Demographic results for the participants were as follows: Except for two, the RN participants were Caucasian, and all but one was female. Five participants were 20 to 29 years of age, almost half (46.5%) were 50 years of age or over, and one was over 60. Over three fourths of the participants were married (78.6%). They had 1 to 40 years of experience in
nursing, with 39.3% having 1–10, 21.6% having 11–20, and 39.3% having 21–40 years of experience. There were no RN participants with less than 1 year of employment at their current organization. There were 13 (46.4%) with 1–5 years of employment at their current organization, 8 (28.6%) who had 6–10 years of employment, and the remainder with over 10 years of employment at their current organization. Over half (60.7%) worked 12-hr shifts, with a plurality of this group (35.7%) working from 7 a.m. to 7 p.m. Of the total sample, 74.4% worked day shifts that ended by 6 p.m. The education level included 8 associate degree, 18 baccalaureate, and 2 master’s prepared nurses, with 16 of the RNs having certifications (57.1%). A nurse manager was defined as an RN who had 24-hr accountability for the operations of one or more hospital or clinic units, regardless of the title given to that position. This position involved direct supervision of charge and staff nurses on all shifts. To be eligible for their staff to participate in this study, the nurse manager must have had one or more years of experience as a nurse manager. Manager experience was important in order to establish that the nurse manager was not in the orientation or initial/transitional stage of learning the role of management. Lack of experience in this position could pose an external threat to the study. Other demographics about the nurse manager were not included to protect the confidentiality of the RN participants. A staff nurse was defined as an RN on a hospital unit responsible for the care of the patients admitted to that unit. To be eligible to participate in the study, a staff nurse RN was required to have a minimum of 6 months of experience in patient care, and had to have been employed under his or her current nurse manager for a minimum of 6 months. A purposive sampling of potentially eligible participants was conducted with nursing staff at each organization, with the permission of the facility’s chief nurse executive. Contact was made through an e-mail address provided by the organization. A flyer containing information about the study and contact information for the researcher was distributed to interested RNs, with options for dates, times, and locations of each of the focus groups. Each focus group was intended to include at least five and no more than eight participants in the order in which they volunteered. No more than three RNs per group from the same unit or with the same manager were enrolled in the study. This increased the likelihood of diversity 127
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Nurse Manager Behaviors That RNs Perceive across staff with different managers from each organization. Based upon availability, RNs who called or e-mailed to volunteer and who met the inclusion criteria were selected and enrolled in the study. Procedures After obtaining approval from the Institutional Review Board, the researcher met with participants to conduct the focus groups. The participants first completed an informed consent and a demographic questionnaire. Recruitment goals for the sample were to include RN participants from each of the two organizations in focus groups of five to eight participants, with a minimum of two focus groups per organization, representing multiple units. The advantage of using a focus group interview method is that people are more likely to explore and clarify their views in a way that may not be as easily accessible in a one-to-one interview (Kitzinger, 1995). The five audiotaped, 90-min focus groups were conducted on site by the researcher at each facility in the evenings when management was not likely to be present. Each group met in a conference room located away from the nursing units. Data were collected through the following two formats: a demographic questionnaire the participants were asked to complete prior to the focus groups; and participants’ responses to a series of semi-structured questions directed by the researcher as part of the focus group discussion (Table 1). An opportunity was provided for all participants to summarize their thoughts and feelings about the discussion prior to the end of the focus group session, and each RN was asked to summarize the greatest take-away thought from the group discussion. Analysis Data across all focus groups were synthesized and coded, with significant statements extracted, categorized, and analyzed for content and themes. A table was created including all initial codes in each focus group for a comparison of commonalities across the five groups. Initial code identification resulted in the following: Group One had 29 codes; Group Two had 35 codes; Group Three had 31 codes; Group Four had 47 codes; and Group Five had 36 codes. The transcripts were reviewed a fourth time, and specific statements that related to the codes were identified and highlighted in the table for each focus group. The statements were made into a list and labeled to correspond to each code. 128 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume 50, No. 2, April-June 2015
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Table 1. Focus Group Interview Questions 1. Tell me about a really memorable day for you at work, good or bad. 2. What do you think makes a day go well and go poorly for you? 3. What part do you think your manager plays in how your day goes at work? 4. What might your manager do to worsen your day at work? 5. What might your manager do to improve your day at work? Possible probes Describe manager behaviors that you view to be positive. Describe manager behaviors that you view to be negative. Talk about behaviors of nurse managers that make you feel good about your job. Talk about behaviors of nurse managers that make you feel bad about your job.
Qualitative content analysis of the data was achieved through repeated iterative discussions with the research team. The research team consisted of two qualitative experts, both with knowledge of nursing leadership and management, and one instrument development expert knowledgeable in the aspects of comparison of the data with past and current research results. The table of codes was reviewed to identify commonalities across the five focus groups and those codes that appeared in at least three out of the five focus groups were chosen for further analysis. Analysis resulted in identification of two conceptual categories, one of which contained three distinct themes, and definitions (Table 2). The first conceptual category was labeled manager behaviors (present or absent) supportive of RNs and consisted of three themes (communication, respect, and feeling cared for). The second conceptual category was the RNs’ perceived disconnect between work issues and the manager’s role. Categories and themes are represented below, with examples of focus group participant responses contributing to study findings. Results Category 1: Manager Behaviors Supportive of RNs As mentioned, the focus group transcript content analysis resulted in agreement on three major themes relative to nurse manager behavior.
Nurse Manager Behaviors That RNs Perceive
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Table 2. Focus Group Categories and Themes
Focus group categories/themes 1. Manager behaviors supportive of RNS—present or absent Communication • Consistency • Fear • Listening • Trust Respect • Fairness • Recognizing Feeling Cared For • Advocate • Flexibility • Lack of breaks/meals • Staffing • Visibility 2. RNs’ perceived disconnect of work issues from the manager’s role
As defined in the focus group discussions
The manager directly speaks with the staff and openly shares information. The manager does what he/she says he/she is going to do. Anticipation of repercussions for speaking up Demonstrated by appropriate verbal and nonverbal responses Privacy is protected, valued through actions and commitment of the manager for betterment of the staff and unit. The manager shows employee he/she is valued as an individual. The manager treats everyone the same. The manager acknowledges good work and contributions of individual staff. The manager provides needed resources for staff’s needs and patient/family care. The manager goes to bat or represents the staff and resolves conflict. The manager is able to bend based upon the needs of the individual or the unit. No time for personal needs to be met (breaks and food) The perception of adequate caregivers for workers (the number of and experience levels of caregivers) The manager is seen by staff on the unit; is frequently present on the unit. The manager does not play a role in the daily tasks and work issues of the nursing unit.
Communication. The theme of communication was identified through the RNs’ discussion of the need to be made aware of the decision-making that was occurring within their organization. The RNs desired communication in which managers were consistent in what they said and did, listened to the personal and professional needs of the staff, responded by promoting open discussion within the unit, and maintained confidentiality, all of which promoted trust. Communication was absent when the staff felt excluded and unaware of decisions being made within the organization. This type of behavior, as perceived by the RNs, resulted in a lack of trust between the staff and the management. One RN explained it this way: I guess communication is a big issue when I see managers that are more open with their communication, both interacting with people on the units, communication, talking to them, how’s their day,
Number of focus groups in which theme occurred
3 4 3 4 3 3 4 5 4 3 3 3 5 5 5
what are their needs, what’s going on, and then the lack of that, when people don’t do that, I think that’s a real barrier. Most of the RNs discussed the importance of direct verbal communication between the nurse manager and the staff, especially to inform them of what was occurring in the organization and to discuss decisions made in administrative committees that might directly affect the unit and staff. The nurses believed that direct verbal communication helped them to be more informed, better organized, and “on the same page” as management. One RN stated: I think communication is key and I think anybody who has the communication skills and really promotes those skills is a better manager and the nurses that are better communicators are happier in their job because they get their needs met. 129
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Nurse Manager Behaviors That RNs Perceive Listening was a form of communication discussed by the staff and illustrated as a manager who was receptive to their suggestions and responded in a way that was timely by actually doing something in response to the nurse. One nurse described a manager who listened in this manner: A good listener. They take it in and they get back to you in a timely manner, but they truly hear, respond and you can tell when somebody is truly listening to what you’re saying and gets back with you. According to staff responses, managers must learn to avoid the “grapevine” by not listening or joining in gossip about their employees. Although at times vital information can be learned in this manner, if the nurses perceive the manager is gossiping, a trusting relationship can be destroyed. The RNs perceived managers who walked the walk and talked the talk by not involving themselves in gossip as remaining professional. Respect. A second theme identified was respect, which was described as being present when the manager promoted fairness in interacting with the employees on the unit. Managers displayed respect by treating everyone the same in all aspects of enforcing policy and discipline, by holding each individual accountable, and by providing fairness with scheduling. Respect was also present in the manner in which the manager acknowledged the good work of the staff on an individual basis for the contributions made on the unit and for providing good patient care. Respect was absent when the nurse manager was not equitable in staff discipline or scheduling, or demonstrated a lack of recognition for the level of care and compassion shown to patients and their families on a daily basis. As shown by the data, a nurse manager earns the respect of employees by being fair, providing recognition when deserved, and being available to employees. According to staff, managers should involve the employees in unit decision-making and should share with staff the credit and compliments received by acknowledging the employees’ contribution, efforts, and ideas in order to build respect. Staff responses indicated that when a person has respect for his or her manager and feels it is reciprocated, the person wants to do a good job and impress the manager. When there is a lack of respect, 130 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume 50, No. 2, April-June 2015
R. A. Feather et al. often productivity decreases and the relationship between the nurse and the manager suffers. One RN remarked: It is the same as teaching, if you tell a kid they’re great, you’re going to do well, you’re wonderful, I’m glad you’re here, it’s the same thing. That person is going to be happy and productive and satisfied rather than if you had someone that you didn’t respect. A good general rule for nursing manager behavior and represented in the data was to praise publicly, punish privately. The RNs stated the manager should first discuss positive issues about the employee and then the areas that need improvement. Staff nurses believed that at times managers should provide performance improvement plans for each employee that show an interest in the individual’s development as a professional. In addition, the manager should maintain confidentiality and not share this information with other employees. One RN described how a manager should handle respect regarding a confidential problem: “If there’s a problem she won’t announce it to the world, she will take you aside and tell you what happened and how you can do better and why that happened.” Managers were expected to model the kind of behavior they expected from employees. The RNs discussed how it is disrespectful to the employees to show up late for meetings or for work, blame administration or the unit when problems occur, use their time at work improperly with personal tasks, or gossip about employees. The RNs believed that expectations should be made clear and enforced through policies by management in all circumstances, including their own behavior. In all five of the focus groups, a good manager was described as one who went out of their way to show appreciation for staff individually and collectively, with gestures such as a pat on the back, a card, a piece of chocolate, or a word of simple praise. One RN, when discussing the lack of recognition for the positive things, stated: “The things that are mistakes are always recognized, but the things you feel like you really pushed to accomplish with a lot of effort most times are not recognized.” Another nurse stated her feelings about how even the smallest level of acknowledgment is appreciated: “I guess I’m just a sucker for, you know, just simple praise.”
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Nurse Manager Behaviors That RNs Perceive
Feeling Cared for. The theme of feeling cared for was identified as the RNs spoke of how it made them feel to have a nurse manager willing to defend them in situations with other employees, patients, and physicians. They felt cared for when the manager was aware of their personal needs while working. This involved providing adequate staffing to ensure the staff got breaks and meals when the unit was busy, or by providing flexibility with the schedule and allowing time off to care for themselves or the needs of their families. In general, just being visible on the unit showed the staff that the manager was interested in their needs and aware of their workload, and was willing to help in any way possible. One RN commented regarding the nurse manager that: “She is there, she rounds, and she asks you if you’re doing okay. If she sees that you’re about to go, she pulls you in a room and says ‘Sit down for a minute. Drink something. Catch your breath.’ ” The RNs reported feeling uncared for when managers were invisible on the unit as a consequence of attending meetings or simply remained in their offices with doors closed. Nurse managers who were visible to their staff were perceived as being more involved and more caring about how the unit shift was going.
RNs’ discussion included not being supported by managers to take a break or even go to the bathroom, which made them feel that the manager did not care about them and did not support them as a professional. One nurse described what a day was like for her on the unit:
We do a lot to care for family members and we do a lot of end of life care planning with family and patients. That was a time when I felt like, you know, I needed, I wish there was more of a support system.
Nurse manager visibility was discussed in all five of the focus groups, showing the importance of this factor to the RNs. Discussion also involved the positive aspects of the manager’s role as caring even at times the manager was not present, if the nurses perceived the climate on the unit as one of caring for one another, like a family. One nurse stated:
One RN shared a decision she made to leave a position as a result of low job satisfaction and the lack of feeling cared for: I left the last unit because of my manager. Maybe that wouldn’t have happened; maybe it could have been avoided. I loved the patient population so it wasn’t that I was dissatisfied there, it was just a lot of it was that we needed support from the manager and that needed to change. Another area of feeling cared for that was discussed was the manager’s ability to be flexible with the staff in meeting their needs for their personal life, such as scheduling, family emergencies, and vacation time. Often the RNs shared feelings related to lack of caring by the nurse manager such as when nurses did not get their personal needs met during their shift. The
On a typical day I work it’s always hectic and always a struggle to get my lunch or dinner in. I’m lucky if I’ve got it in. Half the time I don’t and the other half I’ll just take a break and you know, shove something down my throat. One RN described frustration when staff perceived the nurse manager as being unaware of the demands of the job of an RN: I do wish the managers . . . could put their self in our shoes sometimes. Because, you know, we do have limits, not only physically but emotionally too. I mean, sometimes at the end of the day when I know when we go home we’re just wiped out. We’re usually there ’til 6, sometimes later. We stay until the patients are done and it can be a long day. It’s mentally exhausting as well as physically.
I think what my manager does for me even when she’s not there every day, is the climate of, you know, we’re a family and we’re going to work together. I’ve been in other places where there’s a climate of if you do something wrong then you’re going to be punished. Category 2: RNs’ Perceived Disconnect of Work Issues From the Manager’s Role Each of the five focus groups discussed the RN’s typical day at work and the problems that often occurred on a daily basis. However, most of the discussion did not include the nurse manager’s role in the everyday life on the unit. There seemed to be a disconnect between RNs’ perceptions regarding their actual work issues and the nurse manager’s role on the hos131
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Nurse Manager Behaviors That RNs Perceive pital unit. Dictionary.com (Disconnect, n.d.) defines disconnect as one part being detached from another. A disconnect was apparent to the research team when the RNs often stated that the nurse manager did not play a role in their day-to-day job in providing patient care. One RN did not relate the manager to the daily needs of the unit: “Our manager is fantastic, the one we have right now, but as far as my day to day, she doesn’t really have an effect on my day.” The RNs in this study recognized the role of the manager as being task oriented in relation to attending meetings and scheduling staff, for example, but did not discuss the role of the manager in solving problems on the unit. Many of the nurses did not make a connection between the daily tasks of the manager and the manager’s role in solving work issues when they occurred during a shift. A nurse shared feelings about how the manager loses that connection with the clinical aspect of the job when taking on the manager role: They have more administrative things than really nursing things. Like they’re not held together. The connection is broken, when they step up. I see it being different when you are a clinical nurse and you go one step up. Most of them when they are managers, they are managers, not clinical managers. The RNs spoke of the importance of being a team and of being dependent on each other to problem solve. Many of them did not mention the manager as their “go to” person to assist them in addressing concerns with staffing, patient care, and negative physician relationships. Participants made statements about how the manager was not there on night shift; therefore, he or she did not have an impact on the nurses’ work on a daily basis. This led to the conclusion of “out of sight, out of mind,” and the manager was perceived as not being there to meet the individual needs of the staff. Another RN described her perception of the role of the nurse manager in comparison with the charge nurse: I think the charge nurse actually plays a bigger role than your manager. Our manager is there, but if something goes down you’re going to go to your charge nurse first, so they are more important. That’s just me, not in the step-by-step involvement. With my manager, only if something major goes wrong do you ever see them. 132 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume 50, No. 2, April-June 2015
R. A. Feather et al. In addition, a disconnect was evident from the RNs’ expectation that the nurse managers maintain a competency level for patient care equal to that of the bedside nurse. The nurses often shared opinions in relation to the manager, no longer knowing how to be a nurse, such as this comment: She’s there. She makes an appearance and she’s nice. I’ve just heard other people, when it’s been really busy like, she’ll say she’ll get them some help and then the help she gives is saying, “You’re doing a great job,” but doesn’t jump in and put on a pair of gloves or do anything like that. The RNs felt the managers are not able to relate to the many problems the nursing staff have on a dayto-day basis, including the physical stress and strain of being directly involved in patient care. One RN commented, “I’d just like some feedback because I feel like my boss has no idea what kind of a job I do because she’s . . . there’s a big gap in between what she does and what happens on the floor.” Discussion As suggested by Herrin and Spears (2007), a supportive environment is one of the most important factors associated with job satisfaction for nurses. In addition, Lake and Friese (2006) found nurse practice environments to have poor ratings based on nurse manager supportiveness and staffing adequacy. The results of the focus group discussions indicated that RN job satisfaction was influenced by supportive behaviors by nurse managers, including good communication, showing respect, and providing a feeling of being cared for to the staff. The RN focus group participants in this study shared their need to receive communication from the nurse manager that was consistent for all employees on all shifts. This type of communication promoted trust by providing evidence that the manager was listening to the RNs and responding appropriately in a timely manner, while protecting their privacy by not sharing confidential information with others. They also discussed the importance of being able to speak freely without repercussions from the manager and not being labeled as negative when identifying a problem on the unit or within the organization. The results supported a study by Kramer and Schmalenberg (2004) that asked nurses employed at Magnet hospitals to identify behaviors that attracted
R. A. Feather et al. and retained RNs in those organizations. The researchers found that nurse manager-supportive behaviors played a vital role in RN job satisfaction and retention. Such behaviors as identified by Kramer et al. (2007) were: being approachable/safe, ensures adequate and competent staffing, walks the talk, watches our back, supports group cohesion/teamwork, cares, provides conflict resolution, displays self-confidence, and provides feedback. These results are similar by comparison with those identified by the RNs in the focus group discussions. The RNs in this study emphasized the importance of these very specific manager behaviors in relation to their job satisfaction and a positive relationship with their nurse managers. They needed to trust the practice environment as a safe, comfortable place to work. A study by Bono, Foldes, Vinson, and Muros (2007) investigated the role that leadership has on employees’ emotions and found that managers who have a positive mood maintain an ongoing influence on the optimism and enthusiasm of the employee, but noted that when employees feel the need to regulate their emotions as a response to fear of repercussions, they are less satisfied with the job and more stressed. A study about nurse perceptions of respect by Laschinger (2004) agreed with the opinions of our participants. The study found that nurses believed that managers did not show respect when there appeared to be a lack of concern by not dealing with the staff in a sensitive manner and not being truthful. This behavior led to a lack of recognition, poor interpersonal relationships, and unreasonable workloads resulting in stress in the workplace and, ultimately, decreased job satisfaction (Laschinger, 2004). The publication The Hallmarks of the Professional Practice Environment (American Association of Colleges of Nursing, 2002) emphasized the contributions of nurses and support of professional development. Expressions of respect and recognition by the manager for the knowledge and contribution to the healthcare process may well be more important than financial rewards for professional nurses (McGuire, Houser, Jarrar, Moy, & Wall, 2003). While this study produced results consistent with others in the literature related to nurse manager behaviors and the link to job satisfaction, it also discovered a disconnect between RNs’ perception of their own work and the nurse manager role. RN responses related to lack of manager visibility on the care unit, and also lack of manager feedback to staff about how manager work connects to the staffs’ work contributed
Nurse Manager Behaviors That RNs Perceive to this disconnect. Expectations that nurse managers maintain the same skill level as staff and be more available to jump in when the unit is busy may demonstrate a lack of understanding, or knowledge deficit, of the manager’s role as well as the demands of the nurse manager role that preclude the necessary interaction and visibility expected by some staff. Though it may be an expectation that the manager should be present or visible on the unit during emergencies or at times when staffing is insufficient in order to provide a desired level of patient care, it may be unrealistic, given the other role expectations of the nurse manager. However, because nurses believe this is something they need or expect from the manager and the manager does not meet these expectations, job satisfaction for the RNs may decrease. A perceived disconnect from the manager’s actual role responsibilities may be an important contributor to staffs’ perceptions of lack of effective communication, respect, and feeling cared for, factors that staff described as important to job satisfaction. While some literature reports similar findings to results in this study, the identification of the importance of the disconnect represented by RN perceptions of their work and the manager work, and how the disconnect may contribute to staff dissatisfaction, are not as prevalent. The findings of this study have implications for increasing and maintaining RN staff satisfaction for nurse managers, healthcare organizations, and staff nurses. Implications Consistent with the IOM (2003) report, the RNs in this study emphasized the need for managers in healthcare organizations to strengthen their leadership skills to increase job satisfaction among RNs. For example, the RNs in this study spoke of the importance of recognition by the manager not only through annual performance appraisals but also on a day-today basis as an acknowledgment of their hard work and contribution to safe, quality patient care. Lake and Friese (2006) found that few hospitals have practice environments that are favorable for nurses. As suggested by research, a supportive environment is one of the most important factors associated with job satisfaction for nurses, and nurse practice environments are rated poorly on nurse manager supportiveness and staffing adequacy (Herrin & Spears, 2007; Shirey et al., 2008). And yet, expressions of respect and recognition by the manager for the knowledge and contribution to 133
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Nurse Manager Behaviors That RNs Perceive the healthcare process are more important than financial rewards for professional nurses (McGuire et al., 2003). Findings from this study support nurse manager attention to purposing allocation of time and effort to visibility with staff that includes modeling of behaviors of direct communication skills conveying feedback, respect, and care for others. There is a critical need to identify effective organizational strategies that support nurse manager performance of behaviors that lead to RN staff satisfaction and desired patient care outcomes, as well as increased recruitment to nurse manager positions in the future. A study conducted by Jackson Healthcare (Vital Signs, 2012) about the career outlook and future risks for nursing stated that half of nurses intended to stay in their current positions over the next 3 to 5 years, but only 13% plan to seek a leadership position in nursing. There is a need for healthcare organizations to evaluate the demands of the nurse manager role to identify supports that would assist the manager in providing for the needs of staff for job satisfaction. For example, realistic organizational expectations related to how managers are involved in decision-making and participation in meetings, as well as creative strategies for inclusion of manager input without removal from their care unit environments for repeated and extended amounts of time, would be helpful. An evaluation of the multiple processes involved in care unit management, as well as the span of control of the nurse manager, should be conducted to provide the necessary supports for the administrative functions of the manager role. Given that this role arose directly from the clinical level of the organization, includes multiple levels of RN educational and experiential background, and varies across units and organizations, perhaps the complexity of the role functions has not received the resource support that other administrative and management positions have in other nonclinical departments. Managers as leaders have two consistent broad and independent behavioral dimensions as described by Hersey and Blanchard (1977). One dimension is production or task oriented, and the other is employee oriented with a focus on relationships, building teamwork, and employee identification with the organization. What type of individual secretarial, financial, and data management support is available to nurse managers for the first dimension cited above to enable their performance of the latter dimension requiring visibility and interaction with staff? 134 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume 50, No. 2, April-June 2015
R. A. Feather et al. And lastly, the role of the nurse manager is vital in creating a healthy care work environment, and therefore it is important for staff to have realistic expectations regarding the role of the nurse manager (Shirey, 2006). A lack of understanding of these roles by RNs can lead to lower job satisfaction that may ultimately have an effect on patient outcomes. Staff education, as well as purposed interaction by the nurse manager, will inform staff about the important role of the manager and connection to their work, and potentially influence the recruitment of future managers from the RN staff. Limitations The nature of self-reporting, the size of the sample, and the use of focus groups with the potential for “groupthink” are the primary limitations to this study. The researcher encouraged open inquiry, with each member of the group being provided an opportunity to share his or her viewpoint and limited participation in this study to only two participants from any individual unit to prevent groupthink (Sullivan & Decker, 2009). Self-reporting by RNs may not have provided an entire description of the phenomenon of interest nor a full picture of nursing job satisfaction related to management behavior. The sample size was limited to those RNs who were available within the time frame of the focus groups, and to the managers represented by this sample of RN participants. Additionally, the use of only two community-based hospitals in one geographical area limits the generalizability of the results of the study for other types and/or larger facilities. Summary This study used RN staff focus groups from two Magnet hospitals to identify specific nurse manager behaviors that were perceived by RNs as influencing the RNs’ job satisfaction. This study identified two major categories of behaviors reported by RNs related to job satisfaction. The first category related to a specific category of manager behaviors supportive of RNs with three themes included: communication, respect, and feeling cared for. The second category was labeled RNs’ perceived disconnect of work issues from the manager’s role. This category identified lack of behaviors that lead to RN dissatisfaction, including lack of manager visibility as well as the RNs lack of
R. A. Feather et al. understanding of the role of the nurse manager. The results have implications for nurse manager education about what is important for staff for job satisfaction, organizational support of the nurse manager role and functions, and need for RN staff education about the nurse manager responsibilities and the connection to their work. Acknowledgments. This research was funded through a dissertation/thesis scholarship provided by the Indiana University School of Nursing, Indianapolis, IN. References American Association of Colleges of Nursing. (2002). Hallmarks of the professional nursing practice environment. Journal of Professional Nursing, 18(5), 295–304. American Health Care Association. (2010). Reports of Findings Nursing Facility Staffing Survey 2010. Retrieved from . www.ahcancal.org American Nurses Association. (2013). Recruitment and retention of nurses. Retrieved from www.nursingworld.org/ MainMenuCategories/ThePracticeofProfessionalNursing/ workforce/Recruitment Andrews, D., & Dziegielewski, S. (2005). The nurse manager: Job satisfaction, the nursing shortage and retention. Journal of Nursing Management, 13, 286–295. doi:10.1111/j.1365-2934.2005.00567x Bono, J., Foldes, H., Vinson, G., & Muros, J. (2007). Workplace emotions: The role of supervision and leadership. Journal of Applied Psychology, 92(5), 1357–1367. Boyle, D., Bott, M., Hansen, H., Woods, C., & Taunton, R. (1999). Manager’s leadership and critical care nurses’ intent to stay. American Journal of Critical Care, 8(6), 361– 371. Cummings, G., Olson, K., Hayduk, L., Bakker, D., Fitch, M., Green, E., & Conlon, M. (2008). The relationship between nursing leadership and nurses’ job satisfaction in Canadian oncology work environments. Journal of Nursing Management, 16(5), 508–518. doi:10.1111/ j.1365.2834.2008.00897x Disconnect. (n.d.). Dictionary.com. Retrieved from http:// dictionary.reference.com Gormley, D. (2011). Are we on the same page? Staff nurse and manager perceptions of work environment, quality of care and anticipated nurse turnover. Journal of Nursing Management, 19, 33–40. doi:10.1111/j.1365-2834.2010 .01163.x Herrin, D., & Spears, P. (2007). Using nurse leader development to improve nurse retention and patient outcomes. Nursing Administration Quarterly, 31(3), 231–243. doi:10 .1097/01.NAQ.0000278937.49491.34 Hersey, P., & Blanchard, K. (1977). Management and organizational behavior. Englewood Cliffs, NJ: Prentice Hall. Institute of Medicine. (2003). Keeping patients safe: Transforming the work environment of nurses. Institute of Medicine of
Nurse Manager Behaviors That RNs Perceive the National Academies. Retrieved from http://www.iom .edu Kitzinger, J. (1995). Qualitative research. Introducing focus groups. British Medical Journal, 311(7000), 299–302. doi:10.1136/bmj.311.7000.299 Kramer, M., Maguire, P., Schmalenberg, C., Brewer, B., Burke, R., Chmielewski, L., & Waldo, M. (2007). Nurse manager support. What is it? Structures and practices that promote it. Nursing Administration Quarterly, 31(4), 325–340. Kramer, M., & Schmalenberg, C. (2004). Development and evaluation of Essentials of Magnetism tool. Journal of Nursing Administration, 34(7/8), 365–378. Lacey, S., Teasley, S., Cox, K., Olney, A., Kramer, M., & Schmalenberg, C. (2011). Development and testing of an organizational job satisfaction tool. Journal of Nursing Administration, 41(1), 15–22. doi:10.1097.NNA .0b013e3182002871. Lake, E., & Friese, C. (2006). Variations in nursing practice environments. Nursing Research, 55(1), 1–9. Laschinger, H. K. S. (2004). Hospital nurses perceptions of respect and organizational justice. Journal of Nursing Administration, 34(7/8), 354–364. Ma, C., Samuels, M., & Alexander, J. (2003). Factors that influence nurses’ job satisfaction. Journal of Nursing Administration, 33(5), 293–299. McGuire, M., Houser, J., Jarrar, T., Moy, M., & Wall, J. (2003). Retention: It’s all about respect. Health Care Manager, 22(1), 38–44. Montalvo, I. (2007). The National Data Base of Nursing Quality Indicators. Online Journal of Issues in Nursing, 12(3), Manuscript 2. doi:10.3912/OJIN.Vol12No03Man02 Pfeifer, G. (2013). The top health news story of 2012: The affordable care act proves resilient. American Journal of Nursing, 113(1), 14–15. doi:10.1097/01.NAJ .0000425736.60860.06 Sandelowski, M. (2000). Whatever happened to qualitative description? Research in Nursing & Health, 23(4), 334–340. doi:10.1002/1098-240X(200008) Schmalenberg, C., & Kramer, M. (2008). Essentials of a productive nurse work environment. Nursing Research, 57(1), 2–13. doi:10.1097/01.NNR.0000280657.04008.2a Shirey, M. (2006). Stress and coping in nurse managers: Two decades of research. Nursing Economics, 24(4), 193– 204. Shirey, M., Ebright, P., & McDaniel, A. (2008). Sleepless in America. Nurse managers cope with stress and complexity. Journal of Nursing Administration, 38(3), 125–131. doi:10.1097/01.NNA.0000310722.35666.73 Shobbrook, P., & Fenton, K. (2002). A strategy for improving nurse retention and recruitment levels. Professional Nursing, 17(9), 534–536. Smith, J. (2012). The unhappiest jobs in America. Forbes. Retrieved from www.forbes.com/sites/jacquelynsmith/ 2012/03/27/the-unhappiest-jobs-in-america/2 Staiger, D., Auerbach, D., & Buerhaus, P. (2012). Registered nurse labor supply and the recession—Are we in a bubble? New England Journal of Medicine, 366(16), 1463– 1465. doi:10.1056/NEJMp1200641 Stuenkel, D., Nguyen, S., & Cohen, J. (2007). Nurses’ perceptions of their work environment. Journal of Nursing 135
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Nurse Manager Behaviors That RNs Perceive Care Quality, 22(4), 337–342. doi:10.1097/01.NCQ .0000290415.50263.e6 Sullivan, E., & Decker, P. (2009). Thinking critically, making decisions, solving problems. In M. Connor (Ed.), Effective leadership and management in nursing (pp. 117–118). Upper Saddle River, NJ: Pearson Education, Inc. Taunton, R., Boyle, D., Woods, C., Hansen, H., & Bott, M. (1997). Manager leadership and retention of hospital staff nurses. Western Journal of Nursing Research, 19(2), 205–226.
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R. A. Feather et al. U.S. Department of Labor, Bureau of Labor Statistics. (2012). Registered nurses. Occupational outlook handbook (2012– 2013 ed.). Retrieved from http://www.bls.gov Vital signs. (2012). Vital signs 2012: A national nursing attitudes and outlook report. Jackson Healthcare, LLC and Jackson Nurse Professionals, LLC. Retrieved from http:// www.jacksonhealthcare.com/media/164537/ nursestrendsreport_ebook0113_lr.pdf
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Nurse Manager Behaviors That RNs Perceive to Affect Their Job Satisfaction Rebecca A. Feather, PhD, RN, NE-BC, Patricia Ebright, PhD, RN, FAAN, and Tamilyn Bakas, PhD, RN, FAHA, FAAN Rebecca A. Feather, PhD, RN, NE-BC, is Assistant Professor, School of Nursing, Indiana University, Bloomington, IN; Patricia Ebright, PhD, RN, FAAN, is Associate Professor and Associate Dean for Graduate Programs, School of Nursing, Indiana University, Indianapolis, IN; and Tamilyn Bakas, PhD, RN, FAHA, FAAN, is Professor and PhD Program Coordinator, School of Nursing, Indiana University, Indianapolis, IN. Keywords Behavior, engagement, job satisfaction, manager Correspondence Rebecca A. Feather, PhD, RN, NE-BC, Indiana University School of Nursing, Bloomington, IN E-mail: [email protected]
Feather
Ebright
PURPOSE. Nurse manager behaviors and job satisfaction are commonly addressed in the literature; however, registered nurse (RN) perceptions of nurse manager behaviors provide a unique perspective that may inform future strategies designed to enhance RN job satisfaction. In this paper, the perceptions of RNs were explored through focus groups to learn the behaviors of nurse managers that most influence RNs’ job satisfaction. METHODS. Five focus groups were conducted through semi-structured interviews of a total of 28 RNs to provide data that were coded through qualitative content analysis for themes. FINDINGS. The findings provide nurse managers with data related to the perceptions of RNs and the behaviors of managers that influence job satisfaction. The findings identified two conceptual categories of RN perceptions of nurse manager behaviors: manager behaviors supportive of RNs (communication, respect, and feeling cared for) plus the RNs’ perceived disconnect of work issues from the manager’s role. CONCLUSION. Findings support past research in relation to the perceptions of RNs wanting to be respected, included in communication, and the need to feel cared for by nurse managers to have higher levels of job satisfaction.
Bakas
One of the biggest challenges for a healthcare facility today is not only recruitment of registered nurses (RNs) but also retention. This is especially true in the current healthcare reform environment, with the vast number of changes still to come as the Affordable Care Act moves into full swing between now and 2014 (Pfeifer, 2013). The U.S. Department of Labor, Bureau of Labor Statistics (2012) projects a need for 711,900 RNs by the year 2020, an increase of 26% since 2010.
A 2003 Institute of Medicine (IOM) report pointed out the urgent need for healthcare organizations to recruit and retain RNs in times of short supply (IOM, 2003). Due to the influx of patients entering the system with the expansion of Medicaid, as well as the mandated purchase of health insurance in 2014, it is vital for hospitals to recruit and retain as many RNs as possible (Pfeifer, 2013). Unfortunately, a study by Staiger, Auerbach, and Buerhaus (2012) projected that as the recession lifts and job recovery takes place, 125
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Nurse Manager Behaviors That RNs Perceive many RNs who entered the workforce due to the recession between 2005 and 2010 will likely leave at a time when they are needed the most. Projected shortages of RNs by 2015 will come as the demand for health care is sharply increasing (Staiger et al., 2012). Many RNs leave the workforce due to negative experiences with nurse managers (Taunton, Boyle, Woods, Hansen, & Bott, 1997). Further exploration of the importance of nurse manager behavior from the perspectives of RNs might provide valuable information needed to develop future strategies for retention. The purpose of this study was to explore nurse manager behaviors that RNs perceive as most influencing their job satisfaction.
R. A. Feather et al. Although researchers have reported that nurse managers play a vital role in creating the daily work environment and, therefore, have an effect on RN retention (Shirey, Ebright, & McDaniel, 2008), a review of the literature showed that a gap still exists in our understanding of the specific links between nurse manager behaviors and RN job satisfaction. This finding points to the importance of exploring nurse manager behaviors directly from the perceptions of the RNs employed by them. Identifying the RN perceptions of the managers’ own staff may lead to new strategies to enhance RN job satisfaction and, ultimately, improve RN retention in the workforce. Literature Review
Background Many factors influence retention of RNs, such as being part of the decision-making process and feeling respected by management (American Nurses Association, 2013). Although past research has provided evidence, there is an overall link between nurse manager behaviors and RN job satisfaction; RN perceptions of manager behavior in the current healthcare environment need to be revisited to provide updated research about why RNs leave or stay in their current positions. A past study on job satisfaction in 30 leading hospitals found that nearly 100% of the nurse participants reported the nurse manager as a factor in their decision to leave the organization (Taunton et al., 1997). Other studies, based on exit interviews with RNs, found that nurse manager behaviors were what most influenced staff nurses’ decisions to leave their positions (Kramer et al., 2007; Shobbrook & Fenton, 2002). A recent study cited in Forbes (Smith, 2012) found that RNs had the second highest unhappiness rate for their job in the United States. Nurses who responded to the survey cited poor compensation, lack of growth opportunities, and workplace culture as being the biggest factors in their dissatisfaction, along with difficult coworkers and managers. Another study surveying nurse attitudes and outlooks (Vital Signs, 2012) found “poor, unsupportive, unresponsive management” to be the top nurse dissatisfier (31% of those surveyed), along with “lack of respect and appreciation from management” (14% of those surveyed), rounding out the top five items leading to dissatisfaction in the workplace. Other dissatisfiers mentioned in the study were work overload/high patient-to-nurse ratios/long hours (31%), low compensation/pay cuts/no raises (15%), and inadequate staffing (15%). 126 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume 50, No. 2, April-June 2015
Nurse managers’ leadership behaviors have been identified as the factors most likely to improve job satisfaction and retention of hospital staff nurses (Andrews & Dziegielewski, 2005). A synthesis of the literature involving outcomes related to nurse manager behaviors and staff job satisfaction covering the time period from 1997 to 2008 revealed that research related to the “post-reconstruction” era of the early 1990s is limited. This era included changes within nursing management that involved elimination of a layer of middle managers in many healthcare organizations. Many of the changes that occurred during this period of time contributed to a nursing shortage (Boyle, Bott, Hansen, Woods, & Taunton, 1999). The literature from 2009 to 2012 does show continued research in the area of job satisfaction and the work environment, but no studies focused solely on RN perceptions. Furthermore, the more recent literature documents disagreement between RNs and nurse managers on what specific behaviors most influence the job satisfaction of staff nurses (Gormley, 2011; Stuenkel, Nguyen, & Cohen, 2007). In addition, the literature shows a lack of consistency in definitions of job satisfaction and in conclusions that could suggest specific management behaviors to promote job satisfaction in RNs. Several studies measured job satisfaction as a factor in the development of a nursing model (Cummings et al., 2008) or as supporting evidence for the value of the Magnet setting (Schmalenberg & Kramer, 2008), yet there is no consistent definition of job satisfaction in the nursing literature. Recent research by Lacey et al. (2011) described professional work satisfaction as being “closely related to the type of environment that promotes or enables professional practice” (p. 15).
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R. A. Feather et al. This definition is one that provides a description of job satisfaction that relates to perceptions of RNs and nurse manager behaviors that promote or hinder professional practice. However, most research indicates that data are not readily available about perceptions of RNs about nurse manager behaviors that directly affect the RNs’ job satisfaction. This study defines job satisfaction of the nurse as cognitive and affective reactions of what the employee wants to receive from their nursing manager compared with what is actually received while an individual is employed as an RN (Ma, Samuels, & Alexander, 2003). Methods A qualitative descriptive design was used to gather data describing nurse manager behaviors perceived by RNs as influencing the RNs’ job satisfaction. Qualitative descriptive studies offer a comprehensive summary and are the method of choice when straight descriptions of phenomena are desired (Sandelowski, 2000). Sample A sample of 28 RNs working in two communitybased hospitals in the Midwest participated in one of five focus groups. Inclusion criteria included hospitals with a minimum of 50 licensed beds and national accreditation. Each hospital had a retention rating that was well above the national average of 55% at the time of the study (American Health Care Association, 2010). Turnover for one facility was 5% and for the other, 6.6%. Both hospitals were Magnet certified and participated in the collection of the National Database of Nursing Quality Indicators (NDNQI) to evaluate nursing care, improve patient outcomes, and identify linkages between nurse staffing and patient outcomes at the unit level. While the NDNQI includes a section that measures job satisfaction, it focuses on the evaluation of the work environment as a whole and is not specific to staff nurse perceptions of nurse manager behaviors (Montalvo, 2007). Demographic results for the participants were as follows: Except for two, the RN participants were Caucasian, and all but one was female. Five participants were 20 to 29 years of age, almost half (46.5%) were 50 years of age or over, and one was over 60. Over three fourths of the participants were married (78.6%). They had 1 to 40 years of experience in
nursing, with 39.3% having 1–10, 21.6% having 11–20, and 39.3% having 21–40 years of experience. There were no RN participants with less than 1 year of employment at their current organization. There were 13 (46.4%) with 1–5 years of employment at their current organization, 8 (28.6%) who had 6–10 years of employment, and the remainder with over 10 years of employment at their current organization. Over half (60.7%) worked 12-hr shifts, with a plurality of this group (35.7%) working from 7 a.m. to 7 p.m. Of the total sample, 74.4% worked day shifts that ended by 6 p.m. The education level included 8 associate degree, 18 baccalaureate, and 2 master’s prepared nurses, with 16 of the RNs having certifications (57.1%). A nurse manager was defined as an RN who had 24-hr accountability for the operations of one or more hospital or clinic units, regardless of the title given to that position. This position involved direct supervision of charge and staff nurses on all shifts. To be eligible for their staff to participate in this study, the nurse manager must have had one or more years of experience as a nurse manager. Manager experience was important in order to establish that the nurse manager was not in the orientation or initial/transitional stage of learning the role of management. Lack of experience in this position could pose an external threat to the study. Other demographics about the nurse manager were not included to protect the confidentiality of the RN participants. A staff nurse was defined as an RN on a hospital unit responsible for the care of the patients admitted to that unit. To be eligible to participate in the study, a staff nurse RN was required to have a minimum of 6 months of experience in patient care, and had to have been employed under his or her current nurse manager for a minimum of 6 months. A purposive sampling of potentially eligible participants was conducted with nursing staff at each organization, with the permission of the facility’s chief nurse executive. Contact was made through an e-mail address provided by the organization. A flyer containing information about the study and contact information for the researcher was distributed to interested RNs, with options for dates, times, and locations of each of the focus groups. Each focus group was intended to include at least five and no more than eight participants in the order in which they volunteered. No more than three RNs per group from the same unit or with the same manager were enrolled in the study. This increased the likelihood of diversity 127
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Nurse Manager Behaviors That RNs Perceive across staff with different managers from each organization. Based upon availability, RNs who called or e-mailed to volunteer and who met the inclusion criteria were selected and enrolled in the study. Procedures After obtaining approval from the Institutional Review Board, the researcher met with participants to conduct the focus groups. The participants first completed an informed consent and a demographic questionnaire. Recruitment goals for the sample were to include RN participants from each of the two organizations in focus groups of five to eight participants, with a minimum of two focus groups per organization, representing multiple units. The advantage of using a focus group interview method is that people are more likely to explore and clarify their views in a way that may not be as easily accessible in a one-to-one interview (Kitzinger, 1995). The five audiotaped, 90-min focus groups were conducted on site by the researcher at each facility in the evenings when management was not likely to be present. Each group met in a conference room located away from the nursing units. Data were collected through the following two formats: a demographic questionnaire the participants were asked to complete prior to the focus groups; and participants’ responses to a series of semi-structured questions directed by the researcher as part of the focus group discussion (Table 1). An opportunity was provided for all participants to summarize their thoughts and feelings about the discussion prior to the end of the focus group session, and each RN was asked to summarize the greatest take-away thought from the group discussion. Analysis Data across all focus groups were synthesized and coded, with significant statements extracted, categorized, and analyzed for content and themes. A table was created including all initial codes in each focus group for a comparison of commonalities across the five groups. Initial code identification resulted in the following: Group One had 29 codes; Group Two had 35 codes; Group Three had 31 codes; Group Four had 47 codes; and Group Five had 36 codes. The transcripts were reviewed a fourth time, and specific statements that related to the codes were identified and highlighted in the table for each focus group. The statements were made into a list and labeled to correspond to each code. 128 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume 50, No. 2, April-June 2015
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Table 1. Focus Group Interview Questions 1. Tell me about a really memorable day for you at work, good or bad. 2. What do you think makes a day go well and go poorly for you? 3. What part do you think your manager plays in how your day goes at work? 4. What might your manager do to worsen your day at work? 5. What might your manager do to improve your day at work? Possible probes Describe manager behaviors that you view to be positive. Describe manager behaviors that you view to be negative. Talk about behaviors of nurse managers that make you feel good about your job. Talk about behaviors of nurse managers that make you feel bad about your job.
Qualitative content analysis of the data was achieved through repeated iterative discussions with the research team. The research team consisted of two qualitative experts, both with knowledge of nursing leadership and management, and one instrument development expert knowledgeable in the aspects of comparison of the data with past and current research results. The table of codes was reviewed to identify commonalities across the five focus groups and those codes that appeared in at least three out of the five focus groups were chosen for further analysis. Analysis resulted in identification of two conceptual categories, one of which contained three distinct themes, and definitions (Table 2). The first conceptual category was labeled manager behaviors (present or absent) supportive of RNs and consisted of three themes (communication, respect, and feeling cared for). The second conceptual category was the RNs’ perceived disconnect between work issues and the manager’s role. Categories and themes are represented below, with examples of focus group participant responses contributing to study findings. Results Category 1: Manager Behaviors Supportive of RNs As mentioned, the focus group transcript content analysis resulted in agreement on three major themes relative to nurse manager behavior.
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Table 2. Focus Group Categories and Themes
Focus group categories/themes 1. Manager behaviors supportive of RNS—present or absent Communication • Consistency • Fear • Listening • Trust Respect • Fairness • Recognizing Feeling Cared For • Advocate • Flexibility • Lack of breaks/meals • Staffing • Visibility 2. RNs’ perceived disconnect of work issues from the manager’s role
As defined in the focus group discussions
The manager directly speaks with the staff and openly shares information. The manager does what he/she says he/she is going to do. Anticipation of repercussions for speaking up Demonstrated by appropriate verbal and nonverbal responses Privacy is protected, valued through actions and commitment of the manager for betterment of the staff and unit. The manager shows employee he/she is valued as an individual. The manager treats everyone the same. The manager acknowledges good work and contributions of individual staff. The manager provides needed resources for staff’s needs and patient/family care. The manager goes to bat or represents the staff and resolves conflict. The manager is able to bend based upon the needs of the individual or the unit. No time for personal needs to be met (breaks and food) The perception of adequate caregivers for workers (the number of and experience levels of caregivers) The manager is seen by staff on the unit; is frequently present on the unit. The manager does not play a role in the daily tasks and work issues of the nursing unit.
Communication. The theme of communication was identified through the RNs’ discussion of the need to be made aware of the decision-making that was occurring within their organization. The RNs desired communication in which managers were consistent in what they said and did, listened to the personal and professional needs of the staff, responded by promoting open discussion within the unit, and maintained confidentiality, all of which promoted trust. Communication was absent when the staff felt excluded and unaware of decisions being made within the organization. This type of behavior, as perceived by the RNs, resulted in a lack of trust between the staff and the management. One RN explained it this way: I guess communication is a big issue when I see managers that are more open with their communication, both interacting with people on the units, communication, talking to them, how’s their day,
Number of focus groups in which theme occurred
3 4 3 4 3 3 4 5 4 3 3 3 5 5 5
what are their needs, what’s going on, and then the lack of that, when people don’t do that, I think that’s a real barrier. Most of the RNs discussed the importance of direct verbal communication between the nurse manager and the staff, especially to inform them of what was occurring in the organization and to discuss decisions made in administrative committees that might directly affect the unit and staff. The nurses believed that direct verbal communication helped them to be more informed, better organized, and “on the same page” as management. One RN stated: I think communication is key and I think anybody who has the communication skills and really promotes those skills is a better manager and the nurses that are better communicators are happier in their job because they get their needs met. 129
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Nurse Manager Behaviors That RNs Perceive Listening was a form of communication discussed by the staff and illustrated as a manager who was receptive to their suggestions and responded in a way that was timely by actually doing something in response to the nurse. One nurse described a manager who listened in this manner: A good listener. They take it in and they get back to you in a timely manner, but they truly hear, respond and you can tell when somebody is truly listening to what you’re saying and gets back with you. According to staff responses, managers must learn to avoid the “grapevine” by not listening or joining in gossip about their employees. Although at times vital information can be learned in this manner, if the nurses perceive the manager is gossiping, a trusting relationship can be destroyed. The RNs perceived managers who walked the walk and talked the talk by not involving themselves in gossip as remaining professional. Respect. A second theme identified was respect, which was described as being present when the manager promoted fairness in interacting with the employees on the unit. Managers displayed respect by treating everyone the same in all aspects of enforcing policy and discipline, by holding each individual accountable, and by providing fairness with scheduling. Respect was also present in the manner in which the manager acknowledged the good work of the staff on an individual basis for the contributions made on the unit and for providing good patient care. Respect was absent when the nurse manager was not equitable in staff discipline or scheduling, or demonstrated a lack of recognition for the level of care and compassion shown to patients and their families on a daily basis. As shown by the data, a nurse manager earns the respect of employees by being fair, providing recognition when deserved, and being available to employees. According to staff, managers should involve the employees in unit decision-making and should share with staff the credit and compliments received by acknowledging the employees’ contribution, efforts, and ideas in order to build respect. Staff responses indicated that when a person has respect for his or her manager and feels it is reciprocated, the person wants to do a good job and impress the manager. When there is a lack of respect, 130 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume 50, No. 2, April-June 2015
R. A. Feather et al. often productivity decreases and the relationship between the nurse and the manager suffers. One RN remarked: It is the same as teaching, if you tell a kid they’re great, you’re going to do well, you’re wonderful, I’m glad you’re here, it’s the same thing. That person is going to be happy and productive and satisfied rather than if you had someone that you didn’t respect. A good general rule for nursing manager behavior and represented in the data was to praise publicly, punish privately. The RNs stated the manager should first discuss positive issues about the employee and then the areas that need improvement. Staff nurses believed that at times managers should provide performance improvement plans for each employee that show an interest in the individual’s development as a professional. In addition, the manager should maintain confidentiality and not share this information with other employees. One RN described how a manager should handle respect regarding a confidential problem: “If there’s a problem she won’t announce it to the world, she will take you aside and tell you what happened and how you can do better and why that happened.” Managers were expected to model the kind of behavior they expected from employees. The RNs discussed how it is disrespectful to the employees to show up late for meetings or for work, blame administration or the unit when problems occur, use their time at work improperly with personal tasks, or gossip about employees. The RNs believed that expectations should be made clear and enforced through policies by management in all circumstances, including their own behavior. In all five of the focus groups, a good manager was described as one who went out of their way to show appreciation for staff individually and collectively, with gestures such as a pat on the back, a card, a piece of chocolate, or a word of simple praise. One RN, when discussing the lack of recognition for the positive things, stated: “The things that are mistakes are always recognized, but the things you feel like you really pushed to accomplish with a lot of effort most times are not recognized.” Another nurse stated her feelings about how even the smallest level of acknowledgment is appreciated: “I guess I’m just a sucker for, you know, just simple praise.”
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Nurse Manager Behaviors That RNs Perceive
Feeling Cared for. The theme of feeling cared for was identified as the RNs spoke of how it made them feel to have a nurse manager willing to defend them in situations with other employees, patients, and physicians. They felt cared for when the manager was aware of their personal needs while working. This involved providing adequate staffing to ensure the staff got breaks and meals when the unit was busy, or by providing flexibility with the schedule and allowing time off to care for themselves or the needs of their families. In general, just being visible on the unit showed the staff that the manager was interested in their needs and aware of their workload, and was willing to help in any way possible. One RN commented regarding the nurse manager that: “She is there, she rounds, and she asks you if you’re doing okay. If she sees that you’re about to go, she pulls you in a room and says ‘Sit down for a minute. Drink something. Catch your breath.’ ” The RNs reported feeling uncared for when managers were invisible on the unit as a consequence of attending meetings or simply remained in their offices with doors closed. Nurse managers who were visible to their staff were perceived as being more involved and more caring about how the unit shift was going.
RNs’ discussion included not being supported by managers to take a break or even go to the bathroom, which made them feel that the manager did not care about them and did not support them as a professional. One nurse described what a day was like for her on the unit:
We do a lot to care for family members and we do a lot of end of life care planning with family and patients. That was a time when I felt like, you know, I needed, I wish there was more of a support system.
Nurse manager visibility was discussed in all five of the focus groups, showing the importance of this factor to the RNs. Discussion also involved the positive aspects of the manager’s role as caring even at times the manager was not present, if the nurses perceived the climate on the unit as one of caring for one another, like a family. One nurse stated:
One RN shared a decision she made to leave a position as a result of low job satisfaction and the lack of feeling cared for: I left the last unit because of my manager. Maybe that wouldn’t have happened; maybe it could have been avoided. I loved the patient population so it wasn’t that I was dissatisfied there, it was just a lot of it was that we needed support from the manager and that needed to change. Another area of feeling cared for that was discussed was the manager’s ability to be flexible with the staff in meeting their needs for their personal life, such as scheduling, family emergencies, and vacation time. Often the RNs shared feelings related to lack of caring by the nurse manager such as when nurses did not get their personal needs met during their shift. The
On a typical day I work it’s always hectic and always a struggle to get my lunch or dinner in. I’m lucky if I’ve got it in. Half the time I don’t and the other half I’ll just take a break and you know, shove something down my throat. One RN described frustration when staff perceived the nurse manager as being unaware of the demands of the job of an RN: I do wish the managers . . . could put their self in our shoes sometimes. Because, you know, we do have limits, not only physically but emotionally too. I mean, sometimes at the end of the day when I know when we go home we’re just wiped out. We’re usually there ’til 6, sometimes later. We stay until the patients are done and it can be a long day. It’s mentally exhausting as well as physically.
I think what my manager does for me even when she’s not there every day, is the climate of, you know, we’re a family and we’re going to work together. I’ve been in other places where there’s a climate of if you do something wrong then you’re going to be punished. Category 2: RNs’ Perceived Disconnect of Work Issues From the Manager’s Role Each of the five focus groups discussed the RN’s typical day at work and the problems that often occurred on a daily basis. However, most of the discussion did not include the nurse manager’s role in the everyday life on the unit. There seemed to be a disconnect between RNs’ perceptions regarding their actual work issues and the nurse manager’s role on the hos131
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Nurse Manager Behaviors That RNs Perceive pital unit. Dictionary.com (Disconnect, n.d.) defines disconnect as one part being detached from another. A disconnect was apparent to the research team when the RNs often stated that the nurse manager did not play a role in their day-to-day job in providing patient care. One RN did not relate the manager to the daily needs of the unit: “Our manager is fantastic, the one we have right now, but as far as my day to day, she doesn’t really have an effect on my day.” The RNs in this study recognized the role of the manager as being task oriented in relation to attending meetings and scheduling staff, for example, but did not discuss the role of the manager in solving problems on the unit. Many of the nurses did not make a connection between the daily tasks of the manager and the manager’s role in solving work issues when they occurred during a shift. A nurse shared feelings about how the manager loses that connection with the clinical aspect of the job when taking on the manager role: They have more administrative things than really nursing things. Like they’re not held together. The connection is broken, when they step up. I see it being different when you are a clinical nurse and you go one step up. Most of them when they are managers, they are managers, not clinical managers. The RNs spoke of the importance of being a team and of being dependent on each other to problem solve. Many of them did not mention the manager as their “go to” person to assist them in addressing concerns with staffing, patient care, and negative physician relationships. Participants made statements about how the manager was not there on night shift; therefore, he or she did not have an impact on the nurses’ work on a daily basis. This led to the conclusion of “out of sight, out of mind,” and the manager was perceived as not being there to meet the individual needs of the staff. Another RN described her perception of the role of the nurse manager in comparison with the charge nurse: I think the charge nurse actually plays a bigger role than your manager. Our manager is there, but if something goes down you’re going to go to your charge nurse first, so they are more important. That’s just me, not in the step-by-step involvement. With my manager, only if something major goes wrong do you ever see them. 132 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume 50, No. 2, April-June 2015
R. A. Feather et al. In addition, a disconnect was evident from the RNs’ expectation that the nurse managers maintain a competency level for patient care equal to that of the bedside nurse. The nurses often shared opinions in relation to the manager, no longer knowing how to be a nurse, such as this comment: She’s there. She makes an appearance and she’s nice. I’ve just heard other people, when it’s been really busy like, she’ll say she’ll get them some help and then the help she gives is saying, “You’re doing a great job,” but doesn’t jump in and put on a pair of gloves or do anything like that. The RNs felt the managers are not able to relate to the many problems the nursing staff have on a dayto-day basis, including the physical stress and strain of being directly involved in patient care. One RN commented, “I’d just like some feedback because I feel like my boss has no idea what kind of a job I do because she’s . . . there’s a big gap in between what she does and what happens on the floor.” Discussion As suggested by Herrin and Spears (2007), a supportive environment is one of the most important factors associated with job satisfaction for nurses. In addition, Lake and Friese (2006) found nurse practice environments to have poor ratings based on nurse manager supportiveness and staffing adequacy. The results of the focus group discussions indicated that RN job satisfaction was influenced by supportive behaviors by nurse managers, including good communication, showing respect, and providing a feeling of being cared for to the staff. The RN focus group participants in this study shared their need to receive communication from the nurse manager that was consistent for all employees on all shifts. This type of communication promoted trust by providing evidence that the manager was listening to the RNs and responding appropriately in a timely manner, while protecting their privacy by not sharing confidential information with others. They also discussed the importance of being able to speak freely without repercussions from the manager and not being labeled as negative when identifying a problem on the unit or within the organization. The results supported a study by Kramer and Schmalenberg (2004) that asked nurses employed at Magnet hospitals to identify behaviors that attracted
R. A. Feather et al. and retained RNs in those organizations. The researchers found that nurse manager-supportive behaviors played a vital role in RN job satisfaction and retention. Such behaviors as identified by Kramer et al. (2007) were: being approachable/safe, ensures adequate and competent staffing, walks the talk, watches our back, supports group cohesion/teamwork, cares, provides conflict resolution, displays self-confidence, and provides feedback. These results are similar by comparison with those identified by the RNs in the focus group discussions. The RNs in this study emphasized the importance of these very specific manager behaviors in relation to their job satisfaction and a positive relationship with their nurse managers. They needed to trust the practice environment as a safe, comfortable place to work. A study by Bono, Foldes, Vinson, and Muros (2007) investigated the role that leadership has on employees’ emotions and found that managers who have a positive mood maintain an ongoing influence on the optimism and enthusiasm of the employee, but noted that when employees feel the need to regulate their emotions as a response to fear of repercussions, they are less satisfied with the job and more stressed. A study about nurse perceptions of respect by Laschinger (2004) agreed with the opinions of our participants. The study found that nurses believed that managers did not show respect when there appeared to be a lack of concern by not dealing with the staff in a sensitive manner and not being truthful. This behavior led to a lack of recognition, poor interpersonal relationships, and unreasonable workloads resulting in stress in the workplace and, ultimately, decreased job satisfaction (Laschinger, 2004). The publication The Hallmarks of the Professional Practice Environment (American Association of Colleges of Nursing, 2002) emphasized the contributions of nurses and support of professional development. Expressions of respect and recognition by the manager for the knowledge and contribution to the healthcare process may well be more important than financial rewards for professional nurses (McGuire, Houser, Jarrar, Moy, & Wall, 2003). While this study produced results consistent with others in the literature related to nurse manager behaviors and the link to job satisfaction, it also discovered a disconnect between RNs’ perception of their own work and the nurse manager role. RN responses related to lack of manager visibility on the care unit, and also lack of manager feedback to staff about how manager work connects to the staffs’ work contributed
Nurse Manager Behaviors That RNs Perceive to this disconnect. Expectations that nurse managers maintain the same skill level as staff and be more available to jump in when the unit is busy may demonstrate a lack of understanding, or knowledge deficit, of the manager’s role as well as the demands of the nurse manager role that preclude the necessary interaction and visibility expected by some staff. Though it may be an expectation that the manager should be present or visible on the unit during emergencies or at times when staffing is insufficient in order to provide a desired level of patient care, it may be unrealistic, given the other role expectations of the nurse manager. However, because nurses believe this is something they need or expect from the manager and the manager does not meet these expectations, job satisfaction for the RNs may decrease. A perceived disconnect from the manager’s actual role responsibilities may be an important contributor to staffs’ perceptions of lack of effective communication, respect, and feeling cared for, factors that staff described as important to job satisfaction. While some literature reports similar findings to results in this study, the identification of the importance of the disconnect represented by RN perceptions of their work and the manager work, and how the disconnect may contribute to staff dissatisfaction, are not as prevalent. The findings of this study have implications for increasing and maintaining RN staff satisfaction for nurse managers, healthcare organizations, and staff nurses. Implications Consistent with the IOM (2003) report, the RNs in this study emphasized the need for managers in healthcare organizations to strengthen their leadership skills to increase job satisfaction among RNs. For example, the RNs in this study spoke of the importance of recognition by the manager not only through annual performance appraisals but also on a day-today basis as an acknowledgment of their hard work and contribution to safe, quality patient care. Lake and Friese (2006) found that few hospitals have practice environments that are favorable for nurses. As suggested by research, a supportive environment is one of the most important factors associated with job satisfaction for nurses, and nurse practice environments are rated poorly on nurse manager supportiveness and staffing adequacy (Herrin & Spears, 2007; Shirey et al., 2008). And yet, expressions of respect and recognition by the manager for the knowledge and contribution to 133
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Nurse Manager Behaviors That RNs Perceive the healthcare process are more important than financial rewards for professional nurses (McGuire et al., 2003). Findings from this study support nurse manager attention to purposing allocation of time and effort to visibility with staff that includes modeling of behaviors of direct communication skills conveying feedback, respect, and care for others. There is a critical need to identify effective organizational strategies that support nurse manager performance of behaviors that lead to RN staff satisfaction and desired patient care outcomes, as well as increased recruitment to nurse manager positions in the future. A study conducted by Jackson Healthcare (Vital Signs, 2012) about the career outlook and future risks for nursing stated that half of nurses intended to stay in their current positions over the next 3 to 5 years, but only 13% plan to seek a leadership position in nursing. There is a need for healthcare organizations to evaluate the demands of the nurse manager role to identify supports that would assist the manager in providing for the needs of staff for job satisfaction. For example, realistic organizational expectations related to how managers are involved in decision-making and participation in meetings, as well as creative strategies for inclusion of manager input without removal from their care unit environments for repeated and extended amounts of time, would be helpful. An evaluation of the multiple processes involved in care unit management, as well as the span of control of the nurse manager, should be conducted to provide the necessary supports for the administrative functions of the manager role. Given that this role arose directly from the clinical level of the organization, includes multiple levels of RN educational and experiential background, and varies across units and organizations, perhaps the complexity of the role functions has not received the resource support that other administrative and management positions have in other nonclinical departments. Managers as leaders have two consistent broad and independent behavioral dimensions as described by Hersey and Blanchard (1977). One dimension is production or task oriented, and the other is employee oriented with a focus on relationships, building teamwork, and employee identification with the organization. What type of individual secretarial, financial, and data management support is available to nurse managers for the first dimension cited above to enable their performance of the latter dimension requiring visibility and interaction with staff? 134 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume 50, No. 2, April-June 2015
R. A. Feather et al. And lastly, the role of the nurse manager is vital in creating a healthy care work environment, and therefore it is important for staff to have realistic expectations regarding the role of the nurse manager (Shirey, 2006). A lack of understanding of these roles by RNs can lead to lower job satisfaction that may ultimately have an effect on patient outcomes. Staff education, as well as purposed interaction by the nurse manager, will inform staff about the important role of the manager and connection to their work, and potentially influence the recruitment of future managers from the RN staff. Limitations The nature of self-reporting, the size of the sample, and the use of focus groups with the potential for “groupthink” are the primary limitations to this study. The researcher encouraged open inquiry, with each member of the group being provided an opportunity to share his or her viewpoint and limited participation in this study to only two participants from any individual unit to prevent groupthink (Sullivan & Decker, 2009). Self-reporting by RNs may not have provided an entire description of the phenomenon of interest nor a full picture of nursing job satisfaction related to management behavior. The sample size was limited to those RNs who were available within the time frame of the focus groups, and to the managers represented by this sample of RN participants. Additionally, the use of only two community-based hospitals in one geographical area limits the generalizability of the results of the study for other types and/or larger facilities. Summary This study used RN staff focus groups from two Magnet hospitals to identify specific nurse manager behaviors that were perceived by RNs as influencing the RNs’ job satisfaction. This study identified two major categories of behaviors reported by RNs related to job satisfaction. The first category related to a specific category of manager behaviors supportive of RNs with three themes included: communication, respect, and feeling cared for. The second category was labeled RNs’ perceived disconnect of work issues from the manager’s role. This category identified lack of behaviors that lead to RN dissatisfaction, including lack of manager visibility as well as the RNs lack of
R. A. Feather et al. understanding of the role of the nurse manager. The results have implications for nurse manager education about what is important for staff for job satisfaction, organizational support of the nurse manager role and functions, and need for RN staff education about the nurse manager responsibilities and the connection to their work. Acknowledgments. This research was funded through a dissertation/thesis scholarship provided by the Indiana University School of Nursing, Indianapolis, IN. References American Association of Colleges of Nursing. (2002). Hallmarks of the professional nursing practice environment. Journal of Professional Nursing, 18(5), 295–304. American Health Care Association. (2010). Reports of Findings Nursing Facility Staffing Survey 2010. Retrieved from . www.ahcancal.org American Nurses Association. (2013). Recruitment and retention of nurses. Retrieved from www.nursingworld.org/ MainMenuCategories/ThePracticeofProfessionalNursing/ workforce/Recruitment Andrews, D., & Dziegielewski, S. (2005). The nurse manager: Job satisfaction, the nursing shortage and retention. Journal of Nursing Management, 13, 286–295. doi:10.1111/j.1365-2934.2005.00567x Bono, J., Foldes, H., Vinson, G., & Muros, J. (2007). Workplace emotions: The role of supervision and leadership. Journal of Applied Psychology, 92(5), 1357–1367. Boyle, D., Bott, M., Hansen, H., Woods, C., & Taunton, R. (1999). Manager’s leadership and critical care nurses’ intent to stay. American Journal of Critical Care, 8(6), 361– 371. Cummings, G., Olson, K., Hayduk, L., Bakker, D., Fitch, M., Green, E., & Conlon, M. (2008). The relationship between nursing leadership and nurses’ job satisfaction in Canadian oncology work environments. Journal of Nursing Management, 16(5), 508–518. doi:10.1111/ j.1365.2834.2008.00897x Disconnect. (n.d.). Dictionary.com. Retrieved from http:// dictionary.reference.com Gormley, D. (2011). Are we on the same page? Staff nurse and manager perceptions of work environment, quality of care and anticipated nurse turnover. Journal of Nursing Management, 19, 33–40. doi:10.1111/j.1365-2834.2010 .01163.x Herrin, D., & Spears, P. (2007). Using nurse leader development to improve nurse retention and patient outcomes. Nursing Administration Quarterly, 31(3), 231–243. doi:10 .1097/01.NAQ.0000278937.49491.34 Hersey, P., & Blanchard, K. (1977). Management and organizational behavior. Englewood Cliffs, NJ: Prentice Hall. Institute of Medicine. (2003). Keeping patients safe: Transforming the work environment of nurses. Institute of Medicine of
Nurse Manager Behaviors That RNs Perceive the National Academies. Retrieved from http://www.iom .edu Kitzinger, J. (1995). Qualitative research. Introducing focus groups. British Medical Journal, 311(7000), 299–302. doi:10.1136/bmj.311.7000.299 Kramer, M., Maguire, P., Schmalenberg, C., Brewer, B., Burke, R., Chmielewski, L., & Waldo, M. (2007). Nurse manager support. What is it? Structures and practices that promote it. Nursing Administration Quarterly, 31(4), 325–340. Kramer, M., & Schmalenberg, C. (2004). Development and evaluation of Essentials of Magnetism tool. Journal of Nursing Administration, 34(7/8), 365–378. Lacey, S., Teasley, S., Cox, K., Olney, A., Kramer, M., & Schmalenberg, C. (2011). Development and testing of an organizational job satisfaction tool. Journal of Nursing Administration, 41(1), 15–22. doi:10.1097.NNA .0b013e3182002871. Lake, E., & Friese, C. (2006). Variations in nursing practice environments. Nursing Research, 55(1), 1–9. Laschinger, H. K. S. (2004). Hospital nurses perceptions of respect and organizational justice. Journal of Nursing Administration, 34(7/8), 354–364. Ma, C., Samuels, M., & Alexander, J. (2003). Factors that influence nurses’ job satisfaction. Journal of Nursing Administration, 33(5), 293–299. McGuire, M., Houser, J., Jarrar, T., Moy, M., & Wall, J. (2003). Retention: It’s all about respect. Health Care Manager, 22(1), 38–44. Montalvo, I. (2007). The National Data Base of Nursing Quality Indicators. Online Journal of Issues in Nursing, 12(3), Manuscript 2. doi:10.3912/OJIN.Vol12No03Man02 Pfeifer, G. (2013). The top health news story of 2012: The affordable care act proves resilient. American Journal of Nursing, 113(1), 14–15. doi:10.1097/01.NAJ .0000425736.60860.06 Sandelowski, M. (2000). Whatever happened to qualitative description? Research in Nursing & Health, 23(4), 334–340. doi:10.1002/1098-240X(200008) Schmalenberg, C., & Kramer, M. (2008). Essentials of a productive nurse work environment. Nursing Research, 57(1), 2–13. doi:10.1097/01.NNR.0000280657.04008.2a Shirey, M. (2006). Stress and coping in nurse managers: Two decades of research. Nursing Economics, 24(4), 193– 204. Shirey, M., Ebright, P., & McDaniel, A. (2008). Sleepless in America. Nurse managers cope with stress and complexity. Journal of Nursing Administration, 38(3), 125–131. doi:10.1097/01.NNA.0000310722.35666.73 Shobbrook, P., & Fenton, K. (2002). A strategy for improving nurse retention and recruitment levels. Professional Nursing, 17(9), 534–536. Smith, J. (2012). The unhappiest jobs in America. Forbes. Retrieved from www.forbes.com/sites/jacquelynsmith/ 2012/03/27/the-unhappiest-jobs-in-america/2 Staiger, D., Auerbach, D., & Buerhaus, P. (2012). Registered nurse labor supply and the recession—Are we in a bubble? New England Journal of Medicine, 366(16), 1463– 1465. doi:10.1056/NEJMp1200641 Stuenkel, D., Nguyen, S., & Cohen, J. (2007). Nurses’ perceptions of their work environment. Journal of Nursing 135
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Nurse Manager Behaviors That RNs Perceive Care Quality, 22(4), 337–342. doi:10.1097/01.NCQ .0000290415.50263.e6 Sullivan, E., & Decker, P. (2009). Thinking critically, making decisions, solving problems. In M. Connor (Ed.), Effective leadership and management in nursing (pp. 117–118). Upper Saddle River, NJ: Pearson Education, Inc. Taunton, R., Boyle, D., Woods, C., Hansen, H., & Bott, M. (1997). Manager leadership and retention of hospital staff nurses. Western Journal of Nursing Research, 19(2), 205–226.
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R. A. Feather et al. U.S. Department of Labor, Bureau of Labor Statistics. (2012). Registered nurses. Occupational outlook handbook (2012– 2013 ed.). Retrieved from http://www.bls.gov Vital signs. (2012). Vital signs 2012: A national nursing attitudes and outlook report. Jackson Healthcare, LLC and Jackson Nurse Professionals, LLC. Retrieved from http:// www.jacksonhealthcare.com/media/164537/ nursestrendsreport_ebook0113_lr.pdf
