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Nurse Manager Support: How Do Staff Nurses Define It?

2009; American Association of Critical-Care Nurses; Volume: 29; Issue: 4 Linguagem: Inglês

10.4037/ccn2009366

1940-8250

Claudia Schmalenberg, Marlene Kramer,

Healthcare professionals’ stress and burnout

Nurse manager support, which is essential for a healthy work environment, depends upon staff nurses' perceptions.What is nurse manager support? I do the things that my nurse manager did to show me support plus all the things that I wished she would have done to show me support when I was a staff nurse. But is that what staff nurses today consider support? I don't know; that's a good question. It's never come up in our group sessions. I'd really like to know if what I consider supportive is the same as what the staff would say. (Nurse Manager)Perception is reality! The behaviors of nurse managers that staff nurses perceive as supportive may or may not be the same as the behaviors that nurse managers think are supportive.Stimulated by staff nurses' identification of nurse manager support as 1 of the 8 essentials of a healthy work environment, that is, an environment that promotes job satisfaction and enables staff to give high-quality patient care, we began a 7-year quest to find out: What does nurse manager support mean to clinical nurses on the front line in both teaching and community hospitals? What are the specific behaviors of nurse managers that staff nurses identify as supportive? If nurse managers are to be optimally effective, they must know and enact the behaviors that convey support to staff. Only staff nurses can identify these supportive behaviors and, through valid measurement, provide the necessary feedback to nurse managers, who in turn have the power to change and alter that aspect of the work environment.The role of the nurse manager in acute care settings has undergone several dramatic changes in the past 3 decades, evolving from that of head nurse or clinical expert, to that of department head, to that of nurse manager and leader.1 The role continues to be a major focus of discussion and research today. The leadership of the nurse manager is key to effective functioning of the unit, to high-quality patient care, and to retention of nurses.2 In one study,3 84% of nurses leaving or considering leaving their jobs did so as a result of their relationships with their nurse manager. Taunton et al4 report that 40% of the 124 nurses who separated from their unit during the 6-month period of the study left their nurse manager (transferring to another unit within the same hospital), not the hospital. Effective performance in the nurse manager role is key to the empowerment of staff that is essential to work effectiveness,5 to the strong need for nurses to function autonomously for patient safety and quality care,6–9 and to promotion of the collaborative/collegial relationships between physicians and nurses that are essential to good outcomes for patients.10–12Support of staff is either a highly regarded function of the nurse manager or it is seemingly ignored, as evidenced by the lack of specific supportive role behaviors. Staff nurses in magnet hospitals,13 the American Association of Critical-Care Nurses,14 and the American Organization of Nurse Executives15 identify nurse manager support as essential to a healthy work environment. Nurse manager support is 1 of the 8 essentials of a healthy work environment identified by staff nurses in magnet hospitals; the behaviors specific to the nurse manager role in designating this support were primarily leadership functions.13 Nurse manager support is one of the role functions of nurses in leadership positions identified by the American Association of Critical-Care Nurses under their authentic leadership standard for establishing and sustaining healthy work environments14; specific role behaviors are not listed. Nurse manager support of staff is cited 3 times in the American Organization of Nurse Executives' list of 179 "competencies common to nurses in executive practice regardless of job title"15; supportive role behaviors are not provided. In contrast, the American Nurses Association's standards for nurses in administrative practice16 make no reference to nurse managers' support of staff, the supportive role function, or to supportive role behaviors.As a foundation for evaluating the content of nursing leadership and administration courses, Jennings et al17 analyzed the contents of a 5-year (2000–2005) literature search in CINAHL and MEDLINE. They found 894 citations of leadership, management, or combined competencies or role functions. "Setting the vision" and "developing people" were the primary leadership functions; "managing human resources" and "information management" were the dominant management functions. However, no mention is made of the nurse manager's function in a support role nor are any supportive role behaviors described.The role of interest in this article is that of a middle manager who has 24-hour responsibility for the operation and strategic planning of 1 or more hospital or clinic units, regardless of whether the job is titled nurse manager, supervisor, care center director, clinical coordinator, or managing director. It is to this individual that charge and staff nurses on all shifts report and to whom they are ultimately responsible.Role function is the overall broad responsibilities inherent in a role. Nurse manager functions usually include business, clinical, personnel functions, and career development as well as the "staff support" function that is the focus here. Role behaviors are groups of organized, observable (directly or indirectly through outcomes) activities that support a specific function. Role activities are the more discrete, insular events. Activities are usually related to multiple role behaviors. For example, eliciting information on the viewpoint of staff nurses on an issue such as "changing the policy so that only respiratory therapists can deep suction patients in the intensive care unit" is a role activity essential to the role behavior "Represents the staff 's position in administrative discussions and decisions." "Eliciting information on the position of staff " is also an activity related to role behaviors such as "Resolves conflicts constructively" or "Provides adequate numbers of competent staff." In this article, nurse manager support of staff nurses is the role function of interest; supportive behaviors are the quest; role activities are used as examples or descriptors.If nurse managers are to enact a support role function, supportive role behaviors from the perspective of staff nurses must be identified and effectively measured. The National Database of Nursing Quality Indicators, one of the most widely used instruments to assess job satisfaction among staff nurses, lists supportive nurse management as 1 of 3 work-context indicators that must be measured and measures it with 4 items from the revised Nursing Work Index.19 Three of the items—"The nurse manager is a good manager and leader," "The nurse manager is supportive of nurses," and "Staff are not satisfied with their nurse manager"—are very global and general and require individual respondents to define and interpret these items within their own frame of reference. The fourth item, "The nurse manager backs up the nursing staff in decision making even in conflicts with physicians," cites a specific supportive behavior that is part of the nurse manager's role. This discrepancy in the level of measurement might well account for the counterintuitive finding reported in a study20 that used these same 4 items to measure the effect of nurse manager support on 30-day mortality rates for 46 993 acute medical patients in 75 Ontario hospitals. Tourangeau et al20 reported that lower patient mortality rates were associated with low, not high, levels of nurse manager support as hypothesized.Following the 2001 identification of nurse manager support as 1 of the 8 essential components of a productive, satisfying work environment, we developed a tool, the Essentials of Magnetism (EOM), to measure all 8 of the essential work processes.21 The EOM is designed to measure the steps or components of each work process, not just perceived presence. In line with this principle, the items for the nurse manager support sub-scale of the EOM must consist of the specific behaviors of nurse managers that staff nurses identify as supportive. What are these supportive behaviors? Thus began the quest to identify a comprehensive and universal set of supportive nurse manager role behaviors identified by staff nurses. Little did we realize it would take 7 years and 7 research studies to accomplish this goal.In this article, we synthesize the results of 7 research studies conducted from 2001 to 2007 as they relate to the question of "What behaviors of nurse managers do staff nurses perceive as supportive?" In all of these studies, data were collected through individual interviews with staff nurses working on clinical units/clinics in magnet hospitals and comparison hospitals that were not designated as magnet hospitals, and through quantitative surveying of staff nurses with the EOM and other instruments. Details of the background, methods, and data collection are not presented here, as all those studies have been published.8,9,11–13,21–23The presentation is organized into 4 sections: (1) Manager or leader: which behaviors are the most supportive? (2) Comprehensive: what is the universe or totality of supportive role behaviors of nurse managers? (3) Universal: Are the identified supportive role behaviors meaningful to staff nurses working in all types of hospitals? and (4) Which behaviors are most supportive? Is there a hierarchy? In each of these sections we will follow the pattern: What We Did (methods), What We Learned (results), and Decisions Made (conclusions and interpretation).For many decades, the emphasis in nursing administrative publications has been on examining and labeling whether the nurse manager's job and role behaviors are managerial, that is, focused on maintaining order, coordinating resources, and attending to rules and details, or whether they are leadership, that is, based on relationships and helping people move toward achieving a vision.24 From the individual interviews with 279 staff nurses and focus-group interviews with 132 nurse managers and 61 nurse executives in 14 magnet hospitals,13 we abstracted 5 supportive manager behaviors (Table 1) and 5 supportive leader role behaviors (Table 2). These supportive behaviors became items on the Nurse Manager Support Scale on the EOM21 that was administered to more than 30 000 staff nurses in conjunction with our own studies or by request from individual hospitals.More leader than manager behaviors were identified by staff nurses as supportive by a ratio of almost 3 to 1. Two manager behaviors, providing needed resources and making out staffing/vacation schedules, were cited regularly. Providing direct patient care was cited often by staff nurses in some hospitals but less frequently in others. We also learned that staff nurses were not particularly interested in whether a behavior was labeled leader or manager.The following decisions were made: Continue to include both manager and leader behaviors but include more leader behaviors. Ascertain whether future groups of staff nurses continue to identify these behaviors as supportive. Be alert to see if a pattern develops with regard to the selection of different leader and manager behaviors by staff nurses in some types of hospitals (teaching or community) than in others.We reviewed and culled the literature for any and all mention of supportive role behaviors of nurse managers. Then we conducted 2 nationwide studies in 11 magnet and 2 comparison hospitals, one to identify structures and "best management practices" that promoted collegial/collaborative relationships between nurses and physicians11,12 and the other to identify best management practices related to clinical autonomy.8,9 We EOM-tested more than 4000 staff nurses in 26 hospitals and almost 1000 nurses nationwide on the Web21,25 and began to compile a comprehensive list of supportive role behaviors of nurse managers as identified from interviews and from comments written on the EOM instrument.The 10 leader-manager role behaviors identified in the 2001 study do not adequately represent the construct, nurse manager support. Behaviors such as "Makes it possible for nurses to participate in interdisciplinary patient care rounds" (from the nurse-physician study) and "Holds staff accountable in a positive, constructive way for autonomous decisions made" (from the autonomy study) should be added to the comprehensive list. From the EOM testing of nurses in more than 50 hospitals and on the Web by the end of 2004, and item analysis of the Nurse Manager Support Scale, it became apparent that in some hospitals, staff nurses consistently identified more manager role behaviors as supportive while in others, the behaviors identified were almost totally leader.The following decisions were made: Develop a comprehensive list of supportive role behaviors of nurse managers by adding additional behaviors as identified. Conduct interviews with staff nurses, and also interview nurse managers and physicians to explore their respective definitions of nurse manager support. Identify behaviors that support, and behaviors that do not, and explore differences in perceptions of nurse managers' support behaviors by type of hospital and by the professional role of the interviewee.During the spring and summer of 2006, we interviewed 244 staff nurses, 105 managers, and 97 physicians working on those units in 8 magnet hospitals where staff nurses had previously confirmed that they had excellent nurse manager support.23 We asked each staff nurse interviewee: "What does the nurse manager do that conveys that she/he supports you?" Nurse managers and physicians were asked: What do you (nurse manager) do or (for physicians) what does the nurse manager do that conveys support to staff nurses? We analyzed the interviewee's responses to the preceding questions by grouping like responses into 9 categories of supportive role behaviors.During the 4- to 6-day site visits required to do the interviewing, we also studied various documents of the nursing department —goals, values, mission statements, job descriptions, and performance appraisals—and conducted participant observations of staff and council meetings.From interviewees, we learned that 9 behaviors of nurse managers were identified as supportive (Table 3). From inspection of evaluation and operational data and observations at the meetings attended, we learned that what is perceived as supportive is a function of the systems, structures, and leadership practices operative in particular hospitals. For example, the nurse manager role behavior, "Makes it possible for staff nurses to participate in daily interdisciplinary rounds" is meaningful only when the hospital has such rounds. The role behavior, "Fosters sound autonomous decision making by asking for the evidence-based practice (EBP) evidence we are using" is not understood by nurses in hospitals that are not actively engaged in EBP initiatives.Role behaviors of nurse managers that staff nurses perceive as supportive are also affected by how the organization defines the nurse manager's role and how the organization, the nurse manager, and the staff define the charge nurse's role. Administrators' expectations of the nurse manager and the nurse manager's job description necessarily affect what the manager does. This, in turn, affects staff nurses' perceptions of what they can expect from their manager in terms of support. This is particularly visible with respect to the nurse manager's involvement in behaviors such as giving direct patient care and directing day-to-day unit activities. If much of the day-to-day management of the unit has been allocated to charge and/or staff nurses, nurses do not perceive it as supportive when the nurse manager performs these behaviors and related activities. In fact, it may even be considered "nonsupportive," with the staff nurse concluding that "The nurse manager doesn't think I can do my job."The following decisions were made: To finalize the comprehensive list of supportive role behaviors of nurse managers, we still need more information. Supportive role behaviors of nurse managers are affected and determined by present practices, structures, and definitions of the nurse manager role that vary among hospitals. A complete and extensive list of supportive behaviors must be built and then validated for comprehensiveness.We developed and tested a Nurse Manager Support Scale (see Kramer et al23 for a complete description of the methods and results from this scale). Starting with all the supportive role behaviors garnered from all previous studies,8,9,11–13,21–23 we added the few behaviors found in the literature plus a selection of behaviors derived from the American Organization of Nurse Executives' competencies for nurses in executive practice regardless of job title that seemed appropriate.15 After removing duplicates and eliminating general, nonspecific behaviors such as "The nurse manager supports staff in practicing autonomously," 54 behaviors remained. We then instituted an intensive, 3-stage repetitive validation process with more than 100 nurses in 10 hospitals and in a doctoral program in nursing systems. These respondents deleted, clarified, and reworded items, commenting freely. None of the participants suggested additional supportive behaviors. The resulting 30-item Nurse Manager Support Scale was administered to 2382 staff nurses on all clinical units in 8 magnet hospitals.23Through factor analysis,23 the 30 supportive role behaviors were grouped into 4 categories. Behaviors grouped into the leadership category, such as "Instills and maintains unit and organizational values" and "Manages conflict constructively" were reported to be the most supportive. The managing the work group and resources category, which included behaviors such as "Represents unit and staffs' viewpoint to other departments" and "Facilitates staff cohesiveness and teamwork," was the second most supportive category. The career development category, including the behaviors "Coaches staff in developing career" and "Encourages specialty certification," and the managing the unit category, with behaviors such as "Provides direct patient care in emergencies" and "Orients new staff" were reported to be the least supportive.The following decisions were made: To obtain a final comprehensive list of the most supportive role behaviors of nurse managers, combine the most supportive role behaviors identified by the interviewees with the role behaviors cited as most supportive by the 2300 staff nurses who responded to the Nurse Manager Support Scale.23 Then after eliminating redundancies, submit this list to nurses in a variety of hospitals to ascertain the supportive role behaviors that are universally meaningful.Because this study has not been reported elsewhere, more details on the methods are provided here. The 14 supportive role behaviors remaining from the combined interview and Nurse Manager Support Scale studies were tested for universality by submitting them to staff nurses in a strategically selected sample of 14 teaching and community hospitals of different sizes, under different governing auspices. The 14 hospitals included academic centers, teaching and nonteaching community, Catholic, regional, county, and Veterans Affairs Hospitals. Three hospitals were part of different corporate systems; half of the hospitals had magnet, Baldrige, or other excellence designations. Hospitals ranged in size from 300 to more than 1500 beds and were located in small, medium, and large cities in diverse regions of the United States and Canada. Participation of 10 staff nurses per hospital was sought through the hospital's research council for 2 reasons: (1) we thought that these nurses would be the most likely to understand the reasons for such a vainglorious, somewhat time-consuming process; and (2) we wanted input from the experienced, involved nurses on different units who usually are active in this council. A letter with detailed description of the study and instructions was provided to each nurse either through the research council or by an on-site coordinator.A total of 149 staff nurses from the 14 hospitals participated. They commented on the readability, sentence structure, and "sense"; made additions, deletions, corrections; and then rated each of the 14 items (behaviors) on the basis of the following criteria: 4="This is definitely an essential supportive role behavior of nurse managers"; 3="This is a supportive behavior"; 2="It would be nice if my nurse manager did this, but it is not really essential"; and 1="This is not an important supportive behavior and could be eliminated."All role behaviors were perceived as supportive. Mean item scores ranged from 3.3 (supportive) to 3.82 (definitely supportive). This very narrow range indicates that 90% to 95% of the 149 nurses considered all 14 items to be definitely supportive or at least supportive. Ten of the 14 role behaviors of nurse managers with mean item scores from 3.51 to 3.82 were identified as definitely supportive (rating=4) by all participants (Table 4).The nurses participating in this study took the task very seriously. More than half of them initiated e-mail dialogues with the investigators about some of the items. Some actively campaigned that certain behaviors be included in the list of supportive behaviors. Some nurses used the activity as the basis for papers they were writing for courses in bachelor's or master's programs in nursing. It was clearly evident that the nurses were interested in knowing what they and their peers agreed upon as supportive role behaviors of nurse managers. They put time and effort into the task, and about one-third of respondents indicated that they had consulted with their peers while completing the task.Their many comments and suggestions provided additional insight into how staff nurses view nurse manager support. Some participants noted that "Is accessible, approachable and safe" is a circumstance or condition rather than a behavior. However, the majority indicated that this item definitely represented a supportive behavior, universally understood and meaningful, and should be left in. A third discovery was that some supportive role behaviors are "experience-specific." "Helps us build self-confidence and become self-reliant" is a nurse manager role behavior that 75% of the respondents indicated was definitely supportive for new graduates or nurses relatively new in their careers. It was perceived as "nice but not necessary" for nurses with more fully developed careers.Last, we learned that supportive role behaviors of nurse managers are often "best management" practices. Role behaviors are often supportive in relation to some other work process or event. We have already exemplified this for clinical autonomy and collegial/collaborative relationships between nurses and physicians. Another highly repetitive example is nurse manager support for education and clinical competence, 2 other essentials of a healthy work environment identified by staff nurses.13 A supportive role behavior that is also a best management practice is, "Makes it possible for us to attend continuing education, outside courses, and/or degree completion programs."The 10 universal role behaviors of nurse managers cited by staff nurses in 14 hospitals as "definitely essential and supportive" (Table 4) now constitute the items that measure nurse manager support on the EOM II.26This information has already been presented in the Comprehensive and Universal sections.The mean item scores for the 10 universally supportive role behaviors were so close that weighting of the items is not justified. In contrast to the other essentials, the grounded theory generated for nurse manager support is more relevant to identifying the variables affecting perceptions of support in different hospitals and at different points in one's career than it is to weighting the steps or components of the nurse manager support process.21,23,26The nurse manager figures prominently in the retention and job satisfaction of qualified nursing staff. Nurse manager support runs through the other essentials of magnetism. If you want nurses to practice autonomously, develop collegial relationships with physicians, and attend courses and programs that promote competent performance, the nurse manager must enact supportive role behaviors or these essential work processes will not happen. The role behaviors identified in this series of studies are a good starting point for exploration by both nurse managers and staff nurses. Nurse managers can ask themselves whether they enact these role behaviors or if there are other ways that they convey support to the staff. Staff nurses can do the same. A dialogue between the nurse manager and the nursing staff will help to clarify expectations and improve effective performance. It might also be a good idea for nurse managers to discuss these supportive role behaviors with their director or chief nursing officer as the expectations of those administrators affect the support that nurse managers can provide to the nursing staff.It is in the best interests of the staff nurse and of quality patient care for staff nurses to make their expectations for support clear to the nurse manager. Knowledge of the identified supportive role behaviors may help nurses to more explicitly formulate the support needed from the nurse manager. For example, if a nurse is in a disagreement with a physician as to the best approach to a particular patient's care and did not get what was wanted from the nurse manager, then that nurse needs to approach the manager. The nurse needs to indicate that she "needed the manager to stand up and 'go to bat' for me instead of not doing anything." It may be that the nurse manager is either unwilling or unable to provide the kind of support desired. By approaching the nurse manager and having such a discussion, the staff nurse knows that, in the future in instances such as this, no support will be forthcoming. Staff nurses are then in a position to determine how much they want to fight a particular battle if they have to do it alone. If the nurse manager does go to bat for the nurse, the nurse can let the manager know how supportive and helpful that behavior was. Positive feedback never hurts.Nurse managers must be clear about expected supportive role behaviors but also need to possess the necessary competencies to enact such role behaviors. Nurse managers we have interviewed indicated that they receive mentoring from experienced managers, took classes offered by the human resources department, and attended external education programs. Although the education of nurse managers has improved from the days of "just put them on the unit," programs must be made available so nurse managers can acquire the competencies needed to enact the supportive role behaviors identified by staff nurses.Jennings et al17 noted in their analysis of the literature that most competencies were identified as both leadership and management and that distinguishing between the 2 may not be important. Although, in most instances, distinguishing manager from leader may not be important, doing so can be helpful when deciding what behaviors can be delegated to charge nurses or administrative assistants. With the growing complexity of the nurse manager's role, we cannot just keep adding more role behaviors. At some point, something has to be taken away. "Managing the unit" competencies—scheduling, patient assignments, routine employee paperwork—can be delegated to others. Leadership behaviors such as walking the talk, the instilling of values, are much more difficult to give away even if it would not be a good idea to do so.Second, it may be important to distinguish between leadership and management competencies in light of the finding that managers in hospitals with higher patient mortality rates have wider spans of control.20 It may be that a wider span of control prevents nurse managers from enacting the leader role behaviors that communicate support to the nursing staff.To meet staff nurse expectations of support, nurse managers need support. Administrative assistants or secretaries who can handle the routine employment paperwork, type reports, route memos to appropriate personnel, and schedule meetings save hours of the nurse manager's time. This time could be better used interacting with and supporting nursing staff.Nurse manager support is a critical factor in maintaining healthy work environments. We cannot afford to have nurses leaving the unit and the hospital because their nurse manager was not as supportive as needed or expected.The authors acknowledge the continued cooperation and participation of the 8 magnet hospitals that served as the locus of the final, culminating study for both nurse manager support and perceived adequacy of staffing: John C. Lincoln Hospital, Phoenix, Arizona; St Joseph's Hospital of Atlanta, Atlanta, Georgia; East Jefferson General Hospital, New Orleans, Louisiana; St Cloud Hospital, St Cloud, Minneapolis; Children's Mercy Hospitals and Clinics, Kansas City, Missouri; University of Colorado Hospital, Denver, Colorado; Providence-St Vincent's Hospital, Portland, Oregon; The Miriam Hospital, Providence, Rhode Island.We also acknowledge and thank the nurse managers and staff nurses from the following hospitals and the doctoral students in nursing systems who participated in the studies to establish the validity, reliability, comprehensiveness, and universality of the supportive nurse manager role behaviors: John C. Lincoln Hospital, Phoenix, Arizona; Phoenix Heart Center, Phoenix, Arizona; St Joseph's Hospital and Medical Center, Phoenix, Arizona; University of Arizona, College of Nursing, Tucson, Arizona; Richmond Hospital Services, Richmond, British Columbia, Canada; El Camino Regional Medical Center, Mountain View, California; University of Colorado Hospital, Denver, Colorado; Poudre Valley Hospital, Ft Collins, Colorado; St Joseph's Hospital of Atlanta, Atlanta, Georgia; Rush University Medical Center, Chicago, Illinois; East Jefferson General Hospital, New Orleans, Louisiana; Winchester Hospital, Winchester, Massachusetts; Nashoba Valley Medical Center, Ayer, Massachusetts; St Cloud Hospital, St Cloud, Minnesota; Children's Mercy Hospitals and Clinics, Kansas City, Missouri; Hackensack University Medical Center, Hackensack, New Jersey; Providence-St Vincent's Hospital, Portland, Oregon; Missouri Baptist Medical Center, St Louis, Missouri; Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina; VA Medical Center, Fargo, North Dakota; The Miriam Hospital, Providence, Rhode Island. Critiquing, adding, deleting, and rewording items are tedious, unrewarding but essential tasks that are not exciting. However, the quality of the results is due to the enthusiastic and generous participation of all these people who represented the most important and most influential professionals in our health care system—the clinical nurses on the front line.