Kath, Lisa M. PhD; Stichler, Jaynelle F. DNSc, RN, FACHE, FAAN; Ehrhart, Mark G. PhD
Although most research on job stress in nursing is focused at the bedside, nurses in leadership roles also experience job stress.1 Although nurse leaders at all levels of management face stressors in their roles, frontline nurse managers may be inexperienced in management and less prepared for the stress associated with being the direct interface with staff, physicians, and patients/families. Nurse managers report feeling squeezed between conflicting demands including organizational targets for performance from above, staff expectations from below, and additional expectations from physicians and other department leaders.2 Stressors from all sides can lead to leadership compression stress fractures, where nurse managers begin to perform poorly, be unable to support subordinate staff sufficiently, or suffer from personal emotional or physical reactions to stress.
Ample evidence exists that nurse manager leadership styles, stress levels, and performance have direct effects on nurse satisfaction, turnover, and overall health of the work environment.3-5 A stressed nurse manager will adversely affect the morale of the nursing unit, in turn adversely affecting clinical nurse satisfaction and retention, patient outcomes, and organizational performance.6 Stress can affect the nurse manager’s mental and physical health, ultimately leading to decreased job satisfaction and turnover. As clinical nurses witness the effects of nurse manager stress, recruitment of new managers becomes more difficult because nurses with leadership potential may opt for less stressful roles with often higher levels of compensation rather than management roles. Thus, understanding nurse manager stress, outcomes, and moderators is critically important because of the adverse effects of stress on the health of the nurse manager, staff satisfaction, and patient outcomes.2,7 This study focuses on work stress and the effect on outcomes: job satisfaction, organizational commitment, intent to quit, and physical and mental health symptoms. Also, the impact of possible moderating effects (autonomy, predictability, and subordinate, peer, supervisor, and hospital support) on the outcomes, will be explored.
The conceptual model for the study (Figure 1) draws from the Demands-Control-Support model, positing that negative outcomes result from a combination of high job demands (stressors), low job control (autonomy), and low social support (peers and supervisors).8 Job stress experienced by nurse managers is expected to lead to negative outcomes, particularly under certain conditions (low control and/or low support). Our conceptual model includes an examination of outcomes associated with job stress as well as a number of hospital, job, and psychosocial variables that can moderate the negative effects of job stress. Based on this conceptual model, several research questions were developed.
The purpose of the study was to examine nurse managers’ job stress, outcomes of stress, and moderators. The research questions were as follows:
1. What are the levels of perceived job stress for nurse managers?
2. What outcomes are associated with higher levels of job stress?
3. What hospital, job, or psychosocial characteristics buffer the negative outcomes of job stress?
Review of the Literature
A number of factors have been found to influence nurse manager job satisfaction and ability to cope with stress. Factors include work pressure, job stress, autonomy, and social support.2,9-12 Shirey et al2 conducted a qualitative analysis of 21 nurse managers regarding stress and coping. They found that nurse managers identified both supervisory and peer support were critical factors in decreasing stress. To date, no studies have reported a quantitative examination of nurse manager stress to the extent of the current study.
Regardless of their stress levels and job dissatisfaction, nurse managers tend to stay in their positions.1 Factors contributing to nurse manager retention are described by Parsons and Stonestreet13 as supervisory support, recognition for the quality of care provided on their units, clear expectations and feedback from supervisors, participation in decision making, professional development opportunities, and work and personal life balance.
Research regarding nurse manager stress is important because of the potential impact of nurse manager behaviors on staff, patient, and organizational outcomes. Studies link nurse manager leadership style, specifically transformational leadership, to clinical nurse satisfaction and retention.5,7,14 Reports indicate that managers may perceive themselves to be transformational when, in fact, their subordinates do not perceive their leadership style similarly.7,14 Nurse managers may be unaware of how their stress level affects their leadership style, and stress levels may interfere with the ability to be transformational.
Findings from the literature support this study’s conceptual model that stress experienced by nurse managers could lead to negative outcomes, and there are specific personal and organizational variables that may buffer the effects of stress.
This study used a cross-sectional, quantitative design. All nurse managers from a convenience sample of 36 hospitals in the Southwestern United States were invited to participate. After institutional review board approval, nurse managers, defined as frontline supervisors of clinical nurses who had 24-hours/7-days-a-week or 12-hours/7-days-a-week responsibility for their units, were invited to complete voluntary, confidential paper-and-pencil surveys. Surveys were returned, in person or by mail, directly to the investigators.
The survey was composed of published, intact instruments with sound psychometric properties (Table 1). The items were listed so that job stress was measured after the outcomes, thus not inflating correlations through priming. Most scales utilized a 5-point Likert scale, where 1 = strongly disagree and 5 = strongly agree, with exceptions as noted below. Item responses were averaged to create a scale score, where higher values indicated higher levels of the construct.
Predictor and Outcomes
The study predictor, job stress perceptions, was measured using the 4-item subjective stress scale of Motowidlo et al.15 Job satisfaction was measured using the 3-item scale of Cammann et al.16 Organizational commitment, a measure of emotional attachment to an organization, was measured using the 6-item Affective Organizational Commitment scale of Allen and Meyer.17 Intent to quit was measured using the 3-item scale of Seashore et al.18 For organizational commitment and intent to quit, items were reworded from their original source such that hospital replaced company (eg, I feel personally attached to my hospital). Physical health was measured using the 9-item somatic stress scale of the Copenhagen Burnout Inventory (CBI),19 asking about headaches, palpitations, and so on, experienced during the past 4 weeks. Responses were indicated on a 5-point scale, where 1 = never/hardly ever, 2 = seldom, 3 = sometimes, 4 = often, and 5 = always. Mental health was measured using the 5-item mental health scale of the CBI,19 which asks about mental state (such as “felt downhearted and blue”) experienced during the past 4 weeks. Responses were indicated on a 6-point scale, where 1 = none of the time, 2 = a little of the time, 3 = some of the time, 4 = a good bit of the time, 5 = most of the time, and 6 = all of the time. Responses for physical and mental health were coded such that higher scores indicated more health problems.
Hospital characteristics were obtained from publicly available sources. Job and psychosocial characteristics were assessed by survey. Autonomy is defined as the level of decision authority perceived by the employee/participant and was measured using the 3-item scale of Smith et al.20 Predictability is defined as the extent to which an employee receives adequate information to plan his/her work effectively. This construct was measured using the 3-item predictability scale from the CBI.19 Social support was examined from 4 different sources: subordinates, coworkers, supervisors, and the hospital as a whole. All 3-item scales were based on the Perceived Organizational Support scale of Eisenberger et al21 and the Perceived Supervisor Support scale of Eisenberger et al,22 with only the referent changed for the different sources of social support. For example, “My subordinates really care about my well-being” measured subordinate support, whereas “Nurse leaders at my level really care about my well-being” measured coworker support.
Of 636 nurse managers who were invited to participate, 480 (75.5%) completed the survey. To protect the confidentiality of participants, the survey did not identify gender. A description of the demographic factors in the study sample is included in Table 2. Of those responding, 31% (n = 198) worked at a hospital that had Magnet® status, 31% (n = 194) supervised unionized nurses, and average hospital size was 381 (SD, 179) beds. Most participants worked in a community acute-care facility (50%; n = 313), whereas others worked at community tertiary acute-care facilities (33%; n = 208), academic acute-care facilities (15%; n = 93), and other facilities (2%; n = 16), such as military hospitals. Means, SDs, and intercorrelations for study constructs are reported in Table 3.
Research Question 1: What Are the Levels of Perceived Job Stress for Nurse Managers?
Not surprisingly, nurse managers reported their jobs were stressful, with average stress above the midpoint of the scale (mean, 3.66 [SD, 0.80]). When determining if there were differences in stress by age, education, hospital tenure, and position tenure, only age was weakly but significantly related to stress (r = −0.10, P < .05).
Research Question 2: What Outcomes Are Associated With Higher Levels of Job Stress?
As seen in Table 3, stress was related to all outcomes as expected. Job stress was related (in order of the magnitude of correlation coefficients) to mental health symptoms (r = 0.47, P < .01) and physical health symptoms (r = 0.45, P < .01) and inversely to job satisfaction (r = −0.42, P < .01). The relationship between stress and organizational commitment was weaker than other outcomes (r = −0.20, P < .01). The relationships between the above set of outcomes with intent to quit were investigated separately, because of the focus on retention as a key organizational goal. In general, intentions to quit were low among nurse managers (mean, 2.57 [SD, 1.12]), supporting Shirey’s1 findings that nurse managers, even if dissatisfied and stressed, tend to stay in their positions. Multiple regression analyses indicated that job satisfaction (β = −.38, P < .001) and organizational commitment (β = −.33, P < .001) were primary drivers of intentions to quit.
Research Question 3: What Hospital, Job, or Psychosocial Characteristics Buffer the Negative Effects of Job Stress?
A number of hospital characteristics (number of beds, urban or rural, university or community, Magnet status, and union status) were analyzed for possible buffering effects on the negative outcomes associated with job stress. Surprisingly, none of these hospital characteristics were shown to moderate the relationships between perceptions of stress and the 5 study outcomes.
Autonomy (Figure 2) and job predictability were found to moderate the relationship between perceptions of stress and job satisfaction. Autonomy significantly moderated the relationship between perceptions of stress and intent to quit (Figure 3). Graphs of the moderations, with lines representing 1 SD above and below the mean, demonstrate that autonomy and predictability acted as buffers of the negative effects of stress; therefore, the negative effects of increased stress were reduced when autonomy or predictability was high.
Coworker, supervisor, and hospital support each moderated the relationship between perceptions of stress and job satisfaction, with outcome graphs looking similar to Figure 2. Subordinate support significantly moderated the relationship between perceptions of stress and organizational commitment; however, as shown in Figure 4, this moderation did not indicate true buffering. Those with high subordinate support experienced steeper drops in organizational commitment when stress was high, compared with those who had low subordinate support.
Outcomes of this study supported the proposed conceptual model indicating that job characteristics and social support moderate the negative effects of stress on job satisfaction. Because of significant correlations between job stress and both mental (r = 0.47) and physical health symptoms (r = 0.45), hospitals would be wise to develop strategies supporting nurse managers in their roles and assisting them in identifying and adopting appropriate coping methods to manage stress. The buffering effect of supervisory support on job satisfaction strongly indicates a need for nurse directors to frequently assess how their subordinate nurse managers are managing job demands and coping with inherent role stressors. The reverse buffering effect of subordinate support was puzzling and warrants further study.
This study added new knowledge not previously reported, because hospital characteristics had not been identified as possible factors that could buffer job stress outcomes. Magnet status, unionization status, hospital size, and hospital type were not significant buffers of the effect of stress on outcomes. When interviewing nurse managers informally about this finding, some suggested that although there are many positives associated with Magnet status, it also adds additional stressors with high organizational expectations for exemplary practice, transformational leadership, new knowledge/innovation, and empirical outcomes indicating structural empowerment and enhanced job satisfaction among the nursing workforce.
Results of the current study should be interpreted with consideration of limitations. All hospitals were in the Southwestern United States and may not generalize to experiences of nurse managers in other regions. Survey participation was voluntary, and it is possible that nonrespondents differ from respondents in a meaningful way.23 The response rate was high (76%; n = 480), which minimizes concerns about representativeness of the respondents as compared with nonrespondents. The sample size is large (n = 480) and from a wide variety of hospitals (n = 36), which supports the generalizability of the results across settings. The data reported self-assessed survey responses, which are subject to potential bias. Although analyses with single-source (ie, self-report) data have been shown to be potentially biased,24 simulation studies indicate that it is unlikely that moderation analyses (ie, research question 3 analyses) will yield spurious results due to single-source bias.25 Finally, because the study used a cross-sectional design, it is unknown if stress levels are relatively consistent or if relationships among the variables will be stable over time. A 2nd phase of the study is currently in process using the knowledge gained in this study and using several different variables.
Conclusions and Implications for Nursing Administration
There is a clear need to address the job stress associated with the role of nurse managers.1 The results of this study indicate that nurse administrators should give nurse managers as much autonomy as possible in meeting the multiple demands of their challenging roles. When possible, predictability of the job should be increased by freely sharing/communicating information that allows nurse managers to make the most of their autonomy and enhancing their participation in decision making, thus making the work more predictable. Finally, social support mechanisms should be in place such that coworkers and supervisors find ways to offer operational and emotional support to nurse managers.
The significant negative correlation of stress with age was an interesting finding, especially as the finding was about age and not experience (tenure). The data in the current study cannot shed specific information about why this relationship was significant, but might be useful for hospitals to consider the above recommendations in light of this negative correlation. Specifically, younger nurse managers could be paired with older nurse managers for social support and mentorship. Interestingly, age had a significant positive correlation with autonomy (r = 0.17, P < .001), which may indicate why older nurse managers report less job stress. Special attention might be paid to making sure younger nurse managers receive the autonomy they need in their role or that they are aware of autonomy that may already exist.
Several characteristics, autonomy, job predictability, and support, buffered the effects of job stress on job satisfaction. One factor, autonomy, buffered the effects of job stress on intent to quit. None of the variables were significant at buffering the effects of job stress on organizational commitment, mental health symptoms, or physical health symptoms. These findings, along with previously published results that organizational commitment was the best predictor of the nurse managers’ intent to quit,26 indicate that stress is not a sole reason for nurse managers leaving their jobs. While aforementioned remedies of autonomy, social support, are being developed, organizational leaders should ensure that nurse managers are managing their own mental and physical health. Attention should be paid to factors that influence organizational commitment27,28 to support the retention of nurse managers.
In summary, the results of this study suggest that nurse manager job stress lessens with age and, when unchecked, is associated with negative outcomes that can have a detrimental effect on organizational functioning. A sense of autonomy, high-quality relationships between the nurse managers and their respective supervisors, and support from peers may increase overall job satisfaction of the nurse manager and ultimately affect the quality of patient outcomes and overall work environment for nurses and other professionals. Future research should be conducted to identify other avenues to support nurse managers in executing their difficult but important roles.
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