Cadmus, Edna PhD, RN, NEA-BC, FAAN; Wisniewska, Edyta K. RN, BS
Nurse executives must deconstruct and rebundle the work of the 1st-line nurse manager (FLNM) to leverage their expertise and meet new and dynamic role expectations. Transformational leadership (TL) skills will be essential at every level of leadership including the unit level.1 Bass1 described transformational leaders as having the ability to engage their employees through being charismatic and/or intellectually stimulating and/or meeting the emotional needs of the employees in order to accomplish organizational goals.1 Transformational leadership behaviors impact the work environment and staff, which has a direct relationship to patient and organizational outcomes.2-10 The development of a TL-style takes time, support, and inspirational motivation.11 Focusing on the development of TL skills among FLNMs is an imperative for nurse executives in supporting clinical, leadership, and organizational success.12-14
Evidence demonstrates that independent of knowledge and skill, there are organizational and work design factors that promote or impede transformational behaviors among leaders.3,4,11 As the healthcare environment is redesigned to meet the challenges of access, quality, and value, FLNMs are pivotal in helping to change the environments of acute care hospitals. The Institute of Medicine report, The Future of Nursing Leading Change, Advancing Health, identified that “strong leadership is critical if the vision of a transformed healthcare system is to be realized.”15(p221) The report supports that the FLNMs are uniquely positioned to design new models of care to improve quality, efficiency, and safety. Facilitating new systems and models will require TL skills in shifting thinking and leading change initiatives.
The study of FLNM work has not been widely documented to date. Using the American Nurses Association Scope and Standards for Nursing Administration,16 Shea-Messler17 conducted a qualitative study on the lived experience of nurse managers (NMs). Experiences reported by the NMs were summarized to include frustration, isolation, and a lack of appreciation as they operationalized their roles.17 Although not generalizable, this study identifies some work design and work environment issues that may impede FLNMs in their ability to be transformational.
Surakka18 used different data sets and conducted a qualitative and quantitative content analysis to determine the work of NMs in Finland. The study categorized the work of the FLNM as (1) responsibility-related activities (communication, cooperating, organizing), (2) accountability activities (supporting staff, ensuring staff competencies, developing staff), or (3) and bedside nursing (direct or indirect). Researcher noted that over time the FLNM work evolved from nurse to nurse leader with a greater emphasis on responsibility-related activities or functions (quality monitoring, budget performance management) and less on direct care nursing.18 Although the study provided a framework to document the categories of work, it did not demonstrate the complexity of the role, which is continually evolving.
The Health Care Advisory Board developed a Nurse Manager Job Analysis and Activity Audit,19 which was used in a recent study conducted in an 861-bed academic medical center.20 In the study, 29 NMs were asked to report their perception of the frequency of performing key responsibilities of their role, the level of importance of the activity, and their level of expertise in meeting role expectations.19,20 The study demonstrated a complex workload and differences in performance of NMs were highly influenced by the experience level of the NM.20 The NMs’ experience level also influenced how they perceived the level of importance of their work and the frequency of time spent performing the responsibilities.20 Researchers recommended that the role of the FLNM needed to be reconfigured to accommodate the challenges faced in the evolving healthcare environment.20
The literature links TL behaviors with the antecedents of culture and skills and demonstrates the impact that transformational leaders have on outcomes. Figure 1 depicts the antecedents of TL and the outcomes expected as a result of transformational behavior. Data support that skills set and culture are only a partial explanation of what is needed for TL to occur and that the work and role of the FLNM have been overlooked as a key factor.
The purpose of this phase 1 pilot study was to develop and test an author-developed evidence-based instrument (see Document, Supplemental Digital Content 1, http://links.lww.com/JONA/A264) to categorize the current work of FLNMs and quantify the frequency of activities. This article discusses the development and testing of the instrument.
An extensive literature review identified no comprehensive instruments describing the work of FLNMs in today’s acute care hospitals. Therefore, the FLNM Work Instrument (FLNMWI) (see Document, Supplemental Digital Content 1, http://links.lww.com/JONA/A264) was developed to identify the categories of work and activities and the frequency by which they were performed. Institutional review board (IRB) approval was obtained through Rutgers University in addition to IRB approval at the study sites.
Instrument development occurred in multiple, sequential steps. The initial tool was conceptualized and organized by the principal investigator (PI) in categories of work and included activities that would best describe each category. These categories and activities were derived from the (1) Nurse Manager Leadership Partnership Nurse Manager Skills Inventory (a joint effort between the American Organization of Nurse Executives, American Association of Critical Care Nurses, and Association of PeriOperative Nurses)21,22; (2) job descriptions solicited from 73 NJ acute care hospitals, of which 11 responded; and (3) the experience of the PI, a former chief nursing officer (CNO).
The Nurse Manager Skills Inventory21 was developed around 3 domains: (1) the science: managing the business (ie, financial management, performance improvement, technology, strategic management); (2) the art: leading people (ie, human resource leadership skills, relationship management); and (3) the leader within, creating the leader in yourself (ie, personal and professional accountability, reflective practice, career planning).21(p28) These competencies served as a base for creating activities in the newly developed instrument. In addition, job descriptions were obtained from 11 acute care hospitals to identify missing activities. Initially, a 7-point ordinal scale was used to capture the frequency of work. Six choices of timeframes were provided to assign to the amount of time spent on the activities. This changed as the PI met with the content experts because quantifying the time spent would be based on memory, and the NMs suggested that this would not to be an accurate approach.
The FLNMWI consists of 87 items and 9 subscales (see Document, Supplemental Digital Content 1, http://links.lww.com/JONA/A264), which defines the categories of work (financial management, human resource management, performance improvement, technology, strategic/tactical management, practice, personal and professional accountability, relationship activities, and other). Response categories used to identify the frequency of those activities being performed ranged from never to annually. The survey design limited the participants to a single response.
Content Validity and Reliability Testing
Content validity refers to the degree to which the instrument measures what it is intended to measure based on the judgment of experts.23,24 A review of current literature, 2 focus groups of FLNMs (n = 10), and a review by CNOs (n = 5) were used to establish the content validity of the survey instrument.
The initial pilot group of FLNMs taking the survey consisted of 4 FLNMs. These initial FLNMs were selected from a list of volunteers who agreed to participate in the study. The PI reviewed the transcripts and identified areas of input or possible changes needed for the instrument to include adding items not reflected in the original tool and clarifying terminology that was not clear to the participants. After revisions, a 2nd focus group of 6 FLNM volunteers was conducted to retest the revised instrument. Minimal changes were indicated for the tool after the 2nd focus group. The instrument was then shared with 5 CNOs selected by the PI, to review and evaluate the content validity of the revised tool. Feedback from the CNOs was that that tool was comprehensive and would provide information useful for their practice as they worked with FLNMs. The survey was formatted into SurveyMonkey. One final review of the instrument in the final format in SurveyMonkey was conducted by FLNMs from the initial and 2nd testing group, resulting in positive comments about access and content. The survey was timed to take 15 minutes.
Reliability was assessed using the test/retest method and quantified using percent agreement. Thirteen of the 16 participants provided a full response to the survey twice within a 10-day period. Each question was analyzed to determine the percent agreement. The reliability process was assessed concurrently along with the pilot testing of the instrument.
Data Collection and Analysis
First-line NMs were solicited from 73 acute care hospitals in New Jersey through contact with the CNOs. For purposes of the study, an FLNM was defined as having 24-hour-7-day-a-week responsibility for a patient care unit or units. The sample, provided by CNOs who were willing to participate, included managers from both inpatient and outpatient units. Repeat e-mails and letters were sent to increase participation in the survey at monthly intervals. A description of the study, IRB approval letter, consent materials, and a flyer were provided through e-mail to each hospital CNO to distribute to their FLNMs. The consent was embedded into the tool and was required prior to completion. Sixteen respondents volunteered to complete the instrument twice within 7 to 10 days and were given a special code to identify them in the total sample of participants. Participants were assured of confidentiality by the PI and were not asked to provide their employer or personal identity. Initial data collection was conducted between April and August 2012. Data were analyzed using SPSS (Armonk, New York) and SAS (Cary, North Carolina).
First-line NM characteristics are comparable between the total population surveyed, the focus groups, and the test-retest group (see Table, Supplemental Digital Content 2, http://links.lww.com/JONA/A265). The majority of the FLNMs were in the age range of 40 to 59 years, white, non-Hispanic, with an educational preparation of baccalaureate or higher in nursing. All 3 groups were FLNMs who had between 3 and 10 years of nursing management experience and worked in both not-for-profit community and community teaching hospitals.
Ten FLNMs and 5 CNOs were used to test the instrument for content validity. The following areas were addressed based on their feedback:
Under the financial management, category 3 activities were added including producing reports on financial matters, negotiating prices with vendors, and allocating merit increases for employees. Under human resources (HR), 1 activity was added, collecting data for union negotiations. Under the performance improvement category activities that were added included producing reports for performance improvement activities and educating frontline staff on the performance improvement process. Under the technology category 2, activities were added to include overseeing downtime procedures and participating in informational system selection. Under the strategic management section, 1 activity was added, participating in system-level meetings outside the hospital. Under the clinical practice category, 2 activities were added, investigating complaints and working within a shared governance structure.
Terminology was also addressed based on pilot feedback. In the original instrument, productivity management activities were identified under the financial management category. It was not clear to the FLNMs what this included, and so this item was replaced with monitoring and adjusting nursing hours per patient-day or units of service. The difference between mentoring and coaching was reported to be unclear to some of the FLNMs; however, after clarification and exploration, a decision was made to leave it as was originally designed.
Variability by Organization
In the focus group sessions, FLNMs identified that different organizations manage the full-time equivalents (FTEs) and operation expenses differently, thus creating variability in how they viewed and reported this activity. For example, some felt the FTEs and operation budget were handed down to them, and they had to implement it, whereas others felt they had primary ownership in the management of the FTEs and operating budget. Therefore, we added the qualifier either to delineate, managed by self, or managed with others for clarity.
Difficult to Quantify
Two items were difficult for FLNM respondents to quantify, termination or preparing to terminate employees and involvement with sentinel event activities. Although they would be engaged in these items, they were intermittent and infrequently performed, thus could not be easily quantified regarding time and/or frequency. The FLNMs did feel these were significant parts of their role and should remain in the instrument.
Table 1 identifies the categories of work and the range of agreement for all activities in a category. Table 2 identifies those activities that had 70% agreement or above in the test-retest group as compared with the total sample. This table is further broken down to identify how frequent that activity is performed by the FLNM (ranging from never to annually).
The daily activities of the FLNMs were clustered around nursing practice including rounding on the unit, huddles with staff, providing direction to staff on clinical matters, investigating complaints, and working within a shared governance structure. Other areas cited on a daily basis included (1) relationship activities around customer services and outreach both internal and external to their customers; (2) financial management, which included making staff assignments and changing schedules; (3) performance improvement activities including analyzing incident reports; and (4) HR management around mentoring others and conflict management/negotiating with others.
The FLNMWI is a promising new instrument to assess the work activities of FLNMs. Instability in the test-retest process was demonstrated by variability in frequency responses to the same item over a 10-day period. It is unclear why this instability was present because there was strong content validity. It is presumed that because the instrument was asking the FLNM to recall what they had done at precise intervals, the participants may have had difficulty recalling the timeframe that created the instability. In the continued refinement of the next version of the instrument, the PI will conduct focus groups with FLNMs to discuss reducing timeframe choices as a possibility. In addition, a review of the items that did not have high reliability will be conducted to determine if they need to be reworded or discarded using the test-retest results. Because this is a new instrument, there needs to be continued refinement through further focus group work and the conducting of a factor analysis to determine relationships and patterns among the identified activities.
The practice category had a high test-retest percent agreement on all of the activities except for 1 item, the provision of direct patient care. This may be because this is an area of commonality for all nurses because nursing is a practice profession. However, it is also interesting to note that most of the daily work of FLNMs reported in this pilot was in the practice category.
Many of the other daily activities identified were in the financial management category and included staffing and payroll activities. This should be reviewed by nurse executives and considered potential areas that could be removed from the work of FLNMs, thereby reducing transactional activities. These activities could be performed by others to support FLNMs in meeting other categories of work and outcomes. The HR task of dealing with conflict and negotiating with others was another daily activity. It was clear that customer/patient relations were activities that were conducted on a daily basis. This is certainly congruent with the focus on patient experience in acute care facilities and the impact of the reported scores on pay-for-performance.27
Minimal agreement was noted under the technology category regarding content and frequency of activities. It is presumed by the PI that the activities may not be clearly defined or understandable either by the participants or the instrument. This is an area that needs further exploration because technology is a major initiative and source of activity in acute care and is anticipated to expand in the future.
During the focus group sessions, there was discussion around the amount of time it took to do some of the activities as it related to differences for new managers or managers new to the organization versus those that were experienced in their roles over time. For example, 1 new FLNM identified 16 computer systems in the organization that had to be accessed for various work tasks such as payroll, processing of HR forms, education, and clinical information. As a new manager, a great deal of time was reported to be wasted trying to identify how to get the information needed as orientation from these systems. Assistance and training in this area were reported as limited or nonexistent. More experienced managers spent less time in obtaining the information needed. It is assumed that the ongoing exposure to the systems supported increased comfort levels with access; however, this aspect also needs further study to identify contributing factors.
Reliability testing demonstrated instability in some items. Further work needs to be conducted to investigate why this occurred. This tool was tested only in acute care hospitals in New Jersey, and thus the results are not generalizable. First-line NMs were asked to document their work in a timeframe from never to annually. As a result, there may be items that are overestimated or underestimated in frequency based on memory. The instrument does not identify the time it takes to carry out these activities and therefore limits the ability to quantify the FLNMS work in greater specificity. Because the request to participate came from the CNO, it may have created concern about confidentiality.
Dissemination of Findings
The results of this pilot study to develop and test a new instrument to measure the work of the FLNM will be disseminated to the CNOs and FLNMs in NJ. The results will also be presented at a national conference.
Implications for Nurse Executives/Conclusions
The FLNMWI is designed to quantify the work of the FLNM. As the tool is refined, it will be a valuable tool to nurse executives to identify those activities that are value-added and those that are non–value added. It will also allow for comparisons to other FLNMS who utilize the instrument. In the present form, the tool may assist CNOs in surveying the FLNMs work in their organizations and creating a framework for dialogue about their work. Evidence supports that the most successful FLNMs demonstrate transformative behaviors.1 Because of the complexity of patient care in acute care environments, work has been added to this role, while other activities have not been removed, or support added. With the increasing stress across organizations, CNOs would be well served to identify activities being performed by FLNMs and assess for necessary support or reallocation of duties or further education. Many of the activities being performed by FLNMs could be reassigned to others in the organization to accomplish the work more effectively and efficiently and redirect the time of FLNMs to more essential activities. The FLNMWI can help the executive leaders analyze these opportunities within each organization.
The authors thank the FLNMs who participated in the focus groups to develop the instrument. CNO content experts: Suellyn Ellerbe, MN, RN, NEA-BC; Maria De Marco, MSN, RN, CCRN, NHA; Ann Campbell, RN, MSN, NEA-BC; Trish O’Keefe, MSN, RN, NE-BC; Diane Charsha, MSN, RN, NEA-BC, NNP-BC.
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