Oliver, Beth DNP, RN; Gallo, Kathleen PhD, RN; Griffin, Mary Quinn PhD, RN; White, Maureen MBA, RN; Fitzpatrick, Joyce PhD, RN
The Health Resources and Services Administration (HRSA) predicts there will be a shortage of at least 67000 clinical nurse managers (CNMs) by 2020.1 This is a conservative estimate considering that the average age of a CNM is 49 years.1 This estimate does not take into account attrition, transitioning to other roles, work-life balance issues, and the decline in academic institutions offering nursing administration as a viable career choice.2 Historically, nurses were often promoted for clinical expertise, regardless of their ability to manage operations, build teams, and lead staff. As the healthcare environment becomes increasingly complex and specialized, the CNM role has evolved to require a greater depth and breadth of knowledge, requiring both clinical and operations oversight. The expectation of the CNM is to, at a minimum, meet operational benchmarks and outperform other institutions nationally in quality indicators and patient satisfaction. As a result, recruitment and retention of CNMs are crucial to the future development of healthcare institutions. With the expansion of the CNM’s administrative responsibilities and areas of control, it is important to identify their perceptions of the power they have within the organizations in which they work. This is especially important as CNMs are key to the retention of staff nurses.2-6 The Institute of Medicine report stated that the decrease in the number of CNMs was 1 component of the work environment (WE) that has negatively affected nursing care quality and patient safety.7
This study was based on Kanter’s8 theory of structural empowerment (SE). Kanter8 saw that employees’ work behaviors were influenced by situations and conditions in the WE more than by individual attributes.9 She viewed empowerment as arising from social structures in the workplace that enable employees to be satisfied and more effective in the job.10 According to Kanter,8 WEs that provide access to information, resources, support, and the opportunity to learn and develop are empowering and enhance the employee’s power to accomplish work in an organization. Access to empowering structures is influenced by formal and informal power systems in the organization. Formal power refers to job characteristics that go with one’s job description and are essential to the organization’s goals.11 Informal power refers to the ability to form strong interpersonal bonds with peers, supervisors, or subordinates within the organization.11 Laschinger and colleagues12-14 have conducted several studies of SE among staff nurses. Structural empowerment has been positively linked to job satisfaction and organizational commitment.15 Laschinger and Finegan13 reported that staff empowerment was influenced by trust in management, the perception that management was fair in their practices, and respect for staff in the workplace; these factors influenced job satisfaction and organizational commitment.
Despite the large focus on perceptions of SE among staff nurses, there are few studies of SE among CNMs. In a qualitative study of 16 leaders (4 executive, 12 direct/managerial) from both Magnet® and non-Magnet institutions, Upenieks6 found that 83% of the respondents believed that nurse leaders who have information and access to resources to help clinical nurses in patient care delivery and have the opportunity to learn and develop from work challenges will be effective and satisfied in their role. Patrick and Laschinger11 examined the relationship between SE and perceived level of organizational support and the effect of these factors on the role satisfaction of middle-level nurse managers. They found that SE was a significant predictor of role satisfaction. Regan and Rodriguez16 studied nurse managers (n = 11) and assistant nurse managers (n = 31) in 1 acute hospital and found a moderate level of empowerment. There were no differences between the 2 groups. The researchers attributed the lack of higher empowerment on the inexperience of the NM and assistant NMs, as 60% had less than 3 years of management experience.16
In the only study of SE among middle managers outside nursing, Smith17 examined the influence of SE based on Kanter’s8 theory of organizational commitment, among 79 project managers. Findings of the study demonstrated that when project managers have support, resources, opportunities, and information, they have stronger organizational commitment and allegiance to an organization. The present study was designed to obtain baseline data about SE among nurse managers. Based on study findings, the health system leaders are interested in designing programs to empower CNMs.
A descriptive, cross-sectional study design was used. The study was conducted in a large healthcare system that includes 15 hospitals.
The sample was recruited from the 210 CNMs who worked in the acute care hospitals in the healthcare system. Recruitment of subjects for the study was conducted through announcements at leadership meetings at each hospital. A copy of the abstract describing the proposed study including information about the study was distributed at designated leadership meetings at each hospital.
Variables and Measures
The primary variable for the study was SE, operationally defined as the total score on the Conditions of Work Effectiveness II Scale (CWEQ-II).12 The CWEQ-II consists of 19 items that measure the 6 components of SE described by Kanter8: opportunity, information, support, resources, formal power, and informal power. Items on the subscales are measured on a 5-point Likert scale with scores for each subscale ranging from 1 to 5; scores of the 6 subscales are then summed to give a total empowerment score ranging from 6 to 30. Higher scores indicate higher perceptions of empowerment and more positive conditions of work effectiveness. Scores of low empowerment are 6 to 13, moderate, 14 to 22, and high, 23 to 30. The construct validity of the CWEQ-II was substantiated by a factor analysis. Cronbach’s α reliabilities ranged from .79 to .82, with subscale ranges from .71 to .90.5,12,14 In the present study, reliabilities were as follows: total CWEQ-II = .86: opportunity = .78, information = .82, support = .80, resources = .74, formal power = .73, and informal power = .76.
Procedure for Conducting Research and Data Collection
Institutional review board approval was obtained prior to commencing the study. The survey was sent out electronically using Survey Monkey®, and e-mail reminders were sent to the CNMs weekly for the 3 weeks that the survey was posted. Data were analyzed using SPSS-18 (Chicago, Illinois).21
Two hundred ten CNMs were invited to participate in the online survey; 140 completed questionnaires for a response rate of 66.7%. Eighty-nine percent (n = 124) of the participants were women, and 11% (n = 16) were men. Responses to race revealed that 79% (n = 110) were white, 7% (n = 10) black, 6% (n= 9), Asian and 3% (n = 7) listed themselves as other. The majority (68% [n = 95]) were between the ages of 41 and 55 years, with a median age of 46 years. Forty-seven percent (n = 67) have a bachelor’s degree, 42% (n = 59) a masters, and 2% (n = 3) have a doctorate. The majority of the CNMs (58% [n = 81]) had between 11 and 30 years of experience as a nurse. Regarding experience as a CNM, the majority (54% [n = 75]) had between 1 and 6 years. Asked about certification, 50% (n = 70) indicated they are certified. More than half (68% [n = 95]) said they did not cover more than 1 unit. These results are included in Table 1.
The total mean CWEQ-II score for this sample was 21.38 (SD, 0.48), indicating a moderate level of SE. Subscale scores were as follows: opportunity, mean = 4.11 (SD, 0.77); information, mean = 4.21 (SD, 0.69); support, mean = 3.46 (SD, 0.86); resources, mean = 2.57 (SD, 0.71); formal power, mean = 3.17 (SD, 0.82); and informal power, mean = 3.86 (SD, 0.75).
Demographically, the sample was similar to the nurse population as indicated in the 2008 National Sample Survey of Registered Nurses published by the HRSA.1 The HRSA study found that 83% of nurses are white, non-Hispanic, and 90% are female. Hispanics, blacks, and American Indians are underrepresented in the RN population (22.5%). There are no data on the average age of CNMs in the United States. The Bureau of Labor Statistics states the median age for medical and health services managers is 49.6 years.18
The CNMs perceived moderate levels of empowerment. These scores are consistent with the moderate empowerment scores reported by Patrick and Laschinger,11 who studied SE of 1st-line managers (total score = 20; mean, 3.94) and 2nd-line managers (total score = 21; mean, 3.16). The slightly higher results in the present study may be attributed to the fact that Canada, where Patrick and Laschinger’s study took place, has a different healthcare system than that of the United States. One factor that may contribute to the higher scores in the present study is the health system’s commitment to and the division of nursing’s focus on transparency and communication. The health system is a large organization that stresses communication and collaboration as foundational to its infrastructure. For example, there is a retreat twice a year with senior-level management to review the year’s goals, strategic plan, and vision for the health system. After the retreat, it is expected that pertinent information and plans will be communicated to all employees through leadership and team meetings. Within the department of nursing, the nurse executive meets with the leadership team to review what was shared at the retreat, and each CNM then shares the information with staff.
Other methods of communication used to share the vision, goals, and strategic plan of the organization include town halls, newsletters, daily briefing/huddles with staff, screen savers, and other electronic means. The TeamSTEPPS™20 format of communication has also been implemented system wide. TeamSTEPPS is an evidenced-based team approach to improve communication among all levels of employees, teamwork among healthcare professionals, and patient safety. One key aspect of this process is that everyone on the team is empowered to question clinical decisions in a safe environment. Every employee (including physicians) has been trained on the TeamSTEPPS philosophy and process. Moreover, the CNM is in charge of conducting a daily briefing with staff regarding any issues or clinical concerns on the unit. The CNM ensures that everyone shares the same philosophy.
One of the mechanisms by which CNMs in this health system feel empowered is through collaborative care councils (CCC). The purpose of the CCC is to shift the practice model from multidisciplinary to interdisciplinary by engaging point-of-care providers in decision making and outcome accountability. Building relationships in departments and across all disciplines is the focus along with the common understanding that positive outcomes are achieved through a team approach, not through one person, department, or committee. Clinical nurse managers are part of the CCCs, but they do not serve in the role of chair. Their role is to coach the chair and cochair, bringing a global perspective, and assisting in developing ways to expand staff involvement in key areas of responsibility.
Although the total empowerment score indicates moderate empowerment, there are concerns that the subscale scores are not optimal. One empowerment dimension that is of great concern is the ranking that CNMs gave to the resources subscale. In the present study, the mean was 2.57 (SD, 0.71), which is a low score. This finding was expected, considering that the roles and responsibilities of CNMs have changed and increased over the years to include operational, quality, and financial responsibility as well as patient and staff satisfaction. The CNMs’ daily routine can be unpredictable; often, there is not enough time to complete all of the paperwork and reports required on a daily basis. The CNMs obviously perceive that they do not have adequate resources to do their jobs.
In addition to scoring low on the CWEQ-II subscale on resources, the CNMs scored lower on the formal power job activities scale than did the participants in Patrick and Laschinger’s11 study. Formal power refers to job characteristics that coincide with one’s job description and are essential to the organization’s goals. The lower score in this subscale could be attributed to possibility that in certain instances they feel they are not doing as good a job as they should because they are constantly managing to the situation at hand. The constant demands to manage to the situations at hand, combined with feeling that they are not doing as good a job as expected, may result in them being unable to fully actualize the formal power that is inherent in their roles, leading to a perception of lower formal power (Table 2).
In addition, the CNMs scored lower on the structural dimension of access to support, although their scores were higher than what has been reported in the literature.11 This may be attributed to the fact the CNMs in this study had a strong relationship with their clinical directors whom they can rely on for support, assistance, and guidance. However, the fact that the scores are suboptimal may again be a result of the demands that the CNMs face, and if they are stretched to meet these demands, they may not be able to always access the support available to them, through lack of time. It is possible that CNMs could benefit from training in managing peer relationships as well as upward relationships. This training in itself would be an additional support, and skills gained in managing relationships could reduce stress.
Suboptimal scores on informal power may be due to a self-perception among the CNMs that lags behind the evolving and increasingly interdisciplinary nature of today’s healthcare systems. Perhaps, CNMs would perceive more informal power, if they had support in increasing their self-efficacy in wielding their power and changing their self-perceptions to be consistent with the expectation that their requests will and should be met. Some form of structured training and/or support in improving leadership skills and managing power and politics might improve nurses’ self-efficacy in these areas and boost perceptions of informal power.
Characteristics of the Health System
The context in which CNMs function is obviously a large contributing factor to their perceptions. The healthcare system in which these CNMs function has strengths and areas needing improvement. Among the positive qualities is an organizational culture of safety, quality, and transparency on all levels. The health system has an excellent internal communications system throughout the hospitals. There is a great deal of collaboration between all the facilities. There are monthly nurse executive meetings attended by senior nurse executives of all the health system facilities. These meetings serve as a forum for exchange of information between all facilities in key areas such as quality, finance, operations, and staff development. This information is then relayed to each nurse executive’s directorial team, and the directors in turn share what they have learned from partner institutions at their ongoing dialogues with their CNMs. In this way, the CNMs are enriched and engaged by the experiences of the entire health system.
Sixty-eight percent (n = 95) of the CNMs responded that they cover only 1 unit. Each unit has an assistant nurse manager on days, evenings, and nights. The health system promotes continuing educational classes and has extensive educational programs for all levels of leadership, vice presidents, directors, CNMs, and clinical nurses.
One strategy for addressing the lower than optimal score on subscales would be for the health system to support CNMs in developing strong interdisciplinary partnerships with the departments that they interact with daily. This might take the form of special courses, programs, or education in this area. Additional training in leadership skills might assist the CNMs in developing their image as a leader and assist them in acting in manners that will maximize their efficacy in dealing with other departments. This would help to reduce the stress and burden in getting the resources to get the job done. Leadership skills and role development should be an essential part of the CNM orientation and should be reinforced in an ongoing manner by their supervisors.
As healthcare becomes more interdisciplinary and team based, the importance of informal power will become more apparent. As part of role development and ongoing support, CNMs may benefit from standing meetings (quarterly, monthly, whatever is feasible) where they can discuss issues of mutual concern, develop strategies as a group to address concerns, and support one another in evolving both individual and group identities as empowered leaders. Such meetings could also provide a forum for bringing in resources to the group in the form of outside speakers or mentors who could help the CNMs address both specific and global issues. In addition, meetings would also provide a dimension of social support.
Generous tuition reimbursement is an incentive and inducement to further education and professional development. Not only should CNMs receive this benefit, but also their supervisors should actively encourage their professional development and should serve as mentors, helping the CNMs identify professional development avenues.
Collaborative care councils may be a means to improve low resource scores. These councils are a means through which staff members at all levels may become empowered, with the CNM taking the role of facilitator. Through membership in these councils, staff would participate in developing and implementing solutions to problems. Such active involvement in unit activities could help reduce the workload of the CNM.
It is important to note CNMs not only function in the environment of the health system, but they also help create it. When they help their own staff feel empowered, the CNM helps to create a healthy WE, resulting in decreased turnover rates, increased staff satisfaction, and increased patient satisfaction.12,14,19 Smith17 showed when project managers have support, resources, opportunities, and information, they will have stronger organizational commitment and allegiance to the organization.
Limitations of the Study
This was a convenience sample, which used a survey conducted 1 time only. In addition, this study was conducted in a single healthcare system limiting generalization.
Implications for Nurse Leaders
When employees have access to information, support, resources needed to do the job, and opportunities to learn, they will be effective and will have more positive feelings about their work.12 This study provides a baseline assessment of perceptions of SE among CNMs in 1 large healthcare system. Areas of strength and opportunities for improvement are identified. The future focus needs to be on providing an environment where CNMs feel empowered and in turn can empower their staff. The benefits of an empowered WE are a productive setting where staff satisfaction, patient satisfaction, and quality metrics are achieved.12,14 According to HRSA, CNMs spend 38% of their time in supervision, 25% performing administrative responsibilities, 11.5% providing care and charting, and 9% in dealing with agencies.1 If more time were spent mentoring clinical nurses, empowering the CNM to take on more unit activities, they would have more time to identify staff nurses with high potential for future management positions. Succession planning is an often ignored yet important dimension of preparing CNMs and leaders. These high-potential clinical nurses could be mentored and inspired to transition into management. Feeling more empowered may encourage higher levels of commitment to the organization.11
Nurse executives should constantly strive to develop CNMs and raise them to higher levels, to move from moderate empowerment to high empowerment. Possible mechanisms under review include offering more leadership development programs or courses, which meet on an ongoing basis. It is becoming increasingly apparent that the “void” of CNMs has a negative impact and will have an increasingly negative impact on the ability for hospitals and healthcare systems to function optimally. As a result, there is a growing momentum to provide leadership development for CNMs, recognizing their vital importance in healthcare.
More studies need to be conducted among CNMs. Not only are CNMs integral to any organization, but they are also essential to the retention of clinical nurses.4 The CNM role is important for staff satisfaction, patient satisfaction, and safety and for maintaining quality and financial metrics.14 A strategic plan needs to be developed to determine ways in which we can recruit clinical nurses to aspire to be CNMs. The empowerment of CNMs is essential to such a plan. Furthermore, it would be beneficial to conduct national studies of CNM workforce issues. Accordingly, additional research needs to be conducted on CNMs.
The present study should be replicated in other care settings to see if the issues are the same and to potentially identify regional differences that may shed additional light on the nature of the problem and possible solutions. Also, qualitative research may provide some valuable insight on how we can protect and support this vital role in healthcare. Demographic data must be collected on CNMs and added to a national database on nurse employment across a range of specialties.
The authors thank Heather Laschinger, PhD, for the use of instruments and support.