Straight talk: Nurse manager role stress

Loveridge, Stephanie DNP, RN-BC, NEA-BC

doi: 10.1097/01.NUMA.0000514058.63745.ad
Feature: CE Connection

What did the 12 participants of this qualitative study have to say about the stressors and joys of the job?

Stephanie Loveridge is the managing director of adult and child mental health at Centrahealth in Lynchburg, Va.

The author and planners have disclosed no potential conflicts of interest, financial or otherwise.

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What did the 12 participants of this qualitative study have to say about the stressors and joys of the job?

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Article Outline

Nurse managers have one of the most demanding roles in the hospital environment. Reimbursement changes, pay-for-performance, and an overall decrease in inpatient volume have pushed hospital executives to increase productivity while, at the same time, expecting higher quality. Examining nurse manager role stress is critical for retention in this turbulent age of healthcare reform.

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Nurse manager turnover rates in 2010 were 8.3%.1 The turnover rate is higher among nurse managers than senior leaders, including CNOs, vice presidents, and patient care administrators. The cost of replacing nurse managers is estimated at 75% to 125% of their annual salary.2 A study done in 2014 revealed that 72% of the nurse managers surveyed reported plans to leave their positions in the next 5 years.3 The most common reason? Burnout. (See Literature review.)

However, nurse managers do find ways to cope with the stress of the position. Twelve nurse managers from various inpatient hospital systems were participants in a capstone project. Although 10 out of the 12 nurse managers thought about quitting the role at some point, most found meaning and joy in their daily work, which enabled them to “keep coming back.” The nurse managers interviewed were able to remember why they're in the position—to help their units achieve excellence and their nurses to grow professionally. One remarked, “I do enjoy my team. I absolutely enjoy the people... When I see that energy, it just makes me even more energized...”

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Study design and demographics

A descriptive qualitative design using a purposive sampling method was utilized as the method of inquiry. (See Study overview.) A sample of 12 nurse managers working in three hospital systems in Virginia was chosen. To participate in the study, the nurse managers had to have 2 or more years' experience.

Demographic data were collected via e-mail after obtaining informed consent. Interview questions were asked and an open-ended approach was used. The rights of participants in this study were protected per Institutional Review Board guidelines. Interviews were digitally recorded over the telephone and transcribed; data were analyzed using immersion and reduction. A doctorally-prepared qualitative expert was used for confirmation of study results. Themes were developed using analyst-constructed typologies.

Forty percent of the participants worked in an urban setting, and 60% worked in a suburban or community setting. All hospitals were not-for-profit and Magnet® recognized. Sixty-seven percent of the managers worked in an academic health system. (See Table 1.) All of the participants were female, with a median age of 51. (See Table 2.)

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Results

During the interview, each of the 12 participants was asked a series of questions related to her role. Four essential themes emerged from the interviews: “sink or swim,” “there's no end,” “support me,” and “finding balance.”

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“Sink or swim”

All but one of the participants interviewed indicated a feeling of being “thrown” into their current position without an orientation or mentor. The first year is a vulnerable time for a new leader; most participants didn't feel that they had an orientation to the role. They also struggled with the transition from peer to leader.

Feeling overwhelmed by the immensity of the nurse manager role in the first year was common. Many participants felt confused, unsure of their role and what to do next. Nurse Manager 4 described, “You didn't have an orientation, you didn't have a preceptor—you just went to work and you either sank or swam.” This feeling was also reflected by Nurse Manager 7, “Very little orientation. It was kind of like trial and error.” Nurse Manager 10 explained, “It was rocky because there was no real orientation, no real support. I was flying by the seat of my pants.”

Another aspect of the “sink or swim” feeling in the first year as a nurse manager was related to role transition. Most of the participants transitioned from being a peer on their unit to being the manager. A few participants were friends with their colleagues outside of work and had to sever those ties after assuming a management role. Nurse Manager 11, a manager of 6 years in her late 30s, described her transition and the uncertainty of how she was performing, “...I used to be the popular charge nurse that everybody could go to, everybody could call at night, I could troubleshoot, and all of a sudden here I am in a manager role and handing out discipline and noticing practice. It was hard. I wanted to quit on my first maybe 3 to 6 months because I didn't know whether I was doing a good job or not...”

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“There's no end”

The nurse manager role, by nature, assumes 24-hour-a-day accountability for the managed unit. In these interviews, the participants described feeling overloaded with tasks and struggling to keep up with the pace of change. Initiative fatigue was also reported as a stressor.

The volume of tasks that participants managed was seen by most as overwhelming. The span of control, as well as the additional support provided, varied. One unit manager with over 100 full-time equivalents (FTEs) had a leadership team comprised of an assistant nurse manager, a full-time educator, and an administrative assistant to manage her schedule. Another unit manager with 15 FTEs had no ancillary support. Being on call 24 hours a day was stressful for some, but not all, of the participants.

Nurse Manager 6 described her experience of getting called after hours, “What was going on is our units would call us all the time [after hours]. I mean, we had one nurse manager that literally called in on a Monday morning and said, ‘I'm done. Bye. I'm not doing this anymore.’” Nurse Manager 9, a new nurse manager with 2 years' experience, talked about the never-ending work, “The stressful part is that we're always on. Sometimes you're with your family but you have to respond to an e-mail and get a phone call, or it's 9 o'clock at night and you're still talking to the hospital.” This workload required the managers to play “catch up” at home. Nurse Manager 3 commented on the added responsibility given to her without additional resources, “More has been added and nothing has been taken away...I've added beds, I've added FTEs...and the expectations remain the same.”

In addition to the volume of work, initiative fatigue was reported by all of the participants. With so many metrics, it was challenging for the participants to determine what the important initiatives were because they all seemed important all of the time. Nurse Manager 10, who has 8 years' experience as a manager, summed it up by saying, “You had so many projects going on, you couldn't actually achieve your goals before something else was thrown into your lap.” Nurse Manager 3 elaborated on the need to stay on top of multiple initiatives, “It's because so many initiatives come out, when you do a survey looking at staff engagement, or...professionalism, you get the results and for... 2 months, that's everything we're talking about...it's on everybody's agenda...then when you find out, ‘We have a safety situation going on throughout the entire house,’ it takes a backseat. But the organization still expects the manager to keep data, on top of the [earlier] initiatives...”

The combination of a heavy workload that includes many hours of work at home and the rapid pace of initiatives caused the participants to feel stress.

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“Support me”

Participants voiced a desire for their leaders not to reach out to them after hours unless it's an emergency. Having their leaders understand work-life balance was essential to their job performance. Nurse Manager 2, after writing a letter of resignation (but not turning it in), elaborated, “Sometimes it was when [my leader's] crisis became mine... Even though it didn't matter what you're in the middle of. And it didn't matter if I was [with my family]...you had to stop doing what you were doing and get what this other person needed...”

The need for the senior leader to trust the nurse manager and her autonomy was a distinct theme. Nurse Manager 7 stated it simply, “Just respect the nurse manager's autonomy and not micromanage.” Nurse Manager 11 elaborated, “My need as a manager isn't necessarily to see you [the director] every day, because to me it feels like you're checking on me... I need to know that you trust me to do my job...that I'm managing this team.”

The need for the senior leader to not “jump to conclusions” was also part of this theme. Nurse Manager 9 described this in the context of looking at data, “...Our [senior leader says] ‘This is going to be [discussed at the executive meeting] and this is going to be embarrassing.’ I think as a manager, you feel like, ‘It's a number, but it's not my people.’ I don't think that I have people who are neglectfully keeping extra staff, or neglectfully not scanning their things, or intentionally making a customer upset...”

The need for the senior leader to advocate for the unit and staff at critical times emerged as well. Nurse Manager 11 experienced this positive show of support when her staff members were blaming her for a recent initiative during a staff meeting. She explained, “When all of that was going down...and everybody was hammering at me for what they thought was a decision I made, [my director said] ‘I won't tolerate manager bullying. I've seen this happen. This team has historically done it to their former managers.’ [And he met with the team and told them]...'She (nurse manager) didn't make this decision by herself and we're standing by her. We made this decision [and] we do support her...”

Finally, having clear expectations from senior leaders was also a theme. Although the nurses were clear that they didn't want to be micromanaged, the need for regular meetings regarding feedback was desired. Nurse Manager 10 explained, “What I also need is feedback, ongoing feedback or periodic feedback... I don't want to just assume anything.” Nurse Manager 2 described her disconnect with having four different directors in 9 years, “...Some want all total hands on, some [say] ‘I trust you. You do what you need to do,’ and some [say] ‘You don't do anything good enough [laughter].’ ... So, it's been difficult trying to navigate what each one wants and without a set of expectations, or the expectations don't come until after you've already messed up. Not that you really messed up, but you didn't know what they wanted.”

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“Finding balance”

All participants in the study discussed how the nurse manager role affected their health and personal relationships. They spoke of “growing” into the role and finding a work-life balance. Tenured managers seemed to have already reached that balance, whereas more novice nurse managers were still finding their way. The struggle to “unplug” from electronics after work was common. Some participants found it difficult to find the time to eat right and exercise, but others have made this a priority.

Nurse Manager 12, who's been a nurse manager for 2 years, described her journey toward better health, “I kind of went into a slump the first year...I put on like 30 pounds [chuckles]... Now I'm back down...and walking and exercising, feeling a lot better.” Nurse Manager 2 saw the need for exercise but is, in a sense, “robbing Peter to pay Paul” regarding her sleep. She explained, “...I don't have a lot of opportunity to exercise. So I get up at 3:30 [a.m.] every morning [to] exercise before I get here so that way I can have my whole day. So when I finally do get home, I don't have to put off being with the family even more. That probably stresses me, too, because I average probably about maybe 5 hours tops for sleep.”

Most of the participants (10 out of 12) were married and had remarkable support from their husbands. Their role as a nurse manager most affected their relationship with their children. Many experienced significant guilt about working long hours and being preoccupied when they're home with their children. Nurse Manager 12, who has younger children, stated, “My 10 year old got mad at me... She said...‘You're always on that phone. You're at home now.’”

One of the role stressors described by participants was the fact that they're constantly connected to their phones and e-mail. This has impacted their home life and relationships with their children. Nurse Manager 11, after 6 years in the role, reached a personal point where she stopped answering e-mails at home and the result was an increase in the quality of her family life. She elaborated, “Currently, I've stopped answering e-mails once I get home....It took me awhile. Six years being in management, I've just started doing that in the last 6 months. I came to that out of a personal decision to just stop being connected all the time. My children are starting to grow up and they're starting to notice that mommy's on the phone all the time...the good thing is that I'm starting to connect more with my family life.”

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Limitations

The study was done at three nonprofit Magnet hospitals in Virginia, two of which are major academic teaching facilities. All of the participants were female; the presence of a male nurse manager would've yielded rich data about how men in this role cope with stress. In addition, only two nurses were under age 40; this lack of younger managers leaves a gap of valuable data regarding how generation Y copes with the pressure of being a nurse manager.

Eighty-three percent of the nurse managers studied had a master's degree or higher; this education demographic is likely representative of the Magnet hospital culture and could be considered a limitation. Although another researcher added to the rigor and trustworthiness of this study, the primary investigator was previously a nurse manager herself for 5 years; this experience in the role may have added some degree of bias. Finally, as with any exploratory study with a purposive small sample, the findings are tentative and not generalizable.

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Recommendations

Lack of support from leaders is one of the factors contributing to nurse manager turnover, and the study participants validated this finding.4 For this reason, support from senior leaders and an infrastructure to help nurse managers succeed are recommendations to improve role satisfaction.

All but one study participant voiced that their first year in the role was turbulent due to lack of orientation and mentorship. Although most hospitals do an adequate job of orienting and supporting novice clinical nurses, little is done for frontline leaders. A comprehensive manager orientation, mentorship, and even a support group for new nurse managers are critical in assisting with the transition. Successful organizations that support a learning culture and allow for professional growth retain managers who have less stress, increased job satisfaction, and longer tenure.5

The sheer volume of workload and new initiatives almost necessitates working overtime and taking work home; this further impacts nurse managers' health and relationships with their family. Being on call 24/7 is an added stressor. Organizations should explore specific ways to decrease the stress level of nurse managers, including shared call by division, innovative comanager models, and a unit leadership triad (manager, assistant manager, and educator).

A few participants in this study expressed that shared call by division after hours was a huge satisfier and contributor to work-life balance. For nurses with a large span of control, organizations may consider smaller spans of control (less than 50 direct reports) or comanager models to decrease nurse manager stress and increase job satisfaction.6,7 The comanager model has been shown to increase job satisfaction because it lowers overall span of control by dividing responsibilities between two nurse managers.6 Organizations should also consider using unit-based educators and assistant nurse managers as part of the nurse manager's leadership team to divide the workload. Further research should examine orientation and mentorship programs, as well as comanager models and the leadership triad, and their effects on nurse manager turnover and satisfaction.

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Staying the course

Nurse managers are essential to organizational success due to their impact on patient outcomes at the point of care. Support for nurse managers in the form of clear orientation, mentorship programs, and administrative assistance is critical for this group of dedicated employees. Success is likely to improve nurse retention and satisfaction, and translate to improved patient outcomes.

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Study overview

* The purpose of this qualitative study was to examine nurse manager role stress in the current healthcare environment.

* Twelve nurse managers from three not-for-profit Magnet hospitals in Virginia were sampled.

* One-hour interviews were conducted over the phone; data analysis led to four analyst-constructed typology themes.

* All of the participants were female, with a median age of 51 and 7 years' experience in the role (median).

* Eighty-three percent of the participants had a master's degree or higher.

* Participants spent a median of 50 hours per week physically at work, with another 5 hours per week working at home.

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Literature review

There are many reasons for nurse manager stress, burnout, and turnover cited in the literature. Lack of support is one factor contributing to nurse manager turnover. For many nurse managers, maintaining confidence in planned change when they aren't involved in the decision-making process demonstrates a lack of support from the administration. Budgetary cuts to nursing and a perceived lack of respect from the organization at large are additional factors. Nurse managers often report strong peer support, but lack senior leader support for fair pay and professional growth opportunities.4

Role conflict is also a contributor to nurse manager stress. Being caught “in the middle” between staff and administration is a predominant concern, as is trying to “be all things to all people.”8 Unclear and/or unrealistic supervisor expectations to consistently “put out fires” yet also devote time to strategic planning and innovation is one example of a stressor. Unrealistic expectations lead to frequent feelings of anger of being in a “no-win” situation.9 Many nurse managers express that they're tired physically, emotionally, and psychologically because of their roles.10

Lastly, the sheer volume of work can be overwhelming for nurse managers. The need to constantly reprioritize tasks throughout the day and attend multiple meetings decreases the ability to interact with and engage staff members. Seventy-six percent of managers in one 2010 study cited work volume as the prime contributor to stress, with staffing the unit being the most stressful task.6 The pressure to maintain patient satisfaction scores, employee engagement, and staff safety while ensuring operational efficiency may come to seem like an insurmountable task.

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Bonus content

Head to www.nursingmanagement.com for the information you need to conquer nurse manager stress. Here are some additional resources...

Mental health tips for nurse managers

http://journals.lww.com/nursingmanagement/Fulltext/2015/06000/Mental_health_tips_for_nurse_managers.10.aspx

Does mindfulness-based stress reduction training improve nurse satisfaction?

http://journals.lww.com/nursingmanagement/Fulltext/2015/12000/Does_mindfulness_based_stress_reduction_training.10.aspx

Take our groundbreaking wellness survey on page 7!

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INSTRUCTIONS Straight talk: Nurse manager role stress

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REFERENCES

1. Zastocki D. Retaining nurse managers. http://www.americannursetoday.com/retaining-nurse-managers.
2. Pine R, Tart K. Return on investment: benefits and challenges of baccalaureate nurse residency program. Nurs Econ. 2007;25(1):13–18.
3. Warshawsky NE, Havens DS. Nurse manager job satisfaction and intent to leave. Nurs Econ. 2014;32(1):32–39.
4. Skytt B, Ljunggren B, Carlsson M. Reasons to leave: the motives of first-line nurse managers' for leaving their posts. J Nurs Manag. 2007;15(3):294–302.
5. Mackoff BL, Triolo PK. Why do nurse managers stay? Building a model of engagement: part 2, cultures of engagement. J Nurs Adm. 2008;38(4):166–171.
6. Shirey MR, McDaniel AM, Ebright PR, Fisher ML, Doebbeling BN. Understanding nurse manager stress and work complexity: factors that make a difference. J Nurs Adm. 2010;40(2):82–91.
7. Lee H, Cummings GG. Factors influencing job satisfaction of front line nurse managers: a systematic review. J Nurs Manag. 2008;16(7):768–783.
8. Paliadelis PS. The working world of nursing unit managers: responsibility without power. Aust Health Rev. 2008;32(2):256–264.
9. Shirey MR, Ebright PR, McDaniel AM. Sleepless in America: nurse managers cope with stress and complexity. J Nurs Adm. 2008;38(3):125–131.
10. Firmin MW, Bailey M. When caretaking competes with care giving: a qualitative study of full-time working mothers who are nurse managers. J Nurs Manag. 2008;16(7):858–867.
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