The role of the nursing supervisor is poorly understood. Weaver and Ellerbe1(p48) refer to this position as the “invisible role.” The nursing supervisor is referred to by various names in different organizations, including shift supervisor, clinical coordinator, clinical administrative coordinator, shift administrator, or patient care coordinator.1 For the purposes of this study, the term nursing supervisor or supervisor will be used to refer to individuals responsible for clinical and administrative functions in support of or in representation of unit-, department-, and facility-based nurse leaders on all shifts.
Based on the limited research available, the responsibilities of the nursing supervisor include staffing, clinical quality and patient safety, administrative presence, emergency response, customer satisfaction, census management and throughput, and acting as a resource to nursing staff.2,3 Specific tasks within these domains may include ensuring appropriate staffing including reassigning nurses to different units, coordinating the organizational response during times of high census, making rounds on units to obtain a sense of the activity, coordinating and organizing personnel and other resources, maintaining patient, leading organizational response to external and internal disaster situations, providing hands-on care to support staff including starting intravenous lines and leading code response protocols, visitor and staff safety, and collaboration with hospital administration, all while maintaining fiscal accountability for the organization.1-5 Regarding qualifications, it has been recommended that supervisors have an MSN degree, be certified as a nurse executive through the American Nurses Credentialing Center® (ANCC), possess nursing experience and skills, be certified in Advanced Cardiovascular Life Support (ACLS) and in some circumstances Pediatric Advanced Life Support, and have critical care experience.5,6 Weaver and Ellerbe1 suggest supervisors should possess problem solving and astute critical thinking skills.
It seems that most acute care organizations employ nursing supervisors, yet there is no identifiable data source to confirm this. Not only is the population poorly defined, but also it is unclear what nurse supervisors do in their worked shift or what professional preparation is ideal for individuals in this role. If indeed most organizations utilize the nurse supervisor role, and there has not been an identification of standards for this role, then it is difficult to determine best practices among nursing supervisors. These problems can be addressed through a role delineation study. Role delineation studies are conducted with the goals of describing current practice and performance requirements. At present, no instrument exists to conduct a role delineation study in this population. Additionally, it is unknown if it would be feasible to conduct such a study, as sampling of nurse supervisors may be difficult. Therefore, the purpose of this pilot study was 3-fold: 1) to describe a sample of nurse supervisors working in New Jersey; 2) to develop and test a role delineation questionnaire measuring practice and performance requirements of nursing supervisors; and 3) to assess the feasibility of conducting a role delineation study in nursing supervisors.
In response to the problems stated above, the research questions of this study were as follows:
- What are the personal and professional demographic characteristics of a representative sample of nursing supervisors?
- What are the psychometric properties of a pilot instrument, the Nurse Supervisor Role Delineation Questionnaire, designed to delineate the role of the nursing supervisor?
Convenience and snowball sampling methods were used to recruit nursing supervisors currently practicing in the state of New Jersey. There are 71 acute care hospitals in New Jersey7 and an estimated 112 000 nurses.8 While there is no specific organization devoted to nursing supervisors, many New Jersey nurses belong to the New Jersey State Nurses Association (NJSNA); thus this was the primary site for recruitment. After obtaining institutional review board (IRB) approval from the local IRB, an invitation to participate and a link to the survey were emailed to the NJSNA email distribution list representing 3300 members. After providing informed consent, individuals identifying themselves as a nursing supervisor currently working in acute care completed the online questionnaire. All individuals who received the email were also invited to share the questionnaire link with their nursing supervisor colleagues working in acute care. A reminder email was sent to the distribution list 2 weeks after the initial email. While role delineation studies typically aim to survey a percentage of the discipline population in order to ensure generalizability of findings,9 this study was not able to do so because the population size of nursing supervisors in New Jersey is unknown. Alternatively, the desired sample size was 50 responses as this is generally the minimum acceptable sample for exploratory factor analysis.10
This study followed the framework established by the ANCC for role delineation studies.11,12 According to the ANCC,11 role delineation studies are carried out to describe current practice expectation, performance requirements, and environments and can capture the knowledge and skills necessary to perform those activities. The ANCC framework begins with the generation of a task list, followed by establishing content validity through a panel of content experts. Subsequently, the updated task list and demographic items are piloted on a subset of the target population. Finally, the revised questionnaire is distributed to the target population, and returned data are analyzed to describe the sample population, environment, and prioritization of tasks.11,12 This study served as the pilot study, from which the task list will be further revised.
First, 19 demographic questions were developed by the investigators. Items covered nurse supervisor characteristics including gender, age, and ethnicity; professional characteristics including education, certification, and work history; and professional environment characteristics including hospital Magnet® recognition status, size, and supervisor staffing and reporting. Based on the available evidence,1,2,4,5 a 45-item task list was generated encompassing the relevant work activities of nursing supervisors, for example, “Assigns beds to direct admissions” or “Responds to code blues.”
In the ANCC surveys,11,12 each task is rated on 3 scales including performance expectation, consequences, and frequency. Performance expectation reflects how soon after certification a task would have to be performed (within the 1st 6 months, after the 1st 6 months, or never). Consequences measure how serious the consequences would be if the task was not performed or if it were performed incorrectly (severe, moderate, mild, or none). Finally, frequency reflects how often the task must be performed (always, frequently, occasionally, seldom, or never). Ratings of these 3 constructs are combined in a matrix to provide an overall criticality score for each item that reflects a combination of the performance expectation, consequences, and frequency ratings.11,12
In the current study, performance expectation was not included as it was not determined to be relevant because there is no supervisor certification. Tasks were rated for consequence and frequency, using the ANCC11,12 scales. Each task was rated for frequency from 1 (never) to 5 (always) and consequence from 1 (none) to 4 (severe). A criticality matrix was created to generate a criticality score for each item, weighting the consequence score more heavily than the frequency score, in line with the ANCC model11,12 (Table 1). The questionnaire was reviewed by a panel of content experts for content validity and adjustments were made based on their feedback. The content experts were the managers of the supervisors and were responsible for doing the annual evaluation of the nurse supervisor group. Each expert had more than 15 years of experience. The instrument was then piloted with a small group (n = 3) of internal supervisors and rated on question clarity and relevance. No items were rejected based on their responses.
To address research question 1, demographic data were analyzed by calculating frequencies and percentages to describe the overall sample of nurse supervisors completing the questionnaire and their work environments. To answer research question 2, descriptive statistics were calculated for the criticality values of each statement in the Nurse Supervisor Role Delineation Questionnaire. The statements were ordered by mean score and ranked to identify the tasks with the highest and lowest criticality to the nurse supervisor role. The psychometric properties of the instrument were evaluated through principal component analysis (PCA) with promax rotation, to identify subscales of the instrument and evaluate the strength of each item. Additionally, internal consistency was evaluated.
There were 69 responses to the survey. Of these 69, 14 responses were excluded because they did not meet the inclusion criteria (12 were not nursing supervisors, 2 had previously completed the questionnaire). Fifty individuals went on to complete the demographic portion of the questionnaire, while criticality scores of the Nurse Supervisor Role Delineation Questionnaire were available for 41 subjects on some portion of the role delineation items. All available data were included for PCA in order to maximize the sample size of the analysis.
Research Question 1
The study sample consisted of 50 nursing supervisors practicing in New Jersey. Demographic characteristics are described in Table 2. The majority of participants were white (n = 42 [84%]) females (n = 44 [88%]), 55 years or older (n = 26 [52%]), with 30 or more years of experience as a nurse (n = 27 [54%]). More than a quarter also had 20 or more years of experience as a nurse supervisor (n = 13 [25.5%]). The majority of supervisors were minimally prepared at the bachelor's level (n = 41 [82%]), and nearly half had graduate degrees (n = 22 [44%]). Just under half were certified (n = 24 [48%]), with a mix of clinical and leadership certifications including ACLS and certifications in clinical specialties, advanced practice, nurse executive, and clinical quality.
Regarding role and facility characteristics, most supervisors reported to a lead nurse supervisor or some other nurse leader (n = 48 [96%]). The majority of supervisors were paid hourly (n = 32 [64%]), worked 12 hours shifts (n = 25, 50%), and spent little time providing direct patient care (n = 35 [70%]). Fewer than one-fourth of participants were from hospitals that had received Magnet recognition (n = 12 [24.4%]). Unionized and nonunionized environments were equally represented. Most supervisors were from hospitals of at least 200 beds (n = 32 [65%]) and often worked alone or with 1 other supervisor (n = 45 [90%]).
Research Question 2
To describe the work of the nurse supervisor, Nurse Supervisor Role Delineation Questionnaire item criticality scores were calculated based on frequency and consequence scores. Items were ranked based on mean criticality score (Table 3). Based on the responses of this sample, the most critical supervisor tasks are related to emergency management and staff support, while participation in direct care is least critical.
Subsequently, psychometric testing of the instrument was conducted. A PCA without rotation was used on the 45 items to obtain eigenvalues for each component in the data. Nine components had eigenvalues over Kaiser's criterion of 1 and in combination explained 82% of the variance. Based on a theoretical justification that supervisor responsibilities are related, and moderate to strong correlations between factors, an oblique rotation was selected. A PCA with promax rotation with 9 factors was conducted. However, in examining the 9-factor solution, 2 subscales contained items that were unrelated conceptually. Therefore, solutions with fewer subscales were also explored to determine if an improved model existed that retained a high explanation of variance, while offering factors that were conceptually aligned. Regardless of factor number, there were 3 items that grouped together statistically that did not agree conceptually (facilitates census management meetings, activates and directs the emergency protocol, identifies high-risk social service patients, and initiates referrals). The 7-factor solution explained 77% of variance and had the same factor with conceptually unrelated items. Therefore, the 7-factor solution was retained (Table 3).
Factor loadings were evaluated for each item. With the exception of 2 items (“informs management and administration of census status” and “offers choices to patients and families”), all items loaded to at least 1 factor above the cutoff of 0.4. Because this was a pilot study with a small sample, all items were retained and assigned to the factor with the best conceptual alignment as additional data will determine if they should ultimately be deleted. Several items loaded on multiple factors. Where the difference in loadings was equal or greater than 0.10, the item was assigned to the factor on which it loaded highest. Where the difference in loadings was less than 0.10, a decision was made based on where the item fit best conceptually.
The final solution revealed subscales on which items were conceptually related with few exceptions, including “administrative presence,” “leadership liaison,” “patient safety and experience,” “patient care advocate,” “throughput,” and “external response,” and 1 on which items were unrelated named “miscellaneous.” Overall, internal consistency of the scale was high at 0.97. Internal consistency of the subscales was also high, ranging from .74 to .94 (Table 3), with the “miscellaneous” subscale having the lowest internal consistency (Table 3).
Discussion and Conclusion
The results of this study add to the literature on nursing supervisors in several important ways. First, demographic data are now available on a sample of nursing supervisors. Based on this sample, nursing supervisors are a highly experienced workforce. While this is beneficial to those they lead, it is also concerning as the majority of this sample is less than 10 years from retirement. If this finding is generalizable, succession planning should begin now to cultivate the next generation of nurse supervisors. Additionally, this sample was very homogeneous from gender and ethnicity perspectives. Efforts are warranted to attract a more diverse group of nursing supervisors representing a broader geographic region in order to generalize results.
Regarding professional preparation, fewer than half of respondents met the recommendations for advanced degrees or certification put forth by content experts.1,5 Additional data from a larger and more diverse sample are necessary to understand how this aligns with recommendations for higher education and certification, especially given the position of nursing supervisors as leaders. There does not seem to be a standard for reporting structure or nurse supervisor staffing. Further research is required to understand best practices in structure and utilization of the nurse supervisor role.
The main contribution of this study is the preliminary description of the work of the nursing supervisor. The factors identified through the PCA are consistent with the categories of work described previously through qualitative research and expert opinion.1-5 This study has empirically validated that the work of the nursing supervisor is organized around administrative presence, leadership liaison, emergency response, patient safety, patient experience patient care advocacy, and throughput. The only theme present in other literature and not in these categories is staffing2; however, there were items related to staffing interspersed. It is likely that continued testing of this instrument with large sample size would further refine the factors identified and items related to staffing may consolidate under a single or related factor. Moreover, this study is the 1st to allow initial conclusions to be drawn about the relative importance of different supervisor responsibilities.
Equally important to the findings of this study are the limitations and implications for future research. This analysis was limited by small sample size and missing data. Analysis of patterns in missing data demonstrated participants fatigued as they progressed through the questionnaire. Between the demographic questions and dual ratings of tasks, the instrument had 109 items. This is similar to other role delineation instruments.9 Participants were most likely to complete all demographic questions early in the instrument, while completion of later items was less consistent. Offering incentives may aid in future participation. Otherwise, methods to conduct factor analysis with smaller samples such as regularized or generalized exploratory factor analysis could be considered.13,14 Additionally, advanced methods to estimate missing values could be employed.15 Recruitment of nursing supervisors was challenging. Given the number of hospitals in New Jersey, there are likely many more than 50 nursing supervisors. However, there is no clear path to accessing this population. In the future, resources should be directed to identifying and recruiting a nationwide sample of nursing supervisors to further test this role delineation instrument.
In conclusion, the findings of this study offer an initial description of who nursing supervisors are and what they do. It also offers preliminary data on the development of a valid and reliable instrument to measure the work of nursing supervisors. Nurse executives can use this information to develop competencies, improve job descriptions, and support performance evaluation for nurse supervisors. Future research should focus on replicating this pilot study in a larger and more representative population of nurse supervisors. Additionally, research is needed to explore the impact of the nurse supervisor on quality and patient outcomes. Although more work is required to fully optimize the position, this study is an important step in illuminating the invisible role of the nursing supervisor.
The authors acknowledge the contributions of Nirmala Lekhak, PhD, RN, assistant professor at the University of Nevada, Las Vegas, for her support with statistical analysis.