Effective nursing leadership is essential to fulfill the Institute of Medicine's vision of nurses being full partners with other healthcare professionals. The Institute of Medicine and American Organization of Nursing Leadership have emphasized the importance of developing nurse leaders as a strategy to transform healthcare.1,2 Developing nurse leaders is important because effective leaders can instill staff nurse self-efficacy, which directly translates to staff nurse practice behaviors.3 In addition, nurse managers play an integral role in creating the environment that promotes nurse job satisfaction.4 As healthcare administration becomes more complex and financial challenges continue, the ability of nurse managers to lead patient care environments that produce desirable outcomes becomes more critical.
There are many operational tasks associated with a formal nursing leadership role such as patient placement, staffing, budgets, and supplies; however, nurse managers must not lose sight of the fundamental element of caring.3 Caring for the whole person, as it applies to patient care, has been an integral part of nursing practice for decades. In addition to caring for patients, recent efforts have included the importance of nurses caring for themselves and each other with the assumption that nurses deliver better care when they, too, are cared for. We propose that caring behaviors demonstrated by nurse managers may be equally important for the health and well-being of staff nurses. Thus, to advance healthcare, demonstrating caring behaviors by nurse managers that build relationships with staff nurses and healthcare teams becomes a necessary competency for nurse administrators.3
Staff nurses are the recipients of nurse manager behaviors. We sought to understand nurse manager caring behaviors from the perspective of staff nurses because there is a known disconnect between how nurse leaders perceive their own behaviors and how their behaviors are perceived by staff nurses.4 Gaining understanding of how staff nurses perceive their nurse manager's caring behavior will provide insight into nurse leadership development.
Nurse theorists have defined caring through beliefs, processes, and human interactions. Watson5 developed the theory of human caring based on her own values and beliefs. The middle-range theory of caring by Kristen Swanson6 was built on 5 caring processes: knowing, being with, doing for, enabling, and maintaining belief. Both of these theories were influential in the development of the quality-caring model (QCM) by Joanne R. Duffy.7 Applying and advancing Watson's theory of human caring through the QCM, Duffy8 suggested that positive patient outcomes are produced when patients feel “cared for” by the nurse through a professional interaction that produces a caring relationship. The QCM is composed of the concepts of humans in relationships, relationship-centered professional encounters, feeling “cared for,” and self-advancing systems.7 Consistent with the theory of human caring and the QCM, the concepts that are critical to developing nurse-patient caring relationships also can be applied to the caring relationships developed between nurse managers and staff nurses.
A scoping study is a literature review method that identifies the scope of evidence available on a topic.9 Guided by the QCM and the concepts therein, we decided that a scoping study was the best approach for reviewing published literature and identifying behaviors that are known to be nurse managers' caring behaviors. This study was guided by Arksey and O′Malley's9 scoping study methodological framework. We reviewed available evidence relative to key concepts and our research question to better identify and understand nurse manager caring behaviors.9 The framework steps included constructing the research question, identifying published studies, selecting the studies, charting the data, and collating, summarizing, and reporting the results.9
Research Question and Identifying Published Studies
Arksey and O'Malley9 suggested to clearly define the parameters under consideration for a scoping study while also maintaining a wide approach. To begin the scoping study process, we established the research question: What evidence exists regarding staff nurses' perceptions of nurse manager caring behaviors? To meet the objective of a broad overview of this topic, all types of results were included, including any retrieved doctoral dissertations. The original search was conducted by the 3rd author, a medical librarian, and the 1st author conducted a comprehensive search of the following databases: Ebsco MEDLINE Complete, Ebsco CINAHL Complete, Health Business Elite, Psychology and Behavioral Sciences Collection, PsycINFO, and PsycARTICLES. The following search terms were used: (nursing staff OR registered nurses) AND (nursing management OR nurse managers OR nurse administrators OR nursing administration OR nursing, supervisory OR leadership) AND (caring OR caring behaviors) AND (acute care OR critical care OR intensive care units). Basic limiters used were English language and humans. After removing duplicates, we had 62 publications returned.
Upon further review, we chose to eliminate MEDLINE Complete from our database list, because there were few results and the literature was not relevant to our topic or our research question. We also chose to broaden our search to a wider population of nurses and therefore eliminated the search terms “AND acute care OR critical care OR intensive care units.” The resulting search string was (nursing management OR nurse managers OR nurse administrators OR nursing administration OR nursing, supervisory OR leadership) AND (caring OR caring behaviors), which garnered 499 results. Limiters of research article, English, and exclude book reviews (the latter only within PsycARTICLES) and a date limit of 2009 to 2019 were applied. We did not use geographic limits. The same search was performed in PubMed using the limiters of 10-year date range (years 2009-2019), humans, English, and nursing journals. The PubMed search result totaled 2530. The total articles produced from all database searches totaled 3029.
Article Selection Using Inclusion/Exclusion Criteria
We established inclusion and exclusion criteria before reviewing the search results. The inclusion criteria were established by clearly defining caring behaviors, staff nurses, and nurse managers. Caring behaviors defined through QCM caring factors were mutual problem solving, attentive reassurance, human respect, encouraging manner, appreciation of unique meaning, facilitating a healing environment, basic human needs, and affiliation needs.7 The American Nurses Credentialing Center's Magnet Recognition Program® provided guidance in defining staff nurses and nurse managers. A staff nurse was defined as an RN who provides direct patient care for at least 50% of his or her shift.10 A nurse manager was defined as having 24/7 responsibility over a department(s) where patient care is delivered by RNs.10 Once the inclusion criteria were established, the authors reviewed the published literature for article selection.
The database search produced 3029 results, and there were 27 additional records identified through hand searching. The initial selection step consisted of reviewing all titles of the 3056 publications for relevancy. After screening all the publication titles and abstracts, 3026 records were eliminated. There were 30 articles retained for the next step of full-text review. All selected publications were reviewed by the 1st and 2nd authors. Articles in question of meeting the inclusion criteria were collaboratively discussed by the authors, and consensus was reached. After full-text review, 9 publications were eliminated. A sample of 21 publications were eligible for the next phase of Arksey and O′Malley's methodology, charting the data. While charting the data, 8 additional articles were excluded. These 8 articles were focused on leadership styles,11-13 nonnursing leadership practice,14-16 or chief nurse executive perspective17 or were not focused on nurse manager caring.18 The authors discussed the articles that focused on leadership styles and decided to exclude these to maintain the focus on caring behaviors of nurse managers. The final sample for the scoping study was 13. The flow of article selection is demonstrated in Figure 1.
Charting the Data
The framework stage of Arksey and O′Malley's9 scoping study process is charting the data. A data charting form was developed in the database program Excel. The information recorded in the chart was author(s), study location, intervention, population, aim, methodology, outcome measures, and results. The articles were organized alphabetically by the 1st author. Study locations included country and setting (if provided in the article). The study population was consistently staff nurses (1 of the study inclusion criteria). The charting process allowed the authors to ensure inclusion criteria were consistently followed and provided more rigorous review of the articles. The final accepted charted sample is captured in Supplemental Digital Content 1 (available at http://links.lww.com/JONA/A756).
The final phase of Arksey and O′Malley's9 framework is collating, summarizing, and reporting the results. This phase provided an overall review of the accepted material. We organized the 1st section of the results through numeric analysis, which provides an overview of the quantity of publications in various categories. The 2nd section of the results is presented using a themed analysis approach organized by caring behaviors.
The 1st part of the results summary focuses on a numeric analysis of the findings. The final sample varied in geographic location, outcome measures, and methodologies. The geographic locations of the published evidence varied among the following 7 countries: United States,19-24 Finland,25,26 Scotland,27 Italy,28 China,29 Norway,30 and Canada.31 There were several different outcome measures used in the literature. To stay consistent with our purpose, we chose to focus on the outcome measures relevant to caring behaviors. There were 8 publications that used interview questions for the outcome measure,19,20,22,26,28-31 1 used the Appreciative Management Scale,25 2 used the Caring Factor Survey-Caring of Manager Scale (CFS-CM),21,23 1 used the Caring Nurse-Patient Interaction Short Scale,31 1 used the Multi-factor Leadership Questionnaire,28 1 used a program evaluation,27 and 1 used factor analysis for psychometric testing.24 Different methodologies were found in the literature. There was a mix of both qualitative and quantitative designs published. Six of the publications used a form of qualitative methodology.19,20,22,26,29,30 Qualitative designs included phenomenology,19,29 descriptive,20,22,30 and narrative.26 Five publications used quantitative methodology.21,23-25,27 From the 5 quantitative publications, 2 used a correlational design,21,23 1 used a cross-sectional design,25 1 was a program evaluation,27 and 1 used psychometric analysis.24 The final 2 publications were mixed methods.28,31 One used a correlational design and focus groups,28 and the other used a cross-sectional survey design with a single case study.31 Overall, there were no dominant methodologies or outcome measures.
In the 2nd part of the results summary, we organized the data thematically according to caring factors and relevant leadership behaviors as defined by the QCM.7 Caring behaviors included in the QCM are mutual problem solving, attentive reassurance, human respect, encouraging manner, appreciation of unique meanings, healing environment, basic human needs, and affiliation needs.32 All of these behaviors were reflected in the literature and are summarized in Table 1. There were 3 publications that captured all caring factors because of the instrument used.21,23,24 Bolima21 used the CFS-CM, a tool developed based on Watson's caritas process and concluded that a positive relationship existed between caring leaders and job satisfaction. Olender23 also used the CFS-CM to conclude that there was an inverse relationship between staff nurses' perception of nurse manager caring and exposure to workplace bullying. Finally, guided by the QCM, Wolverton24 completed psychometric testing on the Caring Assessment Tool–Administration, which resulted in a 25-item survey measuring staff nurses' perceptions of nurse manager caring behaviors (Cronbach's α = 0.98). The remainder of the publications were reviewed by individual caring behavior.
Mutual Problem Solving
Mutual problem solving is a leader behavior that demonstrates and facilitates decision making and includes behaviors such as brainstorming, soliciting feedback, providing information, education, engaging staff, clarifying and validating, and practice improvement.32 There were various examples of these behaviors in the literature. Staff nurses reported a continuation of learning after participating in a leadership program.27 Mutual problem solving was described as participating in decision making,30 listening,28 and sharing updated information and new ideas.29
Attentive reassurance is when a leader is physically present and has an optimistic outlook.32 This caring factor was present in most of the publications. Attentive reassurance was found in the literature as recognizing staff nurses,20,22,25,28 debriefing after a patient death,19 being attentive,30 ability to discuss issues related to nursing with the staff nurses,26 and overall visibility.22,31
Human respect demonstrates value for the person as an employee, a health professional, and a stakeholder.32 Duffy32 provides examples of leadership behaviors that demonstrate human respect such as calling employees by name, making eye contact, discussing appropriate personal issues, and sharing with employees that they are worthy and valuable to the organization. This caring factor was present in the literature by nurse managers supporting staff nurses after a patient death,19 having more respectful conversations after a leadership program,27 being fair,22,28 and having an ethical value basis.26
Demonstrating an encouraging manner leads to staff nurse empowerment and risk-taking.32 These behaviors are present when nurse managers are enthusiastic, provide support and training, and exhibit verbal and nonverbal communication skills.32 We found these behaviors present in the literature when nurse managers supported staff nurses after a patient death,19 had consistent communication,22,30 were supportive of staff,22 acted as a staff advocate,28 and participated in more compassionate and respectful conversations after participation in a leadership program.27
Appreciation of Unique Meanings
Leaders can exhibit the caring factor, appreciation of unique meanings, by recognizing differences in culture as well as past and current experiences.32 This caring factor is present in the literature when leaders support staff nurses and their coping mechanisms after a patient death.19 Appreciation of unique meaning was also described in the literature through the nurse manager catering to what is meaningful to the nurses.30
Facilitating a Healing Environment
Facilitating a healing environment involves respecting staff nurse privacy and confidentiality, creating a culture of caring, fostering teamwork, designing a manageable workflow, and providing a safe environment.32 Duffy32 notes that this caring factor may be the most important influencer of staff nurse job satisfaction and patient outcomes. This caring factor is present in the literature as evidenced by the following: nurse leaders having debriefs after a patient death,19 making sure staff get meal breaks,22 staffing support,22 staff nurses feeling safe to speak,22 supporting staff to alleviate suffering,26 team development,28 and flexible work arrangements.29
Basic Human Needs
In addition to being present in all caring factors, basic human needs are described as recognizing higher level needs for group activities and self-esteem.32 All the publications reviewed focused on the personal physical and/or emotional health of staff nurses. Therefore, we believe that all the published evidence reviewed in the sample encompassed basic human needs.
The final caring factor is affiliation needs and is described as being responsive to belonging needs.32 Affiliation needs is also demonstrated by including others in celebrations and work initiatives.32 Examples of this caring factor were not as dominant in the literature. Work-life balance22,29 and personal and team development28 were the only behaviors that represented affiliation needs in the study sample.
Discussion and Conclusion
This scoping study identified published literature regarding staff nurses' perceptions of nurse manager caring behaviors. The current literature provides descriptive evidence on what staff nurses perceive as caring behaviors from a nurse manager. In the past 10 years, there is evidence that examined the relationship between nurse manager caring behaviors and nurse job satisfaction,21,22 nurse retention,21,30 workplace bullying,23 organizational climate,31 and work environment.30 The evidence clearly supports a positive relationship between nurse manager caring behaviors and the positive impact caring behaviors have on nurses and their work environment. However, there is a stark absence of how these behaviors translate from staff nurses to their care of patients. Further research is needed to understand these relationships, especially the relationships between nurse manager caring behaviors and patient outcomes.
Implications for Nurse Leaders
Nurse leaders should use this evidence to identify and incorporate caring behaviors in their practice so that staff nurses feel cared for. Understanding caring behaviors can also be used for leadership development and education. Over time and with practice, nurse managers demonstrating caring behaviors build relationships that result in staff nurses feeling cared for.7,32
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