MANAGERS AND FRONTLINE LEADERS (FLs) are the lynchpin and the direct connection between senior leadership and direct care staff. They exert substantial influence in the work environment with tangible effects on safety and quality measures, patient and employee experience, and the job satisfaction and retention of one of the key resources in the organization—human capital.1,2 Nurse managers help organizations operationalize strategy related to quality care and promote practice environments that cultivate professional autonomy and interprofessional collaboration.1
In 2019, the National Academies of Sciences, Engineering, and Medicine (NAS) called for immediate action for health care systems across the nation and other key stakeholders to address clinician burnout.3 The NAS highlighted the need for transformative and sweeping changes and recognizes the complexity of burnout. Burnout is the result of sustained exposure to multiple competing factors producing imbalances in the ability of a clinician to appropriately respond to demand versus their perceived capacity and the availability of resources.3,4 The cumulative environment stressor then leads to feelings of cynicism, loss of sense of personal achievement, depersonalization, and emotional exhaustion.4 The advent of COVID-19 and its continued presence without a clear outlook on the pandemic's end has led to an exacerbation of burnout in health care workers and nurse leaders.4,5
THE BUSINESS CASE
The year 2022 saw the highest percentage of RN turnover at 27.1% in the past 5 years.6 This is compounded by current reports that nurse leaders identify burnout and emotional health as key concerns in their work environments.5 Additionally, in the most recent longitudinal study by the American Organization for Nursling Leadership, 25% of nurse leaders self-identified as not being emotionally healthy with 20% expressing intent to leave.5 This is a concern because the average cost to replace nurse managers is anywhere from 75% to 125% of their annual salary.7 Other studies quantify the monetary value of turnover from $132 000 to $228 000 or more if the search for the leader's replacement takes longer.8 The Table quantifies the average cost of turnover for frontline nurse managers based on a management team of 10 with a 20% intent to leave and an average salary of $113 084.5,9 The cost only accounts for the replacement of the nurse manager position and does not measure the overall effect of leadership turnover to organizations in terms of quality outcomes, patient/staff experience, and productivity due to vacancies and onboarding activities. It is assumed that nurse manager turnover has a negative effect on all these indicators thus incurring increased cost to an organization.2 Left unchecked and unaddressed, nurse leader burnout and turnover can have a detrimental effect on an organization's ability to provide safe care and be competitive in a market with a high emphasis on value-based care models.
Hypothetical Costing of Nurse Manager Turnover Over 1 Year
|Number Managers in a Team
||Percentage of Intent to Leave5
||Projected Turnover (FTE)
||Cost of Turnover at 75% Based on Projected Turnover
||Cost of Turnover at 125% Based on Projected Turnover
Abbreviation: FTE, full-time equivalent.
BEST PRACTICES FROM NURSE EXECUTIVES
Nurse executives from Advocate Aurora Health, Duke University Health System, Cedars-Sinai Marina Del Rey Hospital, Hackensack Meridian Health, Integris Health, Memorial Hermann Health System, and Providence provided exemplars to share in this column. The best practices identified are not exhaustive nor are they all inclusive but rather a sampling of how nurse leaders can help support and promote well-being among their teams.
The increasing complexity of health care systems over time has also led to an equal, if not greater demand, on FLs' time, attention, effort, and energy.10–14 Almost universally, nurse leaders interviewed for this column identified the need to address workload and span of control as a top priority to help address burnout and increase job satisfaction. Health systems across the nation either have implemented or have plans in place to implement some form of leader flexibility in work hours and schedules.
Renewal days where leaders can focus on well-being and self-care by allowing them to work 1 less day per pay period or leave early on a Friday to address personal needs have received positive responses from managers according to Leah Blackwell, Monica Cfarku, Joanne Laguna-Kennedy, Jacki Lockett, Mary Roesch, and Heather Veltre (email communication, August 2022). Leah Blackwell, Chief Nursing Officer from Memorial Hermann Health System, further expounded on their flexible schedule strategy (email communication, August 2022). According to Ms Blackwell, it is important to “normalize work-life harmony by truly making flexible scheduling strategy as guilt free.” Leaders can flex each pay period (every 2 weeks) between the following options to work a traditional 40-hour week:
- One work from home day for the pay period,
- Work longer days and leave at noon on Fridays, or
- 9/80 work schedule: work 80 hours over 9 days and take the 10th day as an off day.
This form of flexibility allows leaders the freedom of choice based on their needs. They work with their supervisors to balance operational demands while giving them the opportunity to also tend to their personal needs.
Span of control
Manager job strain related to expansive and unrealistic spans of control is significantly related to burnout.10,11 Dr Julie Hilsenbeck, Regional Chief Nursing Officer for Providence Health System in Southern California, described a collaborative project in 2019 by nursing and human resources to develop a standardized and consistent approach to assessing appropriate span of control (email communication, July 2019). Each department was classified into an archetype and given a maximum span of control with most nursing departments not to exceed 65 full-time equivalents (FTEs). Adjustments were made based on patient acuity and demographics, oversight of multiple department or roles, and for smaller departments ensuring that they have at least 0.25 FTE management coverage. Other health systems such as Hackensack Meridian Health have embarked on intentional assessment of nurse manager spans of control by taking into consideration FTEs as a primary measure but also accounting for number of cost centers, hours of operation for the department, and expenses/patient load. According to Micki Patrick, Director of Nursing for Network Clinical Education, larger spans of control can diminish efficiency and effectiveness and the work on standardization provided an opportunity for harmonization of nursing leadership models across the network (email communication, April 2022).
Well-being resources and programs
Promoting programs that help support team building, professional development, physical health, and psychological health are key to improving job satisfaction for leaders.12–15 Mary Roesch, Chief Nursing Officer from Advocate Good Samaritan Hospital in Illinois, shared that Advocate Aurora Health System (AAHS) has extensive support for wellness and has recently hired a leader to specifically address nurse well-being (email communication, August 2022). Some hospitals within AAHS have an integrative medicine department and offer free massages several times a year with reduced rates for the rest of the year. Joanne Kennedy-Laguna, Chief Operating Officer for Cedars-Sinai Marina Del Rey Hospital in California, also shared that they created meditation rooms with massage chairs, calming music, and lighting to help promote a calming work area and provide a space for leaders seeking respite from the daily demands of their roles (email communication, August 2022).
Memorial Hermann and Providence Saint John's Health Center (PSJHC) used massages and personal fitness programs to help promote well-being in health care workers and FLs. At PSJHC, the philanthropic foundation provided financial support to offer free massages monthly to caregivers to help address workplace burnout. Additionally, PSJHC started a free 30-day nutrition and fitness program led by a certified dietician specializing on sports nutrition. The first cohort in 2021 focused entirely on frontline nurse leaders with subsequent cohorts expanding to all health care workers in the hospital. The nutrition and fitness challenge is conducted every 4 to 6 months with enrollees grouped into cohorts. Participants receive daily reminders, group support on nutrition and fitness over a 30-day period, and a body fat/muscle analysis at the beginning and at the conclusion of the program to help track their progress. A pilot research study was completed to assess the effectiveness of this intervention with data analysis pending. Anecdotally, participants of the program provided positive comments regarding their involvement.
Mental health and community support
Health systems are employing the use of app-based meditation/mindfulness tools to help leaders navigate through the day-to-day stressors that they may experience at work or at home. Applications such as Headspace or Calm provide a self-paced platform that enables users on-demand access to meditation and mindfulness tools online or through their smartphone devices. Most health systems also have employee assistance programs or mental health support programs. Leah Blackwell, Mary Roesch, and Joanne Laguna-Kennedy highlighted the need to communicate these resources to leaders, as most may not be aware of their existence or how to access/activate such services (email communication, August 2022). Like other institutions, at Providence, leaders and frontline caregivers can initiate consultations with licensed counselors to provide onsite support for critical incident stress debriefings, 1:1 counseling session, or group support for cumulative stress debriefings.
Other programs aimed to provide work-life harmony for leaders include support for discounted day care services or using social media private groups to help facilitate and coordinate childcare resources/needs for leaders (Leah Blackwell and Joanne Laguna Kennedy, email communication, August 2022). Additionally, senior leadership team members from Memorial Hermann Katy provide family meals to leaders to take home during strenuous times. Leaders can pick up a family-pack meal from 1 of 4 local restaurants. Leaders also receive a signed card from the senior leadership team thanking their family for the sacrifices they make in supporting their loved ones (email communication, August 2022).
Leadership and career development programs
Strong organizational support for leadership development and recognition programs lead to improve satisfaction and retention among nurse leaders.10,12,13,16 All health systems interviewed for this column either have an internal leadership development program and/or support high-performing leaders from their teams to participate in professional organizations and established leadership fellowship programs. Universally, participation in such programs over a period reengages the leader into the organization. Most must complete a quality improvement project that improves their visibility within the organization and helps them further hone their leadership skills. More importantly, such projects often contribute to the advancement of strategic priorities within the hospital, as participants are asked to work on a current problem or resolve a barrier to achieving an organization's quality goal.
Leah Blackwell shared that her team at Memorial Hermann engaged in an exercise in building an agile team by inviting an executive coach and an external consultant to collaborate with leaders in understanding their leadership strengths (email communication, August 2022). Additionally, they have regular meetings wherein they incorporate leadership microlearning activities to help support leaders in tackling the challenges that they face in their work environments. Finally, they host a biweekly book club co-led and facilitated by a nurse manager and nurse educator where they present a chapter of the book to the group, provide one key takeaway, a chapter summary, and engage the team in sharing learnings they may have through discussion.
At PSJHC, all nurse leaders who are new to leadership are required to complete the American Association of Critical-Care Nurses Essentials of Nurse Manager Orientation (ENMO) program. ENMO has didactic, skills, and precepted time built within the program and prepares new leaders to assume their new roles. Like Memorial Hermann, education sessions are planned throughout the year and are targeted to help support the team in their leadership development. Furthermore, based on assessment and performance, high-potential and high-performing leaders are supported to apply to formal leadership fellowship programs delivered by either the health system or professional organizations. Finally, all leaders are enrolled in the Healthy Workforce Academy (HWA) through the Healthy Workforce Institute (HWI), a yearlong online program and community that helps support leaders in building healthy work environments. The HWA provides leaders the tools to begin to address incivility and bullying in the workplace. This is important because in a recent international study, toxic work environment was named as the biggest driver of negative workplace outcomes—burnout and intent to leave.17 Additionally, the same study reported that employees are 6.3 times more likely to express intent to leave and 60% of highly engaged employees also report intent to leave when subjected to a toxic work environment.
Nurse managers and FLs have a direct impact on quality outcomes, experience of care, retention, and job satisfaction of staff. All these items have major implications on the ability of an organization to respond to the emerging demands of our current and future health care delivery systems. Burnout and the COVID-19 pandemic have negatively impacted FLs' job satisfaction and intent to stay in an organization. Because there is no one solution that will address the problem, nurse executives must employ a systems approach to address burnout and the intent to stay in FLs. Access to resources, culture, settings, and readiness for change varies per organization. The nurse executive's understanding of their current state and assessment for the team's readiness for interventions will be key in ensuring the maximum benefits from the best practices provided. Most of the best practices presented were instituted within the past 2 years and lack the outcomes measurement data necessary to justify full-scale implementation. Ideally, measurement of leaders' intent to leave, engagement, burnout, and other quality outcomes indicators over time must be gathered to measure effectiveness. The lack of sufficient evidence to support strong recommendations for interventions was a known issue in 2019 and continues to be the case in 2022.3
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3. National Academies of Sciences, Engineering, and Medicine. Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-being
. Washington, DC: The National Academies Press; 2019. doi:10.17226/25521.
4. Gee PM, Weston MJ, Harshman T, Kelly LA. Beyond burnout and resilience: the disillusionment phase of COVID-19. AACN Adv Crit Care. 2022;33(2):134–142. doi:10.4037/aacnacc2022248.
5. American Organization for Nursing Leadership. AONL COVID-19 longitudinal study: August 2019 report. https://www.aonl.org/system/files/media/file/2021/09/AONL%20COVID-19%20Longitudinal%203%20Written%20Report.pdf
. Published August 2021. Accessed July 30, 2022.
6. NSI Nursing Solutions. 2022 NSI national healthcare retention & RN staffing report. https://www.nsinursingsolutions.com/Documents/Library/NSI_National_Health_Care_Retention_Report.pdf
. Published March 2022. Accessed July 30, 2022.
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16. Kerfoot K. The importance of recognizing nurse leaders. https://www.beckershospitalreview.com/the-importance-of-recognizing-nurse-leaders.html
. Published November 10, 2021. Accessed July 27, 2022.