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Addressing manager retention with the Pathway to Excellence® framework

McCright, Maggie MSN, RN, NE-BC; Pabico, Christine MSN, RN, NE-BC; Roux, Nikki JD, MBA, RN, CEN, NEA-BC, FACHE

doi: 10.1097/01.NUMA.0000542293.75001.38
Department: New Pathway to Excellence®

Maggie McCright is a senior Pathway to Excellence® Program analyst and Christine Pabico is the director of the Pathway to Excellence Program at the American Nurses Credentialing Center in Silver Spring, Md. Nikki Roux is the vice president and CNO at Memorial Hermann Northeast Hospital in North Humble, Tex.



Nurse managers play a significant role in creating and sustaining a positive practice environment. Yet they're met with numerous challenges, such as engaging and retaining clinical nurses, improving patient care outcomes, and managing change. For nurse managers to effectively concentrate on these and other organizational goals, retention is essential.1

A supportive practice environment is a significant predictor of nurse manager job satisfaction and intent to leave.2 The Pathway to Excellence® framework fosters a culture of engagement and empowerment, interprofessional collaboration, and staff well-being.3 Three key Pathway standards can be used to mitigate nurse manager burnout and turnover to improve retention: the leadership standard to support role competencies, the well-being standard to maintain work-life balance, and the professional development standard to encourage lifelong learning and professional practice.

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Nurse manager burnout and turnover

Aside from retirement and promotions, burnout is among the most cited reasons for nurse manager intent to leave.1 Burnout can be the result of organizational stress, an overwhelming workload, a growing span of control, personnel issues, negative professional relationships, work-life imbalance, technology overload, and lack of support from administrators and the organization.4,5

Nurse manager turnover rates are reported to be as high as 50% in some hospitals.6 In one study, it was reported that 72% of 291 nurse managers were planning to leave their positions in the next 5 years.7 The high rates of nurse manager intent to leave and turnover are resulting in more vacant positions and increasing difficulty with recruitment, leading to costs reportedly ranging from $132,000 to $228,000.8,9

This emerging trend is alarming and requires attention for several reasons. Frontline nurses from units with recent nurse manager turnover share feelings of unsteadiness, insecurity about their position, and decreased staff energy and unit morale.10 Nurse manager turnover also impacts organizational productivity and profitability.11 Staff unrest and loss of focus on strategic priorities caused by nursing leadership changes can lead to unfavorable patient, nurse, and other organizational outcomes.12 Given nurse managers' responsibility for meeting established metrics on their units, the stability they provide to the workforce is vital because most pay-for-performance measures are highly sensitive to nursing care.12

What can be done? Creating essential infrastructures that support nurse managers can help increase their satisfaction and retention. Studies on healthy work environments found that the organizational framework must include shared leadership, participatory management, relationship building, role development, evaluation of expectations, and empowerment.13 In addition, the organization must include work-life balance, growth opportunities, and support for education. One 2016 study analyzed the effect of the practice environment on nurse manager job satisfaction and intent to leave and found that career development is critical for reducing turnover.2 Coaching, empowerment, and fair and manageable workloads also impacted job satisfaction.

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Pathway to Excellence® framework

Pathway's mission is to guide the positive transformation of practice environments in multiple settings to build global community healthcare organizations committed to nursing workplace excellence.3 The program seeks to positively affect nurse retention by establishing the foundation of a healthy workplace for all nurses, including nurse leaders. The Pathway standards serve as guidelines for nurses at all levels to modify their workplace and practice environments.

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Leadership standard

The leadership standard fosters the foundation of collaboration among staff and supports a shared governance environment. The standard calls for nurse managers to continuously strive to increase their core knowledge and role competency through leadership development activities and feedback from colleagues and nursing staff. As an example, this standard requires the nurse manager to provide a narrative describing how the CNO supports him or her in resolving an issue. Another element of performance for this standard asks for a list and description of the nurse manager's leadership development activities that enhanced role competence within the past 24 months. In addition, a description of how the organization fosters leadership succession planning must be provided.

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Well-being standard

The well-being standard provides all nurses the opportunity to develop a balance between work and personal life. The criteria for this standard require organizational initiatives that promote work-life equilibrium, nursing input into the planning and evaluation of those initiatives, flexible scheduling, community involvement, and the organization's attention to assessing the wellness of its employees.

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Professional development standard

The professional development standard recognizes the importance of orientation, collaboration, and development. Applicant organizations must demonstrate that they value the importance of lifelong learning, ongoing education, and professional development activities. Key areas of support include assisting nurses at every level to attend conferences outside the organization, become members of professional nursing associations, and pursue lifelong learning opportunities or higher education. In addition, organizations must demonstrate a commitment to supporting specialty certification and learning activities that assist in the development and maintenance of continued competency, enhance professional practice, and lead to the achievement of career goals.

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How the framework impacts nurse manager retention

One example of how a Pathway-designated organization has addressed nurse manager turnover and job dissatisfaction is illustrated by Memorial Hermann Northeast hospital (MHNE), a 255-bed community hospital in a multihospital system located in the greater Houston area that was initially designated a Pathway to Excellence organization in 2012.

At MHNE, the leadership standard is evidenced by the involvement and empowerment of nurse managers in decision-making that impacts bedside care delivery. Engagement in structured forums for budget planning, staff allocation, and capital investment decisions has resulted in sustained satisfaction among nurse managers and nursing staff. Shared governance committees provide both unit-based and campus decision-making/recommendations on topics such as best practices in preventing hospital-acquired infections and the most desired approaches for reward and recognition. The CNO provides 1:1 and group forums for nurse managers to provide feedback and recommendations on campus operations and improvements. A formal leadership program prepares nurse managers for their role with classroom didactic instruction, shadowing, mentoring, and structured guidance for implementing an evidence-based project. This program is available to new and existing nurse managers, as well as up-and-coming leaders as part of a succession planning strategy. In addition, monthly in-person and electronic educational offerings focused on growth and development are provided at the campus and system level.

The well-being standard can be seen most prominently in the Partners in Caring program at MHNE. This program is multifaceted, with a variety of objectives led by interprofessional subcommittees made up of employees from all levels of the organization. The committees focus on team building; rewarding and valuing people; and creating health and well-being among teams that push past the walls of the campus, such as campus family picnics, hospital week celebrations, and holiday festivities. Relaxation rooms were designed by the nursing management team and added to a newly constructed patient care tower; healing gardens are also being planned. There's significant campus-sponsored participation in community outreach activities led by the March of Dimes, American Heart Association, and the United Way, among others. Nurse managers have taken this a step further and organized off-campus team building time each month to share ideas and get to know each other outside of the work setting. Collaboration and overall morale between leadership groups have been positively impacted.

The professional development standard is illustrated in the opportunities that MHNE has provided to nurse managers and nurses in many professional advancement areas. Tuition reimbursement and loan repayment programs have allowed many nurses to progress from LVN and ADN degree programs to BSN and MSN degrees with very little out-of-pocket cost. Certification reimbursement programs and the American Nurses Credentialing Center's Success Pays® program help nurses obtain professional certification at no cost. Formal mentoring processes as part of the retention and engagement program allow nurses at all levels of the organization to experience ongoing learning and development from more experienced professionals in the organization.

Specific metrics demonstrate MHNE's successful translation of the Pathway standards into its culture since its initial journey to Pathway designation. The BSN rate increased from less than 15% to 60%. The professional certification rate increased from less than 7% to 25%. The overall sustained nurse retention rate is 93%, and 50% of the nurse managers were promoted from frontline clinical nurse roles.

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Support and opportunities

An organization's commitment to well-being and professional opportunities for its nurses and nurse managers can result in improved outcomes in the areas of retention, engagement, and an overall culture of professionalism. Providing a positive practice environment that includes reward and recognition, shared decision-making to increase employee engagement, and support for professional development can improve job satisfaction and reduce burnout and turnover. Nurse managers have an essential role in creating and sustaining a positive practice environment. However, organizations must first provide a framework and model of engagement to foster an atmosphere that allows for work-life balance and professional development, and contributes to the ability to manage everyday stressors.

The Pathway to Excellence framework facilitates transformation of the work culture into a positive practice environment. Pathway-designated organizations validate the presence of professional development opportunities, shared governance structures, autonomy in practice, and interprofessional collaboration. Pathway standards foster the development of leaders who continually support and empower nurses to perform at their highest capacity. Moreover, the well-being standard encourages organizations to promote a balance between its employees' work and personal lives. Offering supports and opportunities like these can raise job satisfaction and enhance nurse managers' willingness to stay in the organization.

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