Nurse managers are integral members of any healthcare team, impacting clinical, administrative, quality, and financial outcomes. Nurses who've transitioned into a manager role often oversee one or more clinical units; supervise nursing and ancillary staff; and are responsible for unit budget, staffing, quality metrics, and implementation of organizational initiatives. Due to the demands of the job, turnover among nurse managers can be high, resulting in substantial costs to the organization. Reported levels of job satisfaction, particularly among nurse managers, may be poor and can be influenced by personal and structural factors.1 Nurse manager orientation and mentoring are potential strategies to decrease turnover and improve retention. However, these strategies are often only offered to novice managers, and programs aren't structured around core competencies outlined by the American Organization for Nursing Leadership (AONL), formerly the American Organization of Nurse Executives.2
To meet the complex needs of nurse managers at various stages in their careers and ensure knowledge of AONL core competencies, an intensive 2-day training seminar was developed for all nurse managers within a large urban, academic healthcare system. Seminar components were based on AONL core competencies, including basic knowledge of the surrounding healthcare environment, communication and relationship management, professional competencies, leadership, and business skills and principles. (See Table 1.) The purpose of this study was to evaluate the effectiveness and sustained impact of this training seminar on nurse manager satisfaction and perceived importance of competencies before and at 6 and 12 months after participation.
Nurses in management roles aim to provide seamless cohesion between ensuring high-quality clinical care and compliance with organizational initiatives and regulatory standards. Strong nurse managers play an essential role in staff empowerment and satisfaction, as well as improving patient outcomes and quality nursing care.3 Unfortunately, many nurse managers report moderate stress levels, often related to heavy workloads, inadequate resources, and role ambiguity, leading to decreased job satisfaction and higher levels of burnout.4,5 Ensuring job satisfaction within this cohort can be challenging due to daily demands and responsibilities, particularly during times of change. The nursing profession is also continuing to see an increase in experienced nurse managers nearing retirement age, accompanied by an increase in nurse manager intention to leave and turnover rates.6,7 In addition, fewer nurses are choosing to attend graduate school with a focus on nursing leadership, which, in turn, may produce a serious void in leadership.6 To strengthen nurse managers, healthcare organizations must dedicate time and money to train these leaders and enhance critical skills essential to nursing management. Research indicates that nurse manager satisfaction and competence can be influenced by the extent of organizational change and support, job characteristics, managerial roles, and educational development.8,9
Nurse managers often enter their roles with varying clinical backgrounds and experience levels. Even for the most experienced nurse managers, role expectations and spans of control are changing with the continuously evolving healthcare environment. Establishing a nurse manager network focused on evidence-based practice (EBP) and research can improve the competency of nurse mangers at all experience levels; however, there's a lack of research to support the impact of nurse manager competency training on generalized leadership skills and job satisfaction.10 Interventions aimed at providing managers with the tools they need to effectively navigate their responsibilities may improve satisfaction and competence, which can positively impact retention and hospital costs.
This project was reviewed and approved by the Institutional Review Board as a not-greater-than-minimal-risk study. An observational, prospective cohort design was used. The project took place between 2016 and 2017 within an urban, academic, public healthcare system that includes a medical center, two satellite hospitals, and over 20 ambulatory locations. The sample included 45 nurse managers and assistant nurse managers working within inpatient and ambulatory care areas during a 12-month period. There were no exclusion criteria.
All nurse managers and assistant managers within the healthcare system were invited to voluntarily participate in the 2-day training session. Managers and assistants who registered and attended at least one session received an email link to voluntarily complete anonymous surveys before the session and again at 6 and 12 months after the training. The 2-day program was designed around the results of an internal leader needs assessment, which was built on AONL's nurse manager core competencies and provided insight into the self-perceived needs of nurse managers.2 Program planning, format, and logistics were led by the director of nursing education and professional practice, who also facilitated the process for providing contact hours for program attendees. Internal content experts were identified and invited to present based on nurse manager needs documented through the assessment.
The initial session covered eight topics pertaining to nursing leadership, including importance and relevance to practice, as well as implications specific to organizational policies and procedures: performance appraisal, accountable care organizations, research and EBP, performance improvement, generational differences, mentoring and succession planning, productivity and analytics, and finance. The second session was presented in the same format and covered six topics: effective interviewing, talent recognition and management, crucial conversations and feedback, conflict resolution, corrective action, and malpractice. The content of the combined 2-day session directly aligned with 17 of the 53 components of the Chase Nurse Manager Competency Instrument (CNMCI), including patient acuity systems, research and EBP, effective communication, effective staffing strategies, recruitment strategies, retention strategies, effective discipline, constructive performance evaluation, staff development strategies, interviewing techniques, quality/process improvement, legal issues, conflict resolution, research process, productivity measurements, unit budget control measures, and financial resource monitoring.11
Study surveys included collection of participants' demographic data, such as nurse manager role (manager or assistant manager), age, ethnicity, gender, total years of experience, years of experience as a manager, clinical area, certification, number of full-time equivalents (FTEs) covered, and attendance at one or both training sessions.
Manager satisfaction was obtained by administration of the McCloskey/Mueller Satisfaction Scale (MMSS) before leadership training and at 6 months and 12 months after the training.12 The MMSS is a 31-item tool composed of eight subscales: satisfaction with extrinsic rewards, scheduling, family/work balance, coworkers, interaction opportunities, professional opportunities, praise and recognition, and control and responsibility. The tool has strong reliability coefficients (0.89 to 0.90), and construct validity has been established.13,14 Responses for each item are via a 5-point Likert scale, ranging from 1 (very dissatisfied) to 5 (very satisfied). A modified version of the tool was used in which the scheduling subscale (items 5 to 10) was removed because these items weren't applicable to managerial staff.
Nurse manager perceptions of the importance of knowledge and competency items were evaluated by the CNMCI.11 This 53-item tool is based on the essential nurse manager competencies outlined by the AONL.2 Domains include knowledge of the healthcare environment, communication and relationship management, professional competencies, leadership, and business skills and principles. The tool has established content validity and demonstrated acceptable reliability estimates ranging from 0.75 to 0.95. Respondents were asked to indicate their perceived importance of possessing knowledge of each competency component and being able to actively perform that competency within their daily practice by completing the CNMCI before the leadership training and at 6 and 12 months after the training.
All data were anonymous and entered into a database for analysis with statistical software. Descriptive statistics, including mean, frequencies, and standard deviations (SD), were calculated to describe the study sample and report aggregate survey scores at each time point. Analysis of variance was performed to determine if differences in scores at each timepoint were statistically significant.
Of the 45 participants who attended the training, 33 returned completed surveys. A summary of the demographic characteristics is provided in Table 2. The majority of participants were nurse managers (n = 29, 87.9%), with only 4 (12.1%) being assistant nurse managers. Most had professional certification (n = 26, 78.8%) and were in a management position an average of 8 years (range, 1 to 30; SD, 8.92).
Mean satisfaction scores for priority items over time are displayed in Figure 1. Overall scores varied across measures and timepoints, and there weren't stable trended increases or decreases in scores. The largest gains in trended scores over time were seen in satisfaction with physician colleagues and opportunities for participation on committees. There were statistically significant differences in satisfaction scores over time for relationships with physicians (P <.05). Mean scores for this item significantly increased from baseline to 6 months, but then returned to baseline at 12 months.
Regarding the perceived importance of the 17 competency items addressed in the training, there were persistent variations in scores from baseline to 12 months postseminar for most items. However, trended data indicate the largest increases in scores from baseline to 12 months for importance of competency knowledge related to staffing (mean = 3.81, 4.0), discipline (mean = 3.58, 3.87), interviewing (mean = 3.39, 3.87), performance improvement (mean = 3.59, 3.75), and research/EBP (mean = 3.45, 3.38). (See Figure 2.) Consistent and steady gains were seen in trended data from baseline, 6 months, and 12 months for importance of competencies related to communication (2.94, 3.00, 3.13), recruitment (3.39, 3.43, 3.62), retention (3.48, 3.62, 3.75), interviewing (3.39, 3.52, 3.87), and performance improvement knowledge (3.59, 3.57, 3.75). Because the increases displayed in trended data were modest, none reached the level of statistical significance. Although gains weren't statistically significant, the sustained increase in trended data for some items suggests increased importance of knowledge competency for specific program components over time.
The changes in perceived importance of competency abilities as measured by the CNMCI are displayed in Figure 3. Although the largest gains were seen for importance in competency abilities related to interviewing techniques, productivity, budget, and financial management, many scores peaked at 6 months and returned to baseline after 12 months. Steady gains in perceived importance of competency ability from baseline, 6 months, and 12 months were seen for recruitment (mean = 3.26, 3.30, 3.38), interviewing (mean = 3.35, 3.45, 3.75), performance improvement (mean = 3.31, 3.41, 3.50), and research/EBP (mean = 2.70, 2.86, 2.88).
Findings suggest that nursing management training can be an effective tool for exposing managers at various experience levels to core competencies outlined by the AONL.2 Although this study didn't evaluate actual competency levels of managers participating in the training, it does provide important information about the effect of training on manager satisfaction, as well as how training impacts manager perceptions regarding the importance of these competencies over different timepoints. Standardizing specific core competencies for nurse managers is an important first step toward ensuring that they're equipped with both the knowledge and ability to perform key aspects of their role in our current healthcare systems. Identifying the degree to which managers within an organization perceive the need for these competencies can contribute valuable insight to guide ongoing professional development and learning to foster manager satisfaction and retention over time.
In our study, the largest gains in satisfaction over time were seen in nurse manager satisfaction with physician colleagues and opportunities for participation on hospital committees. Although these factors may not have been specifically addressed in the training seminar, the results highlight the importance of the interdisciplinary work of managers and how continued exposure and competence with this type of work may positively impact satisfaction. Other studies investigating nurse manager satisfaction have reported power—defined as the ability to make or influence change—as being positively and significantly correlated to job satisfaction, along with the ability to have control over the work environment and participate in decision-making.15,16 Specific aspects of power that impact manager satisfaction are organizational support and the ability to contribute to organizational decisions affecting the care area.16 Transparency surrounding decisions that affect nursing may also increase nurse manager job satisfaction.1 Overall, the management training in our study didn't significantly impact manager satisfaction rates over a 1-year period. This suggests that there are likely a multitude of factors that impact manager satisfaction, and participation in training may not be a sole intervention.
Our findings also point to the importance of knowledge and ability competencies from the perspective of the nurse manager, regardless of years of experience. Many of the competency items included in the training seminar aren't formally addressed during nurse manager orientation programs or have never been outlined for experienced managers. Providing nurse managers at all experience levels with this information about core competencies serves to increase their perceived importance of specific knowledge and abilities over time. Although these increases may be slight and not substantial enough to reach statistical significance, they do suggest that there's value in exposing managers to expected core competencies. This exposure stimulates important discussions for managers and can highlight key areas for additional education and training based on their years of experience and current level of competency. Tailored educational strategies for ongoing professional development of managers are important supplements to initial training.
A study by Chase in 1994 and repeated in 2010 indicates that nurse manager perceptions of important competencies may change over time.11,17 The highest ratings in both studies using different cohorts were for competency knowledge in effective communication. However, the next highest ratings were for competency knowledge related to effective discipline, decision-making, retention, problem-solving, conflict resolution, and performance evaluations, with ratings for each vacillating in importance between cohorts.
The highest ratings in our study for knowledge competence over time were for staffing, interviewing, performance management, and conflict management. Similarly, when examining similarities for the highest ratings in ability competencies, the Chase studies reported communication, retention, decision-making, staffing, and conflict resolution.11,17 In our study, the highest competency ability ratings were reported for staffing, interviewing, productivity, and conflict resolution. Thus, the importance of both knowledge and ability surrounding the AONL competencies may vary over time and among cohorts. Future research should investigate the impact of nurse manager years of experience on perceived importance of competencies to identify if core components are needed at critical junctures during tenure as a manager.
Additional studies on the importance of specific nurse manager competencies have focused on the perspectives of nurse executives and clinical nurses. Among nurse executives, competencies centering on finance, analytical thinking, and strategic planning were ranked higher than unit-based competencies identified by managers.18-21 In our study, ranking of competency abilities, including productivity, budgets, and financial management, peaked at 6 months for managers, yet returned to baseline ranking or slightly above baseline at 12 months. This finding suggests that managers may have placed increased importance on these abilities after the training but may not have routinely utilized these competencies after training, so overall ranking decreased over time. This highlights the importance of continued professional development for managers in key competency areas to stimulate learning, application of content, and increased value in routine practice.
As with any study, there were limitations to this work. The single site design limits generalizability to wider audiences; there may be substantial variations in the manager role and views on competencies across healthcare systems. Our study didn't evaluate actual competencies of managers; rather, the focus was on how important managers perceived specific competencies to be in their practice over time. Although this didn't allow for examining the impact of training on actual competence, it does contribute important information from the perspective of managers after being exposed to the AONL competencies. In addition, there are many other factors that may impact nurse managers' perceptions; therefore, caution is advised in the definitive conclusion of a causal relationship between intensive training and nurse manager perceived importance of competencies.
Preparation across the career span
Integration of standardized competencies for nurse managers is a critical step in recognizing the complex responsibilities inherent in their role. Managers at all experience levels, not just those in orientation, may benefit from learning about core competencies. In a rapidly changing healthcare environment, evaluation of managers' perceptions of the importance of competency areas over time may highlight gaps that can be addressed by ongoing education and professional development opportunities throughout the span of their career.
Providing managers with the opportunity to participate in multimodal learning can lead to an increase in the perceived importance of core professional competencies and engage them in honing their own competency. However, it's important to offer ongoing learning opportunities to ensure that competencies are further developed over time. This understanding and engagement, coupled with continuous education, can strengthen nurse leaders who play a crucial role in the delivery of quality healthcare.
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