At a time when burnout, incivility, turnover, and staff shortages are of top concern in the nursing profession, it's important to consider strategies to recruit and retain qualified nurses in acute care inpatient hospital settings. Employees with higher levels of engagement report decreased feelings of burnout and increased job satisfaction.1 Engagement is defined as “a positive, fulfilling, and work-related state of mind that's characterized by vigor, dedication, and absorption.”2
This article describes a review of the current literature to examine strategies nurse leaders can utilize to promote work engagement among frontline nursing staff in inpatient hospital settings. Common themes included ensuring shared values, practicing authentic and transformational leadership, pursuing higher formal education, and providing access to resources. Strategies for nurse leaders included accessibility, open communication, and taking personal interest in staff.
In inpatient settings, nurse leaders are accountable for staff on a 24-hour basis despite the impossibility of being present at all times.3 It's essential to avoid defaulting to top-down management strategies. However, modern healthcare has increased the emphasis on documentation, standardization, and cost-controlling measures, which can generate conflict between nurses and nurse leaders and produce feelings of being a cog in a machine.4 These new organizational values can create conflicting priorities with nursing's traditional humanistic values, which can lead to costly results for healthcare organizations, such as ethical conflict; moral distress; and withdrawal behaviors like lateness, absenteeism, and reduced work effort.5
Nurse leaders have the ability and the responsibility to influence practice environments that promote staff engagement. Work engagement is contagious, and engaged employees go beyond self-interest and are better able to cope with the demands of their job.1 This leads to improved organizational outcomes, such as staff retention, service quality, customer loyalty, decreased mortality, and improved finances.1,6,7 Engaged employees go above their individual job performance and required responsibilities to voluntarily take the lead and benefit the organization.8
The literature used for this review consisted of 11 studies, published between 2015 and 2018 in professional journals, that contained research data conducted in acute care inpatient hospital settings. Studies set outside inpatient areas or incorporating highly specialized patient populations were excluded. The following search terms were used: nurse, nurses, engagement, nurse leaders, and hospitals. The studies were conducted in various countries, including the US, Canada, Denmark, South Korea, and Saudi Arabia. Each article was read in full to discover common themes.
Six studies cited nursing shortages in their respective countries, suggesting retention of engaged nursing staff was a challenge globally. Nurse manager burnout and turnover also contributed to nursing shortages.3 Leaders who created empowering and engaging work environments were more likely to retain qualified and experienced nurses.7
Four major themes emerged from the literature review: ensuring shared values, practicing transformational and authentic leadership, pursuing higher education and competencies, and providing access to resources. (See Literature review findings.)
Ensuring shared values. Being able to find meaningful work and having the ability to express one's values are at the center of work engagement.4 This concept appeared in some way in each article reviewed. Lim and colleagues refer to it as value congruence—an affinity of values pursued by the leader and employees.8 Effective communication and the ability to link nurses' work to the organizational mission, vision, and values promote engagement.6 Healthcare workers often enter their field of work because they find the work meaningful, and being able to connect one's work to self-held values creates meaning.
Nurses are more engaged in work environments that support their own values.4 This means that nurse leaders aren't only responsible for bringing values from the boardroom to the bedside, but also from the bedside to the boardroom.9 Structural empowerment allows nurses to mobilize resources and achieve organizational goals. A structurally empowered work environment encourages frontline nurses to give input about their values, ultimately promoting engagement.7
Practicing transformational and authentic leadership. There are two predominant leadership styles in structurally empowered workplaces: transformational leadership and authentic leadership. Transformational leaders build trusting environments.5 Transformational leadership behaviors that promote nurse engagement include visibility, accessibility, and effective communication.10 Transformational leaders motivate, engage, and empower the team, especially those with higher levels of emotional intelligence.9 Of note, transformational leadership is a core characteristic of leadership in Magnet® hospitals.11
Through honesty and integrity, authentic leaders build trust, hope, and optimism among frontline staff and can reduce levels of employee cynicism.5,9 Authentic leaders are emotionally intelligent and able to practice empathy and intuition to consider diverse perspectives while moving others toward the organization's goals.9 Lim and colleagues explain that emotionally intelligent leaders build trust by recognizing emotions, taking a personal interest, and practicing empathy with frontline staff.8 Staff members who trust their leaders don't doubt the authenticity of the leaders' intentions or behaviors.8 Leaders must take the time to build credible relationships through being transparent, honest, and listening to and being present with frontline staff.9
Pursuing higher education and competencies. Nurses with advanced qualifications, including education level, have significantly higher levels of engagement. Studies find that nurse managers with a master's degree or higher and more experience are more engaged.3,10 Notably, nurse leader engagement promotes frontline nurse engagement. Further, Ducharme and colleagues emphasize the importance of nurse leader onboarding and mentoring programs to develop leadership competencies that cultivate nurturing, reflection, and education, ultimately improving team engagement.11 Competent leaders advocate for team values and produce optimal outcomes.11
Robust onboarding and mentoring programs for frontline nurses are also vital to work engagement. These programs foster a positive work environment and combat negativity in the workplace, such as with incivility. Formal and structured orientation programs encourage camaraderie and structural empowerment.12
Providing access to resources. Lack of access to resources, such as staff, materials, supplies, and information, can lead to cynicism.5,7,12 Aside from tangible resources, intangible resources include relationships, opportunity to advance, and support.7 Nurse leaders themselves are a necessary resource and must be visible and accessible.10 Nurse leaders ensure that staff members have adequate resources to provide patient care, especially in the current state of healthcare, which challenges leaders to reduce costs. Nurse leaders must advocate for the protection of resources that are significant to staff, including education assistance, shared governance, and staffing models. These items provide value in a healthy work environment and promote engagement.11 Ducharme and colleagues found that frontline nurses reported having adequate resources when their nurse leaders perceived themselves as being more influential over the professional practice environment.11 When nurses have access to information, support, resources, and opportunities, they experience structural empowerment.7
Specific strategies for nurse leaders to promote engagement in frontline nursing staff include the following:
- Being visible and accessible, including learning staff members' values and needs and advocating for them to higher-level leadership.
- Practicing open and effective communication, which allows nurse leaders to form credible and authentic relationships with frontline staff.
- Taking a personal interest in staff, which allows nurse leaders to discover what's valued by each individual and encourage him or her to reach personal goals, such as pursuing higher education.
Nurse leaders must recognize that they have the power to influence the work environment.13 They can create an environment with structural empowerment while reducing burnout, incivility, and turnover.14,15 In understanding how to increase frontline staff engagement levels, leaders must first take time to evaluate their own level of engagement. Leaders who model engagement promote engagement among their team.4
Nurse leaders must prioritize being visible and accessible. Leaders are a resource for staff, and lack of leadership contributes to a harmful environment that doesn't have adequate access to resources. Staff members appreciate when they feel comradery with their leaders and see them as “one of us.”4 Practicing open communication and taking a personal interest in staff will strengthen a leader's emotional intelligence, as well as aid in finding value congruence and understanding what necessary resources are lacking. Nurse leaders must take the time to understand what frontline staff members value. With that information, connections can be made between individual and organizational values and the work performed. Staff members are more likely to be engaged when they find their work to be meaningful.4,16
To further build emotional intelligence for both leaders and staff, organizations should provide training sessions. Nurses are constantly exposed to stressful situations that rely on interpersonal communication skills. In addition to giving nurses the tools to practice effective communication on the job, strengthened emotional intelligence can promote engagement by developing trust and improving relationships.8,15 Trust is also reinforced in environments where leaders practice authentic and transformational leadership. Therefore, nurse leaders should seek opportunities to sharpen their skills associated with these leadership styles.
The actions of authentic leaders align with personal values, which presents the leader as genuine, credible, and respectful and facilitates trusting relationships with staff.17 Authentic leadership is associated with increased levels of work engagement and job satisfaction, and these leaders are able to foster work environments that encourage shared decision-making and improved patient care.18 Nurse leaders can build authentic leadership characteristics by participating in self-reflection, seeking regular feedback, and listening to others' perspectives.17
Furthermore, nurse leaders should continue formal studies. As Conley and Prado-Inzerillo and colleagues found, nurse leaders with advanced degrees have higher levels of engagement.3,10 In addition, pursuing education sets a positive example for frontline staff. Leaders should encourage staff members to continue their own studies and utilize resources, such as scholarships or education assistance, if available.
In addition to formal studies, nurse leaders should seek a mentor if they don't already have one and consider developing a unit-based mentoring program for staff. Mentoring at the frontline level allows for emotional exchanges, a central component of building emotional intelligence.8 A mentoring relationship with a strong rapport can reduce stress, promote professional development, and enhance professional socialization, all of which contribute to job satisfaction and retention. Nurse managers or organizational programs may identify prospective mentors and mentees, but it's ultimately the responsibility of the mentor and mentee to develop rapport through shared decision-making and collaboration.19,20
This review was limited to acute care inpatient hospital settings. Therefore, additional strategies to promote nurse work engagement may have been found if the search criteria were widened. Further research should be conducted to examine how implementing these strategies affects work engagement over time. Longitudinal studies may show if work engagement levels are elastic and which strategies to promote engagement are most effective.
Work engagement is key
Nurse leaders play a critical role in promoting nurse work engagement. Not only should frontline nurses be engaged, but nurse leaders must also be engaged in their own work. Strategies for nurse leaders include being available and accessible to nursing staff, practicing open communication, and taking a personal interest in staff. Nurse leaders who strive to exercise these strategies are likely to improve work engagement levels for their teams. With higher levels of work engagement, it's expected that burnout, incivility, and turnover will decrease, and staff shortages and the quality of patient care will improve.
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