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Feature: NEW Quality Improvement Matters

Using focus groups to improve nursing satisfaction

Nelson, Alexandra DNP, RN; Frankenberger, Warren D. PhD, RN

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Nursing Management (Springhouse): March 2020 - Volume 51 - Issue 3 - p 42-48
doi: 10.1097/01.NUMA.0000654884.35169.a4
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Nurse managers have a large span of control with around-the-clock accountability, and one primary responsibility is staff engagement and satisfaction. In addition, nurse managers are challenged with competing priorities, which include creating an environment that supports quality patient care and fiscal stewardship while addressing nursing professional development. There's a significant amount of evidence that points to the positive relationship between a healthy work environment and patient outcomes.1 Nurse managers who are viewed as being supportive and good communicators positively impact the environment by influencing turnover.2 Furthermore, nursing satisfaction and engagement are integral to an overall healthy work environment. Finally, nursing satisfaction is often linked to the ability of unit leaders, including the nurse manager, to create a supportive work environment.3,4

One of the most commonly used tools to assess nursing satisfaction is the National Database of Nursing Quality Indicators® (NDNQI®) Practice Environment Scale (PES), which measures nine domains, including nurse participation in hospital affairs, nursing foundations for quality of care, and nurse manager ability/leadership and support of nurses.5 The literature also identifies that nurse managers who demonstrate supportive behaviors, such as respect, care, and good communication, have increased nursing satisfaction scores.6 Cziraki and Laschinger found that managers who exhibited empowering behaviors had higher nurse engagement scores.7 Managers who were transparent with sharing information and listening to ideas motivated staff members to participate in decision-making and inspired them to derive more meaning from their work.7

Although the PES provides valuable data related to nursing satisfaction, it's difficult to elicit open feedback to improve the work environment and the relationship between nurses and their leaders. This article describes a collaborative approach using focus groups to gather feedback from RNs and the action plan to improve satisfaction on an acute care inpatient pediatric unit.


The nurse manager role encompasses a variety of responsibilities, including supporting operations 24/7, promoting safety and quality, and maintaining staff satisfaction and engagement. Saifman and Sherman discussed the many competing priorities of being a nurse manager, such as balancing competing priorities, helping staff members succeed, making an impact on unit metrics, and managing change.8 Clinical nurses are often asked to evaluate leadership behaviors that encourage staff satisfaction and engagement through confidential surveys administered by hospital leadership.9 These surveys are based on the assumption that positive leadership qualities are related to an overall healthy work environment.

Peng, Liu, and Zeng performed a qualitative study with clinical nurses who identified the caring behaviors that they wanted their nurse manager to exhibit: promote professional growth, support a work-life balance, and practice a democratic leadership style.10 Tourangeau and colleagues used focus groups to explore factors influencing nurses' intention to remain employed.11 One salient theme was nurses' relationship with and support from their manager. Although nurses understood that the nurse manager may be less visible due to a wide span of control, they nonetheless felt that the nurse manager had the authority to influence much of their work environment.11 Desired manager characteristics included fairness, respect, support, and strong interpersonal skills. Clinical nurses indicated that they wanted a transformational nurse manager who demonstrated supportive behaviors, such as role modeling, a clear vision for the unit, and nurse autonomy.11

There isn't one type of leader that all nurses want. Nurses have also stated that although they appreciate the transformational approach, they also value the transactional leader who motivates staff with rewards and in-the-moment feedback.12 Nurse leaders also have generational differences to consider when focusing on approaches to improve satisfaction and retention. For example, millennial nurses often seek opportunities to make a difference and prefer leaders who foster engagement.13 Nurse managers are in a key position to use evidence-based approaches to retain staff in a complex and ever-changing workforce, identifying what characteristics and behaviors are important to their direct reports.


This quality improvement (QI) project took place on a 24-bed inpatient general pediatrics unit with an hours per patient day of 10.5. The budgeted average daily census was 22, but the unit had been running about 6% above budget. The total staff of 56 employees was made up of unlicensed assistive personnel (UAP), unit secretaries, and 46 RNs. A nurse manager, along with a nurse scientist, reviewed the results from the 2017 NDNQI PES survey in which 37 nurses participated. The 2017 results showed several areas that decreased from 2016. (See NDNQI items.)

After reviewing the NDNQI data, the nurse scientist developed targeted questions based on survey items that addressed the following domains: leadership, RN-to-RN interaction, and hospital affairs. Examples of focus group questions included, “Describe the leadership team and their interactions with staff” and “Describe interactions among your nursing colleagues.”

Baseline focus groups were conducted in the fall of 2017. The nurse scientist led the focus groups and the research assistant (RA) manually recorded the responses. Four focus groups were conducted by the same nurse scientist and an RA at three distinct points in time, with nurses from all shifts and levels of experience participating. No individual identifiers were recorded. Neither the nurse scientist nor the RA had a clinical or administrative relationship with the nursing unit, which decreased bias and helped foster trust with the focus group participants. Responses were collapsed into themes and results were shared with the nurse manager and the leadership team. The following areas were identified as opportunities for improvement: praise and recognition, greater support from supervisors, opportunities for advancement or to serve on committees, treating mistakes as learning opportunities, and nurse manager leadership style.

After the initial focus group, and with the support of the nurse scientist, the nurse manager completed a literature search to develop interventions based on the results of the NDNQI data and focus groups. Next, with a human resources (HR) partner, the nurse manager devised a strategy for communicating the focus group feedback and evidence from the literature to the leadership team.

A three-tiered approach was created aimed at improving the following areas based on a combination of satisfaction scores and focus group data: leadership development to address staff feedback related to the leadership team, staff mentorship to address issues such as teamwork and professional advancement, and communication to address consistency and transparency of information. Follow-up focus groups were conducted at 6 months, 1 year, and 18 months after the baseline. The final results were again shared with the nurse manager, the leadership team, and the HR business partner assigned to the clinical area conducting the project.

Table NDNQI:


Leadership development. The first intervention was focused on the development of transformational leadership behaviors. Transformational leaders are inspirational and viewed as being collaborative, managing change, and serving as mentors.14 Nurse managers who are transformational leaders elicit stronger staff engagement.15 Clinical nurses who view their managers as transformational have increased levels of interprofessional teamwork and demonstrate how collaboration between teams can lead to improved patient safety.16

The unit's nursing leadership team consisted of seven members: a nurse manager, an assistant nurse manager, a safety and quality specialist nurse, a clinical nurse specialist, and three clinical nurse experts (CNEs). A CNE spends 80% of his or her weekly time on patient care and 20% on organizational and unit projects with a focus on bedside staff practice mentorship. Only the nurse manager and assistant nurse manager are direct supervisors of staff; all of the leadership roles are responsible for staff engagement and safety promotion. Half the leadership team had been with the unit for more than 5 years and the other half, including the nurse manager, for 2 years or less.

Quarterly leadership retreats were planned, co-led by the HR partner and the nurse manager. At the first retreat, which set the tone for the coming year, the leaders reviewed results of their personal behavioral assessments. This helped with the identification and discussion of people's behavioral differences to recognize how each leader may think and react to situations differently. It also prompted a discussion of how important it was to have a team made up of many behavioral styles. Additionally, the retreat included reflections on the first clinical nurse focus group and goals for the year. Other quarterly retreats focused on team dynamics, resilience, and shared expectations. The leadership team was able to have protected time away from the unit to learn about each leader's strengths and provide the opportunity for transparent communication.

At the end of the year, the results of the second clinical nurse focus groups were reviewed. The visions from the first retreat were evaluated and new visions were set for the following year. Based on each leader's reflections, it was evident that they saw an improvement within the leadership team, as well as in leaders' relationships with clinical nurses on the unit.

Mentorship. The second strategic intervention was the mentorship of unit staff, particularly focusing on staff members who had been on the unit for less than 3 years. The Advisory Board Company suggests organizations that retain staff beyond 3 years will see increased engagement and loyalty, especially among millennials.17 Additionally, it endorses the practice of providing recently hired millennial employees with early growth opportunities, as well as emotional support, to influence retention. With these recommendations in mind, the nurse manager created a list of nurses who had been on the unit for 3 years or less. Each unit leader chose three clinical nurses to meet monthly in an informal manner. Each leader selected one nurse with less than 3 years of experience they didn't know well, one nurse they thought would be a challenge to mentor because they were a low performer, and one nurse they thought would be easy to mentor because that nurse was already a high performer.

Input from these meetings was brought back to a monthly leadership team meeting where issues and solutions were identified. As newer nurses reflected on their orientation, one theme was a desire to have a more connected relationship to a clinical nurse mentor after orientation. To facilitate this, the nurse manager connected with the unit's shared governance committee to build a unit-based nurse navigator program to support new nurses off orientation for their first year. The new nurse is assigned a nurse navigator to be a peer support for interpersonal challenges and help with assimilation onto the unit, such as answering scheduling questions and discussing challenging patients. Clinical nurses with at least 1 year of experience can volunteer to be nurse navigators and attend a 2-hour hospital-wide class that gives them a toolkit for the mentor role.

Standardized communication. The third and final intervention focused on creating standardized communication methods that can be applied by everyone on the leadership team. Nurses want a nurse manager who demonstrates strong interpersonal skills. In the focus groups, clinical nurses also indicated a desire to participate in hospital committees. They perceived that there was a lack of transparency related to professional opportunities to serve on committees and preferred that all nurses were aware of potential committee memberships. Additionally, clinical nurses wanted regular in-person meetings with the nurse manager and wanted to feel more included in care plans for medically complex patients, specifically when a family meeting occurred.

To address this, monthly staff meetings were established at scheduled dates for both day and night shifts, with agenda categories that remained consistent at each meeting. The nurse manager asked for feedback from clinical nurses regarding the format and time of each meeting. After each family meeting, the attending leadership team member emailed a summary to the staff. This not only helped identify which leadership team member was following the patient, but it also helped the clinical nurses communicate better with the families. Committee-work opportunities, both unit-based and hospital-wide, were advertised to all staff members at staff meetings.

Finally, the nurse manager set up scheduled midyear evaluations with direct reports. The outline of what would be included was sent to the employee with the meeting invite. The nurse manager concluded each midyear evaluation by asking for feedback about herself as a nurse manager, as well as a suggestion for one improvement that could be made in the work environment. Themes that came out of these one-on-one meetings ranged from increasing the supply levels of specific items to clarifying what skills the UAP were responsible for performing.


Focus groups were conducted at 6 months, 1 year, and 18 months by the same nurse researcher and RA. Thematic analysis showed improvements, specifically in the areas of nurse manager and supervisory support, RN-to-RN teamwork, and opportunities for advancement. Additionally, a postsurvey, including the NDNQI PES questions from 2017, was emailed to staff in an anonymous online survey format. Out of 27 responses, all items showed an improvement from the 2017 to the 2019 NDNQI results. In the final leadership retreat, unit nurse leaders expressed similarly perceived improvements in unit culture and the culture within the leadership team.

The collaboration between nursing leadership, nursing research, and HR resulted in several leadership/management strategies that may benefit any unit. First and foremost, leaders must be open to honest, constructive feedback, both from their peers and, most important, from the people they manage.12 The approach of using a nurse researcher to conduct focus groups provided a safe forum for nurses to provide direct feedback about leadership. Although not all staff members feel comfortable giving confidential feedback, having a facilitator to guide the discussion can help elicit constructive themes while addressing personal and/or individual concerns. However, it's equally important that leaders are open to feedback and show a sincere willingness to address concerns.9

Mentoring sessions and leadership retreats are also beneficial. The time invested in mentoring clinical nurses is rewarding not only for the nurse, but also for the leadership team member because it confronts the perceived “invisible barrier” between leadership and clinical nurses. It also leads to insightful and easy in-the-moment suggestions that can have a bigger impact than just one nurse. Leadership retreats allow for the leadership team to build trust and, although the topics initially focused on goal setting, by the end the group felt they could trust each other enough to have more intimate conversations. They discussed their fears about being a leader and what they wanted their legacy to be for the unit.

The final takeaway is that staff members value reliable, accessible communication. Having regular, predictable means of communication provides the opportunity for staff members to feel included in changes and participate in the change process. During yearly performance reviews, staff members have shown a willingness to give feedback directly to the nurse manager, as well as verbalize their appreciation for the presence of the nurse manager on the unit when she's available. Staff members are also now practicing open communication with their peers by giving feedback to improve each other's practice. Unit leadership will continue to support these changes throughout the next fiscal year while collecting feedback every 6 months through nurse researcher-led focus groups and continued staff meetings.

Lessons learned

Although this QI project was unit-specific, there are key lessons learned that can be applied to other nursing environments looking to improve nursing satisfaction scores. The first lesson pertains to an openness and willingness to receive feedback. Although critique of your leadership style is a challenge, a willingness to listen will lead to growth as a leader and help you begin the journey to improvement. It's also critical to understand that managing perceptions and expectations is equally as important to effectively lead others. The second lesson is performing a comprehensive literature review. Using evidence to guide an improvement approach will allow your team to accurately identify key issues while utilizing best practices to address issues. The final lesson is using HR not just for employee relations issues, but also for leadership development.


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