Behind the numbers

FigureNurse managers (NMs) play a pivotal role within healthcare organizations, serving as the cornerstone between administrative directives and frontline patient care. These leaders integrate clinical expertise with strong managerial skills to ensure efficient departmental operations, enhance patient satisfaction, improve staff retention, and maintain quality and safety standards.1-3 NMs exhibit exemplary leadership qualities characterized by strong analytical and problem-solving skills and transformative leadership behaviors. They navigate complex situations, identify the root causes of issues, and implement solutions to improve operational efficiency and patient-care outcomes. NMs also foster a culture of excellence and innovation, motivating their teams to excel while empowering nurses to strive for continuous improvement. These leadership qualities are linked to quality and safety indicators, including fewer adverse events and medication errors, higher patient satisfaction scores, and reduced patient mortality.2,3 Furthermore, NMs play an integral role in the support and retention of staff through various strategic initiatives and leadership practices. Supervisor support, praise, recognition, trust in management, and transformational leadership styles, collectively, have a positive influence on direct care nurses' intent to stay within an organization.1 Although NMs are crucial for the success of healthcare organizations, they're unfortunately leaving their roles at alarming rates (see Figure 1). In a 2022 assessment conducted by the American Nurses Foundation to collect insight on nurses' mental health, workplace support, financial well-being, intent to leave, and satisfaction, a survey of 683 NMs revealed that 25% were considering leaving, 16% intended to leave, and 23% had already changed positions in the last 6 months.4 Consequently, these high turnover rates compromise patient safety, care quality, and direct care nurse retention, and also present a financial burden given the challenges of filling the position and the costs associated with replacing NMs.5FIGURE 1:: NM turnoverConsiderable research on direct care nurse retention has been conducted in recent years; however, there has been limited focus on NM support, job satisfaction, and the impact on NM retention. As part of the Vanderbilt University School of Nursing Doctor of Nursing Practice (DNP) matching program, a DNP project was formulated in collaboration with the American Nurses Credentialing Center to address this gap.6 The project was conducted in two phases. The first phase involved a systematic review of the literature on factors influencing NM job satisfaction and retention. Thirty-one peer-reviewed articles were identified and analyzed for evidence-based strategies to support NM job satisfaction and retention. These results were synthesized to begin the development of a toolkit that nursing leaders could use to support their constituent NMs. In phase two, two virtual focus groups of 15 NMs provided direct feedback on the literature review and shared their personal experiences with job satisfaction and retention. Focus group data were qualitatively analyzed to identify commonalities and distinctions in the themes found in the literature review. These findings were collated, leading to the development of a completed toolkit aimed at reducing or mitigating NM turnover. This article provides a summary of the project findings. SUMMARY OF FINDINGS AND RECOMMENDATIONS The final synthesis of the focus group and literature review findings uncovered seven primary components of NM satisfaction and retention (see Figure 2): 1) stress, scope of control, and work empowerment; 2) supervisor relationships; 3) new NM orientation; 4) work engagement, professional development, and career advancement; 5) work-life balance; 6) peer support, team-building, and mental well-being; and 7) an individualized approach to supporting and retaining NMs.FIGURE 2:: Infographic of NM job satisfaction and retentionStress, scope of control, and work empowerment Burnout and stress emerge as two of the most significant drivers of NM intent to leave.7-10 Conversely, NMs who work fewer FTEs (full-time equivalents) report higher satisfaction and intent to stay.11 Insufficient resources, heavy workloads, and extensive responsibilities—particularly those beyond the scope of NM duties—are detrimental to satisfaction and well-being.7,12,13 Studies demonstrate that empowering NMs with fiscal and administrative resources, adequate staffing, and dedicated time for managerial responsibilities enhances their sense of meaning and value in their work.10,14-17 In addition, increasing administrative support and appropriately limiting NMs' scope of control has been shown to increase satisfaction and improve leadership performance.17 Addressing excessive and/or rigid scheduling requirements by limiting meeting times and offering virtual meeting platforms when possible is highly valued by NMs, particularly among younger generations.14,18 Finally, providing opportunities for leadership and shared decision-making demonstrates that the contributions of NMs are valued, leading to decreased stress and burnout.19 Supervisor relationships The existing evidence unequivocally indicates that NMs with positive, supportive relationships with their supervisors report higher job satisfaction and are more likely to stay in their roles.4,20 Survey and qualitative data demonstrate that NMs subjectively value positive, constructive, and respectful supervisor relationships.4,10,12,15,20-22 Furthermore, multiple studies show direct relationships between organizational and leadership support with intent to stay or intent to leave.7,23-27 Facilitating opportunities for collaboration and open dialogue between nursing executives and NMs is crucial for fostering strong supervisor relationships.28,29 Examples include shadowing opportunities; mentorship programs; monthly brown-bag lunches or journal clubs; annual retreats; or quarterly, one-on-one check-in meetings.14,30 Systems should be established to actively involve NMs in decision-making processes.18,19,29 Importantly, emotional intelligence and personal connection are critical to facilitating supportive environments and job satisfaction for NMs, and organizations should prioritize recruiting leaders who exhibit these qualities.7 Millennial and younger generation nurses, who will soon make up the majority of NMs, strongly value feeling heard, understood, involved, and valued by nursing leadership.16,18 Increasing leadership visibility and creating opportunities for personal connections, such as through regular rounding, is one way to facilitate these experiences.14,29 New NM orientation Adequate orientation and training are major factors associated with satisfaction among NMs, yet many new NMs feel wholly unprepared.7,9,18,21,23 Several studies indicate that lack of standardization is a major pitfall of current orientation processes.16,31 Training for new NMs should be standardized and streamlined with target competencies, milestones, regular check-ins, and provision of comprehensive resources, such as a new NM toolkit.16,22,31 The transition from direct care nurse to NM is extremely demanding, and new NMs are often surprised by certain aspects of the role. Ample exposure to NM responsibilities prior to the role transition, such as through shadowing or NM assistant opportunities, is critical to preventing early burnout.18,31 Training in nonclinical responsibilities, such as administrative tasks, healthcare finance, budget, and payroll management, should be prioritized, as these are central to the NM role and often inadequately covered in current training programs.16,18,22,23,31 Finally, formal transition programs may include opportunities for facilitating relationships with supervisors and peers, as both are important during the training period, particularly among younger NMs.16,18,22 Examples include mentorship programs and/or NM “boot camps.”16,22 Work engagement, professional development, and career advancement Promoting a work culture that encourages career advancement and professional development is repeatedly shown to be a crucial contributor to NM job satisfaction.21-23 The approach to fostering this culture should be comprehensive and include both formal and informal opportunities. Time and budget should be set aside for structured enrichment programs, such as conferences, webinars, leadership training, and tuition reimbursement programs.17,22,23,29,32 Notably, NMs also benefit from engaging in less structured activities that both advance their careers and bring personal satisfaction, such as mentoring direct care nurses and participating in collaborative projects.20,21 Interdisciplinary collaboration is pivotal to effective NM leadership. To that end, opportunities to collaborate with advanced nursing providers or physicians through educational initiatives, leadership opportunities, or quality improvement projects are highly valued by NMs.10,22,32 Finally, engaging NMs in academic projects, such as task force leadership, committee participation, quality improvement initiatives, and manuscript writing, enhances job satisfaction, confidence, and autonomy.22 Work-life balance Sixty-seven percent of NMs report work-life balance as one of the most important contributing factors to their job satisfaction (see Figure 3).4 Since the pandemic, the work-life balance of NMs has suffered significantly due to increased staffing needs, staffing constraints, and resource shortages. Opportunities and incentives for NMs to foster work-life balance are imperative to satisfaction, retention, and efficacy in the role.7-9,14,21,23,25,28,33,34 Rigid and demanding schedules are a major contributor to NM burnout and turnover.4,20 Opportunities to facilitate schedule flexibility may include compressed work hours, flextime, or remote work options.9,14,21 Facilitating weekend call schedules is another effective approach.21 When looking ahead at the needs and preferences of the next generation of NMs, work-life balance and schedule flexibility are top priorities. However, the persistent expectations of “24/7” availability and accountability, and constant electronic communication present ongoing challenges.16,18 Leaders should advocate for workplace cultures that don't prioritize or require unreasonable availability.14,16,25FIGURE 3:: Most important factors impacting NM job satisfactionPeer support, team-building, and mental well-being NMs report that supportive NM colleagues and multidisciplinary networks are fundamental to satisfaction.4,20 Workplace social support and level of physician collaboration are predictors of job satisfaction and organizational commitment.19 NMs, particularly those new to the role, should be provided ample opportunities for bonding, such as retreats, peer support groups, a shared NM calendar, or social events.14,22,30,31 Creating platforms for NMs to learn from one another may also facilitate group cohesion. One example of this is a “peer expert” resource list wherein NMs may be consulted for their specialized skill set or knowledge base.22 Interdisciplinary relationships are also important to NMs' well-being and leadership efficacy and may be fostered through co-led projects, contact lists, and networking events.22 The pandemic posed significant professional and emotional challenges for NMs. Programs supporting emotional and mental well-being such as NM wellness committees, regular psychologist or counselor check-ins, and incentivized use of employee-assistance programs can effectively promote satisfaction and retention.35 Additionally, creating systems for NMs to share and discuss challenges in patient care and leadership can foster bonding and enhance interdisciplinary relationships.22,36 Evidence-based training to cultivate characteristics known to be essential for NM success, such as mindfulness, resilience, and self-compassion, may also be beneficial.37-41 Individualized approach to supporting and retaining NMs The reasons that NMs choose to leave or stay are complex and multifaceted. Assessing and addressing job satisfaction on an individual level is the most effective approach to attract and retain NMs.23 Clear and realistic descriptions of NM role expectations should be presented during the hiring process, and prospective NMs should be given ample opportunity to ask questions.7,23,29,31,34 As previously discussed, leadership competency is associated with improved retention rates among NMs.17 Individualized leadership development that focuses on specific leadership competencies at all levels of nursing leadership could enhance NM self-efficacy and satisfaction.7,42 It's also critically important for NMs to feel a sense of pride in their work and be personally connected with their organization's goals and values.7,10,23,26,34,43 Efforts to engage NMs in professional values, foster an organizational commitment to patient care, and promote a sense of purpose should be implemented during the recruitment process and beyond.23 Feeling supported by directors is critical to NM satisfaction. Leaders should seek to build close, individual relationships with NMs, particularly those new to the role.16 Systems should also be created to enable NMs to receive regular feedback and be recognized for meaningful work.7,14,29 Lastly, surveys, one-on-one interviews (or “stay” interviews), and predictive analytics should be used to identify NMs at risk, implement individualized support plans, and continuously reassess organizations' evolving needs.17,21,44 PATHWAY TO EXCELLENCE® Pathway to Excellence Framework Pathway to Excellence® is a voluntary credential that demonstrates an organization's commitment to fostering a positive practice environment through rigorous adherence to six essential program standards (see Figure 4). This evidence-based framework has proven transformative across diverse healthcare settings, empowering NMs to excel in their roles by emphasizing leadership development, fostering supportive relationships, and prioritizing well-being. Effective leadership, as Pathway recognizes, hinges on equipping NMs with a comprehensive orientation, ongoing professional development, and valuable feedback loops from colleagues and nursing staff. In practice, Pathway organizations prioritize retention strategies informed by direct feedback, ensuring NMs feel valued and empowered to lead effectively. They cultivate a climate in which team well-being is paramount, acknowledging that sustainable leadership requires reciprocal support for the well-being of managers themselves. This commitment is integral to the organization's strategic plan, emphasizing its responsibility for identifying and addressing the holistic well-being needs of all employees, including NMs. Furthermore, Pathway organizations promote a culture of recognition that celebrates NMs' contributions, fostering environments where meaningful acknowledgment reduces stress, enhances relationships, and reinforces employees' sense of purpose.FIGURE 4:: ANCC Pathway to Excellence® Framework for Positive Practice EnvironmentsPathway focus on NM support and well-being Incorporating essential elements that promote and support the well-being of NMs in the 2024 Pathway to Excellence application manual was a crucial step in addressing the unique challenges faced by this vital group of healthcare professionals. As frontline leaders, NMs establish the tone for the unit culture and play a pivotal role in fostering a positive practice environment and ensuring high-quality, effective care delivery. Effective NM leadership can mitigate emotional exhaustion and job dissatisfaction among frontline nurses. However, the demanding nature of their responsibilities often subjects NMs to comparable or even higher risks of burnout and stress. By integrating well-being support requirements for NMs into the 2024 application manual, Pathway aims to ensure structured support for NMs, enabling them to lead effectively while sustaining their own health and well-being. Well-supported NMs are better equipped to support their teams, leading to higher employee engagement, job satisfaction, and retention rates among nursing staff. Highlighting the importance of manager well-being sets a standard for organizational culture, emphasizing the value of health and well-being at all levels of the nursing workforce. These new requirements underscore the critical link between the well-being of NMs and the overall success of healthcare organizations, ensuring that the Pathway to Excellence remains a comprehensive, relevant, and forward-thinking framework for nursing excellence. APPLICATION OF THE NM TOOLKIT Benefits and expected outcomes Developing and implementing strategies that support the job satisfaction, retention, and well-being of NMs is critical for healthcare organizations. Stability in NM positions not only ensures continuity in patient care, but also enhances operational efficiency. Moreover, well-supported NMs are more adept at implementing efficient practices and optimizing resource use, thereby enhancing the quality of care, directly benefiting patient safety and satisfaction. In addition to operational benefits, the support that NMs receive can significantly influence the morale and job satisfaction of nursing staff. Empowered and well-resourced NMs foster positive practice environments, leading to higher staff morale, reduced absenteeism, and improved collaboration within healthcare teams. Such environments enhance the overall effectiveness and efficiency of care delivery. Investing in NMs' professional development also cultivates stronger leadership within the organization. These managers, equipped with advanced skills and knowledge, are better prepared to assume higher-level responsibilities and contribute strategically to the organization. Furthermore, initiatives that promote work-life balance and mental well-being reduce burnout, enhancing the longevity and performance of NMs. A focus on mental health and peer support builds a resilient workforce, capable of meeting the demands of the healthcare environment. Thus, supporting NMs isn't merely an operational necessity but a strategic imperative that enhances patient care, financial performance, and organizational stability. Dissemination The Nurse Manager Toolkit is designed to help nurse executives improve NM retention and satisfaction. Assessing the current state of NMs within the organization is crucial before implementing the toolkit. This assessment will identify existing strengths, weaknesses, and areas for improvement, allowing the toolkit to be tailored to address specific challenges effectively. Dissemination of the toolkit requires a well-structured and multifaceted approach. The first step is to introduce the toolkit through formal training sessions and workshops for nurse executives and senior leadership, focusing on the toolkit's practical applications and the evidence-based strategies. Next, integrate the toolkit into existing leadership development programs for ongoing reinforcement and establish a mentorship program in which experienced managers assist newer ones in using the toolkit, fostering a supportive culture. Involving NMs in the implementation and evaluation of toolkit elements is essential for ensuring their relevance, effectiveness, and sustainability within an organization. Engage NMs in developing and evaluating the toolkit's strategies to ensure they meet real-world needs and align with their roles. Regular feedback and follow-up are essential for adapting the toolkit based on emerging challenges and needs. Encourage ongoing dialogue with NMs throughout the implementation phase. Solicit their feedback regularly to identify areas for improvement or modification of toolkit strategies based on evolving needs and emerging challenges. Maintaining open communication and a culture of continuous improvement will maximize the toolkit's impact, enhancing NM retention and satisfaction. To receive a copy of the toolkit, or if you have questions about its use, please email [email protected].