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Nurse manager job satisfaction and intent to leave.

NURSE MANAGERS CREATE and sustain healthy environments that support professional nursing practice and staff nurse job satisfaction (Duffield, Roche, Blay, & Stasa, 2011). Hospital staff nurses credit the quality of their relationships with their nurse managers as a deciding factor to remain in their positions (Cohen, Stuenkel, & Nguyen, 2009; McGuire & Kennerly, 2006). Since relational leadership styles have consistently been associated with better nurse and unit outcomes (Cummings et al., 2010), strategies to build effective nurse manager-unit staff relationships should be a high priority. Interpersonal relationships are developed over time; therefore, it is critical that we entice effective nurse managers to remain in their positions.

Nurse managers who build effective relationships with their staff nurses and are committed to their organizations may also play an important role in leadership succession because the nurse manager role is often the portal to senior nursing leadership. To build effective leadership succession plans, nurse executives need to know more about nurse managers' satisfaction with their current roles and understand their career plans. Therefore, the purpose of this study was to examine nurse managers' job satisfaction and intent to leave their positions.

Review of Literature

Although job satisfaction, retention, and intent to stay among staff nurses have been well researched, relatively few researchers have explored these concepts among nurse managers (Brown, Fraser, Wong, Muise, & Cummings, 2013; Lee & Cummings, 2008). Job satisfaction in Canadian nurse managers was influenced by perceptions of organizational support, the quality of relationships with their supervisors, and structural and psychological empowerment (Spence Laschinger, Purdy, Cho, & Almost, 2006; Spence Laschinger, Purdy, & Almost, 2007). Job satisfaction among nurse managers working in the United States was influenced by supervisor and physician agreement regarding the nurse managers' use of their time (Bunsey, Defazio, Pierce, & Jones, 1991) and power to make changes to their work environment (Hurley, 2005). Ringerman (1990) reported that decentralization resulted in higher nurse manager job satisfaction and, by contrast, Wells (1990) did not find a significant difference in job satisfaction between nurse managers working in centralized versus decentralized organizations. Kath, Stichler, and Ehrhart (2012) found autonomy and job predictability enhanced job satisfaction and reduced nurse managers' intent to quit. Whether measured as empowerment, decentralization, or autonomy, nurse managers' job satisfaction seemed to be influenced by their ability to exercise control over their practice.

Building on the studies of job satisfaction, Parsons and Stonestreet (2003) reported nurse manager retention was influenced by quality communication with their supervisors, empowerment to make decisions, effective staff management systems, professional development, work-life balance, quality of patient care, and adequate compensation. Mackoff (2011) interviewed 30 nurse managers who were in their positions for at least 5 years and known for achieving quality outcomes. Her findings were similar to those reported by Parsons and Stonestreet (2003). Nurse managers reported an empowered nursing workforce, high expectations for achieving quality outcomes, mission-driven decision making, professional development, and the freedom to take risks were important organizational features that influenced their decisions to stay in their positions (Mackoff, 2011). In addition to the organizational cultures, the nurse managers in Mackoff's study also reported a need to maintain a good balance between their work and home life, have evenly distributed workloads, formal education and socialization to their role, and receive adequate compensation. Similarly, Spence Laschinger and co-authors, Wong, Grau, Read, and Pineau Stam (2012) found leadership practices, structural empowerment, and perceived organizational support increased Canadian nurse managers' intent to stay in their positions. Although the U.S. studies used convenience samples of nurse managers recruited from three (Parsons & Stonestreet, 2003) to six (Mackoff, 2011) U.S. medical centers, Spence Laschinger and co-authors (2012) surveyed 788 first-line nurse managers working in 66 hospitals across Canada. The limited number of studies conducted signals the need for more research to understand the current state of nurse manager job satisfaction and retention.

Methods

Design and sample. This study was a secondary analysis of self-administered electronic survey data collected from nurse managers working in U.S. acute care hospitals in March 2011. Nurse managers were defined as the first-line manager of a patient care area(s) with 24-hour responsibility for the operational, fiscal, and performance accountability. Nurse managers who only managed outpatient clinics or were in their positions for less than 3 months were excluded. All nurse managers who were members of the North Carolina Organization of Nurse Leaders (NCONL; n=87) and the American Organization of Nurse Executives (AONE, n=1,125) were invited to participate in the study. Members of NCONL were recruited using email addresses provided by the organization. Members of AONE were recruited through advertisements in the organization's biweekly electronic newsletters. Of the 291 respondents, 108 (44%) were members of AONE only, 26 (11%) were members of NCONL only, 4 (2%) were members of both AONE and NCONL, and 105 (43%) were members of neither organization. We assume that emails containing the survey link were forwarded to nurse managers who would not have received the study invitation. The response rates were 13% for AONE members and 44% for NCONL members. An a priori power analysis for the parent study determined the sample size was adequate to detect significant relationships. Approval to conduct the study was obtained from the University of North Carolina at Chapel Hill Institutional Review Board.

Instruments. Five items were developed by the author to measure nurse manager job satisfaction and anticipated turnover. These items were modeled after items developed by Aiken and colleagues (2001) to measure job satisfaction and anticipated turnover in staff nurses and Jones, Havens, and Thompson (2008) to measure job satisfaction and anticipated turnover in nurse executives. Respondents were asked to rate their satisfaction with being a nurse manager on a 6-point Likert scale (1 = highly dissatisfied to 6 = highly satisfied), likelihood to recommend nursing management as a career choice on 5-point Likert scale (1 = very unlikely to 5 = very likely), and satisfaction with time spent with staff on a 5-point Likert scale (1 = very dissatisfied to 5 = very satisfied). Participants were also asked how long they planned to remain in their current positions. Response categories included 0-2 years, 3-5 years, 5-7 years, 7-9 years, and greater than 10 years. Participants who were planning to leave their positions in the next 5 years were asked to indicate their primary reason (see Table 1). Demographic data included age, gender, race, highest nursing degree, additional non-nursing degrees, years of nursing experience, years of nurse manager experience, and years in current nurse manager position. The questionnaire was reviewed by experts in nursing leadership and job satisfaction research.

Procedure. The questionnaire was developed and distributed using Qualtrics[R] (Provo, UT) software. Recruitment notices with the URL link to the questionnaire were emailed twice a week to nurse managers who were NCONL members. The AONE participants were recruited through the twice-weekly electronic newsletters sent by AONE to its members. The survey was fielded for 3 weeks.

Data analysis. Data were analyzed using SAS version 9.2 (Cary, NC) to run descriptive statistics, one-way ANOVA, t-tests, and chi-square tests for differences.

Findings

The average nurse manager in this sample was a 47-year-old Caucasian female with 9.1 (SD= 7.3) years of nursing management experience and 4.9 (SD=4.7) years in his or her current position. Forty-nine percent of the participants reported more years of nursing management experience than years in their current nurse manager positions. Most held a baccalaureate degree in nursing (n=151, 51.97%) or a master's degree in nursing (n=100, 34.4%) and 2 (0.7%) had a doctorate in nursing. Forty percent of respondents also held non-nursing degrees. After accounting for additional non-nursing degrees, 46% (n=135) reported a baccalaureate, 43.7% (n=129) reported a master's degree, and 1% (n=3) reported a doctorate as their highest overall level of education. When compared with data reported in the 2008 National Sample Survey of Registered Nurses (NSSRN) (Health Resources and Services Administration [HRSA], 2010), age, race, and gender were commensurate. The education levels reported by these nurse managers were generally more advanced than managers and administrators surveyed in the NSSRN. The average span of control was 60.8 (SD=39.2) full-time equivalents (FTEs) across 1.7 units (SD=1.0). In some cases, the nurse managers were responsible for as many as 241 FTEs across seven patient care areas (see Table 2).

Almost 30% (n=84, 29%) were very satisfied and 41% (n=119) were satisfied with their positions as nurse managers. In addition, most were either very likely (n=79, 27%) or likely (n=123, 41%) to recommend nursing management as a career. When asked about satisfaction with the amount of time available to work with staff, there was more variability: 28% (n=81) were either very dissatisfied or dissatisfied, 20% (n=57) were neutral, and 52% (n=151) were either satisfied or very satisfied.

When asked about intent to leave their current positions, 25% (n=74) reported they planned to leave within the next 2 years and another 37% (n=107) planned to leave their positions within the next 3 to 5 years (see Figure 1). Two hundred and ten (72%) participants provided a primary reason for intent to leave their position in the next 5 years. The top four reasons reported were burnout or stress (n=63, 30%), career change (n=56, 27%), retirement (n=47, 22%), and promotion (n= 32, 15%) (see Table 3).

Chi-square and t-tests were used to analyze differences between those planning to leave their positions in the next 5 years and those who planned to stay longer than 5 years. Compared with nurse managers who planned to leave their positions within the next 5 years, those who planned to stay in their positions for more than 5 years were more satisfied with their jobs ([chi square]=25.59, df=3, p=<0.001) and more satisfied with the amount of time they spend with their staff ([chi square]=8.28, df=2, p=0.02). Nurse managers planning to stay in their positions were also more likely to recommend nursing management as a career option ([chi square]=9.18, df=2, p=0.01) and they supervised 11.5 fewer FTEs (t= -2.13, df=259, p=0.03). The most common reasons cited by the nurse managers who were satisfied or very satisfied with their jobs but also planned to leave in the next 5 years included retirement (n=36, 25%), career change (n=33, 23%), promotion (n=29, 20%), and burnout (n=15, 10%) (see Table 3).

When compared with those who planned to stay, those who planned to leave within the next 5 years did not differ significantly in age (t=1.67, df=183.68, p=0.10), highest degree ([chi square]=3.15, df=2, p= 0.20), years of nursing experience (t=0.88, df=285, p=0.38), years of nurse manager experience (t= -0.44, df=288, p=0.66), unit tenure (t=1.02, df=108.75, p=0.31), membership in either AONE or NCONL ([chi square]=1.77, df=1, p=0.20), or hospital size ([chi square]=3.81, df=3, p=0.30).

Discussion

The nurse managers who participated in this study were experienced, well-educated, and managed large spans of control. On average, they had 9 years of experience as nurse managers with about 5 years in their current positions. Roughly half were in at least their second nurse manager position. Further, 62% were planning to leave their current positions in the next 5 years. This suggests for this sample the average "life span" of a nurse manager for any one position is about 5 years. Our findings indicate many nurse managers leave their positions and nursing management; however, some leave their positions for another nurse manager position. What is not clearly understood is what compels nurse managers to leave one nurse manager position to assume another nurse manager position.

Although 70% of the participants were either satisfied or highly satisfied with their jobs and likely or highly likely to recommend nursing management as a career, an equal number reported they were also planning to leave their jobs within the next 5 years. While staff nurse job satisfaction is associated with higher levels of retention (Cummings et al., 2010; Currie & Carr Hill, 2012), this was not the case for this sample of nurse managers, suggesting the need to further explore the distinctive features of nurse manager practice. Given the unique role of the nurse manager, evidence that explains staff nurse job satisfaction (Hayes, Bonner, & Pryor, 2010; Lu, Barriball, Zhang, & While, 2012) and intent to stay (Cowden & Cummings, 2012; Tourangeau, Cummings, Cranely, Ferron, & Harvey, 2010) may not apply to nurse managers.

Burnout (30%), career change (27%), retirement (22%), and promotion (15%) were the top reasons reported for expressed intent to leave. Although burnout was the most cited reason by all of the nurse managers planning to leave their jobs within the next 5 years, retirement was the most common reason cited by the nurse managers who were highly satisfied or satisfied and planning to leave within the next 5 years. Nurse managers who planned to stay in their positions for 5 years or more were more satisfied with their jobs, more likely to recommend nursing management to others, more satisfied with the amount of time they spent with staff, and had smaller spans of control. The image conveyed by nurse managers who plan to retire from their positions should send a positive message to others who may be considering a nursing management position. Given that retirement is an event that can be anticipated, smooth succession planning can take place.

Those expressing intent to leave because of burnout are unlikely to present a favorable impression of the role to others. This could have negative effects on recruitment. When nurse managers experience burnout and are less likely to recommend nursing management as a career, the nurse administrator may have more difficulty filling nurse manager vacancies. Efforts should be taken proactively to prevent nurse manager burnout by implementing strategies to reduce workload demands. Assessing and reducing large spans of control seems a logical place to begin. Shirey, Fisher, McDaniel, Doebbeling, and Ebright (2010) found that a pair of nurse managers managed large spans of control--up to 350 employees--with less reported stress than those managing smaller spans of control alone. While these authors reported the co-manager model led to reduced stress levels, this observation was based on a single pair of co-managers. Based on the evidence reported by staff nurses, smaller spans of control increase their job satisfaction (Cummings et al., 2010) and engagement (Cathcart et el., 2004). While there is no clear evidence defining the optimal span of control or unit-level management structure, evidence does suggest larger spans of control are a source of stress for nurse managers and dissatisfaction for staff nurses.

The nurse managers who planned to stay in their positions were also more likely to be satisfied with the amount of time they spend with their staff, which might reflect more than simply the number of direct reports. Perhaps evaluating the number and importance of meetings and report requirements might increase the time available to managers to interact with, coach, and mentor staff. Evidence also suggests staff nurses are more satisfied with their jobs when they perceive their managers to be supportive and practice relational leadership styles (Cowden, Cummings, & Profetto-McGrath, 2011; Cummings et el., 2010). Leaders who use relational leadership styles establish relationships with their staff and inspire them to achieve organizational goals (Cummings et el., 2010). Relationships are developed over time through consistent patterns of behavior. If nurse managers do not have a sufficient amount of time to engage in meaningful interactions with their staff, the findings from this study suggest nurse managers will be more likely to leave their positions.

Twenty-seven percent of those planning to resign within the next 5 years planned to change careers and 15% planned to assume an administrative role. These findings are consistent with the literature that employees desire challenges in their work (Crawford, LePine, & Rich, 2010). Organizational leaders should capitalize on this interest and provide developmental opportunities for nurse managers who want to assume executive leadership roles. Promoting from within the organization's nurse manager ranks could build commitment to the organization while providing a smooth transition between leaders at the nursing unit level. Providing career counseling services to nurse managers might facilitate transitions into other non-line organizational roles. Alternately, when seasoned nurse managers are looking for a new career challenge, rather than leaving their nurse manager positions they could be asked to identify an organizationally relevant project of interest to pursue. Another strategy to capitalize on their leadership expertise would be to encourage them to apply for leadership roles within their professional nursing organizations. In academe, senior faculty are offered sabbaticals to pursue scholarly activities to develop new insights, techniques, or collaborative relationships that advance their work. Similarly, seasoned nurse managers could be offered sabbaticals to pursue relevant fellowships; for example, in leadership, quality and safety, or health policy.

Limitations

A limitation of this study was the use of a cross-sectional design and convenience sampling strategy. The sample was limited to acute care nurse managers only. Thus, the sample may not be representative of the nurse manager population at large, and may affect the generalizability of the findings. That said, with the exception of the education level, the participants in this study were comparable in age, race, and gender with the respondents reported in the NSSRN.

Recommendations for Nursing Leaders

This study highlights the need for nurse leaders to assess the current state of nurse manager job satisfaction, intent to leave, and turnover in their organizations. A critical analysis of nurse manager turnover and vacancy rates may highlight positions that need to be reconceptualized. Nurse manager job satisfaction was associated with likelihood to recommend nursing management; thus, a dissatisfied nurse manager may paint a negative picture of the role to staff nurses considering nursing management. By restructuring problematic positions, staff nurses may be more willing to consider nurse manager opportunities and, in turn, reduce the time to fill vacancies.

Evaluating the workload of nurse managers and the growing expectations of the role is an important second step. Developing creative unit management strategies may reduce burnout and turnover among nurse managers and cascading effects on unit staff as well. Nurse manager workload is a complex phenomenon and consists of more than the number of direct reports and patient care areas managed. Workload evaluations should also consider committee involvement, report requirements, and the complexity of the patient care services offered within each nurse managers' scope of practice. As unit management strategies are redesigned, they should be evaluated for effects on staff, patient, organization, and financial outcomes.

Nurse leaders need to establish career development programs for nurse leaders at all levels of the organization. Succession planning, career development, and mentoring programs have the potential to keep nurse leaders engaged with their work and committed to the organization. Opportunities to strengthen leadership skills may exist outside of the organization.

The nurse manager role will evolve as organizations respond to changes in health policy and the current economic environment. As nurse leaders develop and test innovative management and leadership strategies, they should disseminate their findings to the broader nursing leadership community.

Recommendations for Future Research

In this study, the expressed intent to leave among nurse managers was commonplace. More theory-guided research is needed to understand the antecedents and consequences of nurse manager job satisfaction, intent to leave, and turnover in acute care hospitals and other clinical settings. While parallels may exist between reasons for turnover in staff nurses and nurse managers, there may be important differences between the experiences of the two groups. For example, evidence suggests the practice environment is a strong predictor of job satisfaction in staff nurses (Cowden & Cummings, 2012; Lu et al., 2012). The Nurse Manager Practice Environment Scale (Warshawsky, Rayens, Lake, & Havens, 2013) was recently developed to gauge the quality of the practice environments of nurse managers and facilitate studies testing this link in nurse managers.

A second direction for future research is to understand the impact of nurse manager turnover on staff, patient, organizational, and financial outcomes. The evidence suggests nurse managers create positive unit-level work environments through the use of relational leadership styles (Cummings et al., 2010). Turnover in the nurse manager role disrupts the relationships and the practice environment. Studies that examine the repercussions of nurse manager turnover are needed to build an evidence-based business case to drive changes in the management structures in health care organizations.

Conclusion

The findings from this study yielded new information about the current state of nurse manager job satisfaction and intent to leave their positions. In general, nurse managers are satisfied with their jobs yet many are actively planning to leave their positions. Some nurse managers plan to leave for continued growth opportunities and to retire, while others are planning to leave due to burnout and stress. These findings underscore the importance of succession planning for the anticipated turnover due to retirements. For those looking to ascend the leadership career ladder, senior nursing leaders should engage nurse managers in career counseling sessions and develop mentoring programs to prepare nurse managers for advancement opportunities within the organization. Furthermore, senior nursing leaders should assess nurse manager workload and expectations of this role. It is possible reductions in workload will result in increased longevity of the current nurse manager workforce. Perhaps the most important lesson from this study is the need for additional research to understand the determinants of job satisfaction in nurse managers.

ACKNOWLEDGMENT: The first author was a participant in the 2012 NLN Scholarly Writing Retreat, sponsored by the NLN Foundation for Nursing Education. This publication was partially supported by grant no. T32NR008856 (B. Mark, principal investigator) from the National Institute of Nursing Research. Contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Institute of Nursing Research, National Institutes of Health.

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NORA E. WARSHAWSKY, PhD, RN, is Assistant Professor, College of Nursing, University of Kentucky, Lexington, KY.

DONNA S. HAVENS, PhD, RN, FAAN, is Professor, School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC.

Table 1.
Questionnaire Items

Item                                    Response Options

How satisfied are you with being    1 = Very Dissatisfied to
a nurse manager?                    6 = Very Satisfied

How likely are you to recommend     1 = Very Unlikely to
nursing management as a career      5 = Very Likely
choice to other nurses?

How satisfied are you with the      1 = Very Dissatisfied to
amount of time that you spend       5 = Very Satisfied
working with your nursing staff?

How long do you plan to remain      0-2 years
in your current position?           3-5 years
                                    5-7 years
                                    7-9 years
                                    10+ years

If you plan to leave your current   Burnout
position in the next 0-5 years,     Career change
indicate your primary reason.       Education plans
                                    Family concerns
                                    Financial reasons
                                    Retirement
                                    Other, specify

Table 2.
Sample Demographics and Comparison 2008 National Sample Survey of
RN Data

Variable                               n       Mean (SD)    Percent

Age                                   286     47.4 (8.8)
Gender
  Female                              262                    90.3
  Male                                 28                     9.7

Organization Membership
  AONE only                            10                       4
  NCONL only                           26                    11.0
  Both AONE and NCONL                   4                     2.0
  Neither AONE nor NCONL              105                    43.0

Highest Nursing Education
  Diploma                              13                     4.5
  Associate                            25                     8.6
  Bachelor                            151                    51.9
  Master                              100                    34.4
  Doctorate                             2                     0.7

Highest Overall Education
  Diploma                               6                     2.1
  Associate                            18                     6.2
  Bachelor                            135                    46.4
  Master                              129                    44.3
  Doctorate                             3                     1.0

Years of Nursing Experience           287     21.3 (10.3)
Years of Nurse Manager Experience     290      9.1  (7.3)
Current Unit Tenure                   284      4.9  (4.7)
Span of Control
  FTEs                                261     60.8 (39.2)
  Number of Nursing Units             291      1.7  (1.0)

Variable                            Range   NSSRN 2008

Age                                 26-68     45.5 (a)
Gender
  Female                                      92.7% (b)
  Male                                         7.3%

Organization Membership
  AONE only
  NCONL only
  Both AONE and NCONL
  Neither AONE nor NCONL

Highest Nursing Education                      (b)
  Diploma                                     11.9%
  Associate                                   33.6%
  Bachelor                                    34.8%
  Master                                      19.6% (c)
  Doctorate

Highest Overall Education
  Diploma
  Associate
  Bachelor
  Master
  Doctorate

Years of Nursing Experience         2-45
Years of Nurse Manager Experience   0-35
Current Unit Tenure                 0-30
Span of Control
  FTEs                              7-241
  Number of Nursing Units            1-7

NOTES:

NSSRN = National Sample Survey of Registered Nurses (HRSA, 2010)

(a) Sample includes all RNs working in nursing.

(b) Subsample includes only those in management and
administrative positions.

(c) Master's and doctorate combined in NSSRN report.

Table 3.
Reasons for Intent to Leave Current Position in 5 years

                      All Participants     Participants Very Satisfied
                    with Intent to Leave     or Satisfied Who Intend
                        in 5 Years             to Leave in 5 Years
                          (n=210)                   (n=146)

Reasons                n          %            n              %

Burnout                63         30           15             10
Career change          56         27           33             23
Retirement             47         22           36             25
Promotion              32         15           29             20
Education plans        23         11           13              9
Family concerns        19          9            8              5
Financial reasons       4          2            1              0
Other                  21         10           11              8
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Author:Warshawsky, Nora E.; Havens, Donna S.
Publication:Nursing Economics
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Date:Jan 1, 2014
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