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Who's the boss?

Nurse manager roles hard to fill

Monday February 6, 2012
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No one wants to be a nurse manager," said Tanya Osborne McKenzie, RN, MSN, MBA, director of the five-unit critical care service line at Salinas Valley Memorial Hospital, in Salinas, Calif. "It's extremely difficult to find nurse manager talent or to hire anyone."

Why are nurses so reluctant to step into these leadership positions?

McKenzie said people find the responsibility and stress aren't worth the title.

"One person left, wanting to go back to the clinical role. He said the job was just way too hard," she said. Staff members who are strong clinicians and would do well in management just won't take on the responsibility, she said.

Nursing leaders and researchers say there's no question it's tough to find and keep nurse managers. Yet hard data on these turnover rates is seemingly nonexistent.

Peter Buerhaus, RN, PhD, FAAN, Valere Potter Distinguished Professor of Nursing and Director of the Center for Interdisciplinary Health Workforce Studies at Vanderbilt University Medical Center, said he hears about the issue frequently — from staff nurses, mid-level nurses and executives — but no one has tracked turnover rates among nurse managers.

Researchers predict the situation only will get worse as the job challenges continue to magnify in the years to come, and unfilled nurse manager positions will affect nurses at all levels, even those with absolutely no interest in management.

Root causes of turnover

Susan Ohlson, RN, PhD, clinical assistant professor and director of the Office of Continuing Studies at the University of Illinois at Chicago College of Nursing, thinks nurse managers, like new grads, often are plopped into a situation and expected to sink or swim.

"Nurses aren't educated in the ways of leadership. We take clinicians and expect them to succeed in management. But it's a completely different set of competencies," she said.

Part of the problem may be people go into nursing to work with patients, attracted to the mission of caring, and then management takes them away from that, said Barbara Mackoff, EdD, director of the Leadership Laboratory, New York University Langone Medical Center, New York.

"The very thing that attracts women and men to nursing is what makes the adjustment to management so hard," she said. Nurses who stay view their management role as "giving care," she said, focusing on how their work directly improves the quality of care for patients. "It's important to keep a line of sight to the patient," she said.

Nurses managers usually have to deal with a huge work load and typically oversee a larger number of people than most managers in other fields Mackoff said. A 2002 study conducted by the American Organization of Nurse Executives showed first-line managers were responsible for an average of 32 staff; in larger hospitals, they managed 54 employees.

Nurse managers have to deal with complex, high-stress environments, said Mary Meadows, RN, MS, MBA, director of professional practice at AONE. The stress, she said, is complicated by an authority-responsibility mismatch. In other words, managers sometimes feel they are responsible for far more than they have the authority or ability to control.

Combating problems

The challenges have spurred several national and regional interactive, short-term, nondegree programs aimed at providing managers practical education and resources.

The UIC College of Nursing has developed a Positive Workplace Partnership program, for example, working with the med/surg staff at Adventist GlenOaks Hospital in Glendale Heights, Ill. Ohlson, who was involved in the program, said it was designed to be something like a new grad program for new managers. The program focuses more on leadership skills than management tactics, using a case study approach based on the participants' needs and problems.

"People need time to grow into the role," Ohlson said. "At most hospitals, when a new manager comes in, education is usually done one at a time, and there's not much structure to it."

AONE has designed and conducted 17 institutes, a spectrum of programs geared toward nursing managers at different stages of experience, including opportunities for both "aspiring mangers" and more experienced leaders. While the organization has no data on the impact of the programs, Meadows said, the feedback is positive, and participants often say "this is the orientation I never got."

Each of the programs has a different curriculum. Learning objectives of the Emerging Nurse Leader Institute, for example, include helping participants learn more about managing people; assessing their individual skill sets; financial management; RN/MD relationships; and negotiation and conflict resolution.

Some of the benefits of formal education programs are the opportunity for nurse managers to learn from each other, understand how to make better decisions and tap their colleagues' knowledge, both inside and outside the institution. Maria Shirey, RN, PhD, MBA, associate professor at the University of Southern Indiana in Evansville, did a study to be published later this year that looked at how nurse managers make decisions. She found those with experience rely more on their networks and are able to use the "big picture" to help guide their decision-making.

"A novice manager allows things to happen to [him or her], and isn't able to connect the dots as well," she said.

Shirey also has found the way management responsibility is structured can go a long way toward creating successful leadership opportunities. For example, she has seen a situation in which two full-time co-managers are responsible for two units and a total of 350 staff members. On a given day, one serves as a resource to staff and the other handles meetings and deals with issues that arise. If a crisis occurs, they're both involved and there are two sets of hands.

McKenzie participated in a basic AONE nurse manager program and, more recently, the Nurse Manager Fellowship program. She said the fellowship program, which starts off like "nurse manager boot camp," encompasses a gradually broader perspective at each of four quarterly retreats. The experience has helped her develop a big–picture perspective on the issues she's facing and on nursing in general because she can compare what is happening in her organization with other hospitals around the country. She also can tap her new national network of colleagues for feedback and advice, she said.

McKenzie said, while the education has been valuable, she still often feels stressed and over-stretched. "I have 150 employees," McKenzie said. "How can I effectively create an environment for them to successfully do their jobs? It's very difficult for them to do that when they don't have the resources."

Keys to success

Mackoff, who with fellow researcher Pam Triolo, RN, PhD, has studied what factors contribute to nurse manager job longevity and excellent job performance, has found there are certain keys to success. They talked with 30 nurse managers at six institutions and discussed what the leaders felt was critical to their survival within their organizations.

Mackoff boils it down to what she calls "engagement," when managers are focusing on the patients and the purpose of their work, and finding gratification in developing others and supporting autonomy. She also said organizations that are capable of retaining excellent managers create a "culture of regard," with shared government, opportunities for educational mobility, respect for risk-taking and support for the decisions nurse managers make. Organizations need to show they value nurses and that nurses are at the table when key decisions are being made, she said.

The success of management has a critical impact on overall nursing turnover, experts say. "There's a consensus in the field that staff nurses leave managers, not organizations," Mackoff said. "Managers are crucial."

Despite the enormous challenges, management has its rewards.

"When things go well and you're able to see that the outcome for patients is positive," McKenzie said, "you feel you're leaving a legacy." •


Barbara Bronson Gray, RN, MN, is a freelance writer.Write to editor@nurse.com or post a comment below.
Want to be a nurse manager? 5 key questions to consider

Maria Shirey, RN, PhD, MBA, associate professor at the University of Southern Indiana in Evansville, suggests potential managers consider these critical questions before taking a leadership job:

1. Do I have a passion for leadership?

Ask yourself whether you enjoy being in charge, managing people and dealing with complex problems, whether you enjoy teaching and motivating people to succeed, whether you’re comfortable dealing with conflict and whether you will be frustrated by leaving the bedside.

2. Do I understand the job requirements?

Be sure you know the job expectations. Talk to others in similar roles within your organization.

3. What support would be available and where would I learn new skills?

Find out how the organization will support your need to learn new skills and understand what knowledge you’ll need to gain.

4. Would I have mentors?

See whether there are people willing to help guide you and answer day-to-day questions as they arise. Find out whether you could take continuing education classes to support your new role.

5. What do I want to be doing in five years?

Consider whether a management role in the organization will support your five-year goals for your career and your lifestyle.