Nurse Manager Support: How Do Staff Nurses Define It?

Nurse manager support, which is essential for a healthy work environment, depends upon staff nurses’ perceptions.What is nurse manager support? I do the things that my nurse manager did to show me support plus all the things that I wished she would have done to show me support when I was a staff nurse. But is that what staff nurses today consider support? I don’t know; that’s a good question. It’s never come up in our group sessions. I’d really like to know if what I consider supportive is the same as what the staff would say. (Nurse Manager)Perception is reality! The behaviors of nurse managers that staff nurses perceive as supportive may or may not be the same as the behaviors that nurse managers think are supportive.Stimulated by staff nurses’ identification of nurse manager support as 1 of the 8 essentials of a healthy work environment, that is, an environment that promotes job satisfaction and enables staff to give high-quality patient care, we began a 7-year quest to find out: What does nurse manager support mean to clinical nurses on the front line in both teaching and community hospitals? What are the specific behaviors of nurse managers that staff nurses identify as supportive? If nurse managers are to be optimally effective, they must know and enact the behaviors that convey support to staff. Only staff nurses can identify these supportive behaviors and, through valid measurement, provide the necessary feedback to nurse managers, who in turn have the power to change and alter that aspect of the work environment.The role of the nurse manager in acute care settings has undergone several dramatic changes in the past 3 decades, evolving from that of head nurse or clinical expert, to that of department head, to that of nurse manager and leader.1 The role continues to be a major focus of discussion and research today. The leadership of the nurse manager is key to effective functioning of the unit, to high-quality patient care, and to retention of nurses.2 In one study,3 84% of nurses leaving or considering leaving their jobs did so as a result of their relationships with their nurse manager. Taunton et al4 report that 40% of the 124 nurses who separated from their unit during the 6-month period of the study left their nurse manager (transferring to another unit within the same hospital), not the hospital. Effective performance in the nurse manager role is key to the empowerment of staff that is essential to work effectiveness,5 to the strong need for nurses to function autonomously for patient safety and quality care,6–9 and to promotion of the collaborative/collegial relationships between physicians and nurses that are essential to good outcomes for patients.10–12Support of staff is either a highly regarded function of the nurse manager or it is seemingly ignored, as evidenced by the lack of specific supportive role behaviors. Staff nurses in magnet hospitals,13 the American Association of Critical-Care Nurses,14 and the American Organization of Nurse Executives15 identify nurse manager support as essential to a healthy work environment. Nurse manager support is 1 of the 8 essentials of a healthy work environment identified by staff nurses in magnet hospitals; the behaviors specific to the nurse manager role in designating this support were primarily leadership functions.13 Nurse manager support is one of the role functions of nurses in leadership positions identified by the American Association of Critical-Care Nurses under their authentic leadership standard for establishing and sustaining healthy work environments14; specific role behaviors are not listed. Nurse manager support of staff is cited 3 times in the American Organization of Nurse Executives’ list of 179 “competencies common to nurses in executive practice regardless of job title”15; supportive role behaviors are not provided. In contrast, the American Nurses Association’s standards for nurses in administrative practice16 make no reference to nurse managers’ support of staff, the supportive role function, or to supportive role behaviors.As a foundation for evaluating the content of nursing leadership and administration courses, Jennings et al17 analyzed the contents of a 5-year (2000–2005) literature search in CINAHL and MEDLINE. They found 894 citations of leadership, management, or combined competencies or role functions. “Setting the vision” and “developing people” were the primary leadership functions; “managing human resources” and “information management” were the dominant management functions. However, no mention is made of the nurse manager’s function in a support role nor are any supportive role behaviors described.The role of interest in this article is that of a middle manager who has 24-hour responsibility for the operation and strategic planning of 1 or more hospital or clinic units, regardless of whether the job is titled nurse manager, supervisor, care center director, clinical coordinator, or managing director. It is to this individual that charge and staff nurses on all shifts report and to whom they are ultimately responsible.Role function is the overall broad responsibilities inherent in a role. Nurse manager functions usually include business, clinical, personnel functions, and career development as well as the “staff support” function that is the focus here. Role behaviors are groups of organized, observable (directly or indirectly through outcomes) activities that support a specific function. Role activities are the more discrete, insular events. Activities are usually related to multiple role behaviors. For example, eliciting information on the viewpoint of staff nurses on an issue such as “changing the policy so that only respiratory therapists can deep suction patients in the intensive care unit” is a role activity essential to the role behavior “Represents the staff ‘s position in administrative discussions and decisions.” “Eliciting information on the position of staff “ is also an activity related to role behaviors such as “Resolves conflicts constructively” or “Provides adequate numbers of competent staff.” In this article, nurse manager support of staff nurses is the role function of interest; supportive behaviors are the quest; role activities are used as examples or descriptors.If nurse managers are to enact a support role function, supportive role behaviors from the perspective of staff nurses must be identified and effectively measured. The National Database of Nursing Quality Indicators, one of the most widely used instruments to assess job satisfaction among staff nurses, lists supportive nurse management as 1 of 3 work-context indicators that must be measured and measures it with 4 items from the revised Nursing Work Index.19 Three of the items—”The nurse manager is a good manager and leader,” “The nurse manager is supportive of nurses,” and “Staff are not satisfied with their nurse manager”—are very global and general and require individual respondents to define and interpret these items within their own frame of reference. The fourth item, “The nurse manager backs up the nursing staff in decision making even in conflicts with physicians,” cites a specific supportive behavior that is part of the nurse manager’s role. This discrepancy in the level of measurement might well account for the counterintuitive finding reported in a study20 that used these same 4 items to measure the effect of nurse manager support on 30-day mortality rates for 46 993 acute medical patients in 75 Ontario hospitals. Tourangeau et al20 reported that lower patient mortality rates were associated with low, not high, levels of nurse manager support as hypothesized.Following the 2001 identification of nurse manager support as 1 of the 8 essential components of a productive, satisfying work environment, we developed a tool, the Essentials of Magnetism (EOM), to measure all 8 of the essential work processes.21 The EOM is designed to measure the steps or components of each work process, not just perceived presence. In line with this principle, the items for the nurse manager support sub-scale of the EOM must consist of the specific behaviors of nurse managers that staff nurses identify as supportive. What are these supportive behaviors? Thus began the quest to identify a comprehensive and universal set of supportive nurse manager role behaviors identified by staff nurses. Little did we realize it would take 7 years and 7 research studies to accomplish this goal.In this article, we synthesize the results of 7 research studies conducted from 2001 to 2007 as they relate to the question of “What behaviors of nurse managers do staff nurses perceive as supportive?” In all of these studies, data were collected through individual interviews with staff nurses working on clinical units/clinics in magnet hospitals and comparison hospitals that were not designated as magnet hospitals, and through quantitative surveying of staff nurses with the EOM and other instruments. Details of the background, methods, and data collection are not presented here, as all those studies have been published.8,9,11–13,21–23The presentation is organized into 4 sections: (1) Manager or leader: which behaviors are the most supportive? (2) Comprehensive: what is the universe or totality of supportive role behaviors of nurse managers? (3) Universal: Are the identified supportive role behaviors meaningful to staff nurses working in all types of hospitals? and (4) Which behaviors are most supportive? Is there a hierarchy? In each of these sections we will follow the pattern: What We Did (methods), What We Learned (results), and Decisions Made (conclusions and interpretation).For many decades, the emphasis in nursing administrative publications has been on examining and labeling whether the nurse manager’s job and role behaviors are managerial, that is, focused on maintaining order, coordinating resources, and attending to rules and details, or whether they are leadership, that is, based on relationships and helping people move toward achieving a vision.24 From the individual interviews with 279 staff nurses and focus-group interviews with 132 nurse managers and 61 nurse executives in 14 magnet hospitals,13 we abstracted 5 supportive manager behaviors (Table 1) and 5 supportive leader role behaviors (Table 2). These supportive behaviors became items on the Nurse Manager Support Scale on the EOM21 that was administered to more than 30 000 staff nurses in conjunction with our own studies or by request from individual hospitals.More leader than manager behaviors were identified by staff nurses as supportive by a ratio of almost 3 to 1. Two manager behaviors, providing needed resources and making out staffing/vacation schedules, were cited regularly. Providing direct patient care was cited often by staff nurses in some hospitals but less frequently in others. We also learned that staff nurses were not particularly interested in whether a behavior was labeled leader or manager.The following decisions were made: Continue to include both manager and leader behaviors but include more leader behaviors. Ascertain whether future groups of staff nurses continue to identify these behaviors as supportive. Be alert to see if a pattern develops with regard to the selection of different leader and manager behaviors by staff nurses in some types of hospitals (teaching or community) than in others.We reviewed and culled the literature for any and all mention of supportive role behaviors of nurse managers. Then we conducted 2 nationwide studies in 11 magnet and 2 comparison hospitals, one to identify structures and “best management practices” that promoted collegial/collaborative relationships between nurses and physicians11,12 and the other to identify best management practices related to clinical autonomy.8,9 We EOM-tested more than 4000 staff nurses in 26 hospitals and almost 1000 nurses nationwide on the Web21,25 and began to compile a comprehensive list of supportive role behaviors of nurse managers as identified from interviews and from comments written on the EOM instrument.The 10 leader-manager role behaviors identified in the 2001 study do not adequately represent the construct, nurse manager support. Behaviors such as “Makes it possible for nurses to participate in interdisciplinary patient care rounds” (from the nurse-physician study) and “Holds staff accountable in a positive, constructive way for autonomous decisions made” (from the autonomy study) should be added to the comprehensive list. From the EOM testing of nurses in more than 50 hospitals and on the Web by the end of 2004, and item analysis of the Nurse Manager Support Scale, it became apparent that in some hospitals, staff nurses consistently identified more manager role behaviors as supportive while in others, the behaviors identified were almost totally leader.The following decisions were made: Develop a comprehensive list of supportive role behaviors of nurse managers by adding additional behaviors as identified. Conduct interviews with staff nurses, and also interview nurse managers and physicians to explore their respective definitions of nurse manager support. Identify behaviors that support, and behaviors that do not, and explore differences in perceptions of nurse managers’ support behaviors by type of hospital and by the professional role of the interviewee.During the spring and summer of 2006, we interviewed 244 staff nurses, 105 managers, and 97 physicians working on those units in 8 magnet hospitals where staff nurses had previously confirmed that they had excellent nurse manager support.23 We asked each staff nurse interviewee: “What does the nurse manager do that conveys that she/he supports you?” Nurse managers and physicians were asked: What do you (nurse manager) do or (for physicians) what does the nurse manager do that conveys support to staff nurses? We analyzed the interviewee’s responses to the preceding by like responses into of supportive role the to to do the we also of the nursing department job and performance conducted of staff and we learned that behaviors of nurse managers were identified as supportive (Table From of and data and the we learned that what is perceived as supportive is a function of the and leadership practices in hospitals. For example, the nurse manager role “Makes it possible for staff nurses to participate in interdisciplinary rounds” is meaningful only when the hospital has such The role autonomous decision making by for the practice we are is not by nurses in hospitals that are not in behaviors of nurse managers that staff nurses perceive as supportive are also by the the nurse manager’s role and the the nurse manager, and the staff define the charge role. of the nurse manager and the nurse manager’s job what the manager in staff nurses’ perceptions of what they can from their manager in of support. This is particularly with to the nurse manager’s in behaviors such as direct patient care and unit If of the management of the unit has been to charge staff nurses, nurses do not perceive it as supportive when the nurse manager these behaviors and related In it may even be with the staff nurse that “The nurse manager think I can do my following decisions were made: the comprehensive list of supportive role behaviors of nurse managers, we need more role behaviors of nurse managers are and by and definitions of the nurse manager role that among hospitals. and list of supportive behaviors must be and for developed and a Nurse Manager Support Scale et for a of the and results from this with all the supportive role behaviors from all we added the behaviors found in the literature plus a selection of behaviors from the American Organization of Nurse Executives’ competencies for nurses in executive practice regardless of job that and behaviors such as “The nurse manager supports staff in behaviors We an with more than nurses in 10 hospitals and in a in nursing These respondents and of the additional supportive behaviors. The Nurse Manager Support Scale was administered to staff nurses on all clinical units in 8 magnet the 30 supportive role behaviors were into 4 Behaviors into the leadership such as and unit and and constructively” were reported to be the most supportive. The managing the work group and resources which behaviors such as “Represents unit and viewpoint to other and staff and was the most supportive The career development the behaviors staff in and and the managing the unit with behaviors such as “Provides direct patient care in and were reported to be the following decisions were made: a comprehensive list of the most supportive role behaviors of nurse managers, the most supportive role behaviors identified by the with the role behaviors cited as most supportive by the staff nurses who to the Nurse Manager Support Then this list to nurses in a of hospitals to the supportive role behaviors that are this study has not been reported more on the are here. The 14 supportive role behaviors from the combined interview and Nurse Manager Support Scale studies were for by to staff nurses in a of 14 teaching and community hospitals of different under different The 14 hospitals teaching and and Three hospitals were part of different of the hospitals had or other in from to more than and were in and in of the and of 10 staff nurses hospital was through the research for 2 (1) we that these nurses would be the most to the for such a and (2) we from the nurses on different units who usually are in this with of the study and was to each nurse either through the research or by an of staff nurses from the 14 hospitals They on the and made and each of the 14 items on the of the following is an essential supportive role behavior of nurse is a supportive would be if my nurse manager did but it is not really and is not an supportive behavior and be role behaviors were perceived as supportive. item from to This very that to of the nurses all 14 items to be supportive or supportive. of the 14 role behaviors of nurse managers with mean item from to were identified as supportive by all (Table nurses in this study the very than of with the some of the that behaviors be in the list of supportive behaviors. nurses used the activity as the for they were for in or in It was that the nurses were interested in what they and their upon as supportive role behaviors of nurse managers. They and into the and of respondents that they had with their while the many comments and additional into staff nurses nurse manager support. that and is a or than a However, the that this item a supportive and and should be left was that some supportive role behaviors are and is a nurse manager role behavior that of the respondents was supportive for or nurses in their It was perceived as but not for nurses with more developed we learned that supportive role behaviors of nurse managers are often “best management” Role behaviors are often supportive in to some other work or We have this for clinical autonomy and collegial/collaborative relationships between nurses and highly is nurse manager support for and clinical 2 other essentials of a healthy work environment identified by staff supportive role behavior that is also a best management practice is, “Makes it possible for to courses, 10 universal role behaviors of nurse managers cited by staff nurses in 14 hospitals as essential and (Table the items that measure nurse manager support on the EOM information has been presented in the and mean item for the 10 supportive role behaviors were so that of the items is not In to the other the for nurse manager support is more to the perceptions of support in different hospitals and different in career than it is to the steps or components of the nurse manager support nurse manager in the retention and job satisfaction of nursing staff. Nurse manager support through the other essentials of If you nurses to practice relationships with and and that competent the nurse manager must enact supportive role behaviors or these essential work will not The role behaviors identified in this of studies are a good for by both nurse managers and staff nurses. Nurse managers can whether they enact these role behaviors or if there are other that they convey support to the staff. Staff nurses can do the between the nurse manager and the nursing staff will to and effective It might also be a good for nurse managers to these supportive role behaviors with their or nursing as the of those the support that nurse managers can provide to the nursing is in the best of the staff nurse and of quality patient care for staff nurses to make their for support to the nurse manager. of the identified supportive role behaviors may nurses to more the support needed from the nurse manager. For example, if a nurse is in a with a as to the best to a care and did not what was from the nurse manager, that nurse to the manager. The nurse to that she the manager to up and to for me of not It may be that the nurse manager is either or to provide the of support the nurse manager and such a the staff nurse in the future in such as no support will be Staff nurses are in a position to they to a if they have to do it If the nurse manager does to for the the nurse can the manager know supportive and that behavior feedback never managers must be supportive role behaviors but also need to the necessary competencies to enact such role behaviors. Nurse managers we have interviewed that they from managers, by the human resources and the of nurse managers has from the of on the must be made so nurse managers can the competencies needed to enact the supportive role behaviors identified by staff et al17 in their analysis of the literature that most competencies were identified as both leadership and management and that between the 2 may not be in most manager from leader may not be so can be when what behaviors can be to charge nurses or administrative the of the nurse manager’s we just adding more role behaviors. some has to be the unit” patient be to others. behaviors such as the the of are more to give even if it would not be a good to do it may be to between leadership and management competencies in of the finding that managers in hospitals with patient mortality rates have of It may be that a of nurse managers from the leader role behaviors that support to the nursing staff nurse of support, nurse managers need support. or who can the type to and of the nurse manager’s This be used with and nursing manager support is a in maintaining healthy work We to have nurses leaving the unit and the hospital their nurse manager was not as supportive as needed or the and of the 8 magnet hospitals that as the of the study for both nurse manager support and perceived of of and of The also and the nurse managers and staff nurses from the following hospitals and the in nursing who in the studies to the and of the supportive nurse manager role and of of of of and The and items are but essential that are not However, the quality of the results is to the and of all these people who the most and most in our care clinical nurses on the front

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