Nursing Leadership
Nurse managers and leaders are crucial to improving working relationships and providing clinical support to maintain a positive health care environment. Management leadership is also key to influencing retention of existing staff, since “leadership styles can empower nurses, decrease occupational stress, and increase work effectiveness” (British Columbia, 2000, p. 64). Many nurse managers currently working in hospitals and other care facilities report that they are significantly overworked, with many more direct reports under their control than is manageable. As a result, nurses feel as though their concerns are not being addressed and their needs are not being met, while their managers feel burnt out, stressed, and ineffectual.
Addressing leadership in nursing is an important step towards creating healthier work environments, improving patient care and enhancing the relationships between nurses and management. According to the Assess and Intervene report, “leaders empower nurses by providing purpose and meaning to their work; helping them understand the importance of their role in the organization; soliciting their participation in decision- making processes; enhancing their skills; providing resources required for effective performance; [and] showing confidence in their ability to perform at a high level” (British Columbia Ministry of Health, 2000, p.64). These elements of a healthy work life have an impact on retention, as nurses and nurse managers are more likely to stay in jobs where they feel appreciated and supported. Strategies designed to improve retention rates in health care must necessarily include leadership and management supports.
Retention of staff is both an expectation and a major responsibility of managers. Saskatchewan’s health reform initiatives in the 1990s led to a reduction for those in nursing management as well as reductions in front line staff, support staff and ancillary services. These reductions meant remaining managers became responsible for several
units, some over broad geographical areas, and often more than one geographical site. Traditional managerial roles, which included recruiting, mentoring, coaching, motivating, providing decision support, team-building, evaluating roles and making adjustments as needed, as well as input into clinical care, were significantly reduced or lost altogether. The loss of such a vital relationship between manager and staff has eroded recruitment, retention and quality patient outcomes, as evidenced over the past number of years. This is well-recognized in a number of studies undertaken in the past decade.
Evidence points to the fact that positive relationships exist between nursing leadership styles and workplace satisfaction, nursing turnover rates and nursing leadership styles, and patient outcomes and nursing turnover rates (Gagnon, Ritchie, Lynch, Drouin, Cass, Rinfret, Rouleau, Valois, Shannon, Smith, Leiriao, & Soundif, 2006; Laschinger and Wong, 2007).
The Laschinger and Wong study speaks to the relationship between Nursing Leadership Styles and Nursing Recruitment and Retention Initiatives as manifested by positive work- life and patient care. In their profile, Nursing Management within Canadian Hospitals, they identify the significant changes that have taken place within the ranks of nursing. The purpose of the study was to profile nursing leadership structures in Canadian hospitals in relation to organizational and structural characteristics of nursing management roles, and also to draw inferences as to how these characteristics affected quality of work life and quality of patient care.
The study (Laschinger and Wong, 2007) concluded:
• The last two decades of health care reform has resulted in larger spans of control and more “direct reports” for nurse managers. Nurse managers at all levels have adapted to these large spans of control with first line managers averaging 71 direct reports, which far exceeded the benchmark found in other work settings.
• The significant and ongoing restructuring that has taken place has not addressed the need for succession planning and had produced barriers to role effectiveness for nurse leaders through broadened role and functions, and increased organizational size. Many nursing leaders are now responsible for non-nursing personnel.
• Senior nurse leaders with staff authority were more likely to use an “enabling/encouraging the heart” leadership style. This style had a positive impact on their feelings of job and work satisfaction and reports of positive patient care.
Any attempt at conducting a successful study of nursing recruitment and retention strategies must first examine the concept of nursing turnover and delve into its cause and effect. A study entitled Understanding the Costs and Outcomes of Nurses Turnover in Canadian Hospitals (O’Brian-Pallas, Tomblin-Murphy, Shamian, 2008) was recently submitted to the Canadian Institute for Health Information, linking nursing leadership to nursing human resources. Currently awaiting publication, the report describes a pan- Canadian research project focusing on nursing turnover, examining its impact on patient and nurse outcomes and associated system costs. The study included eighteen health care sites, representing over 41 hospitals and 181 nursing units across ten Provinces in Canada including Saskatchewan. Main conclusions from this study include:
• Effective leadership within health care organizations is pivotal to reducing turnover because it addresses predisposing factors of turnover intent.
• Turnover of nurses is a major problem in Canadian hospitals. The costs of turnover are a major concern to the system. Key drivers of turnover are temporary replacement costs and initial decreased productivity of new hires.
Saskatchewan research by Leurer, Donnelly, and Domm (2007) explored the insights of experienced nurses regarding initiatives they believed would effectively retain nurses like themselves in the nursing profession. Saskatchewan nurses compared the current
situation to the situation prior to the health care restructuring of the 1990s. They expressed a desire to return to a management structure that includes more front line managers, who would be empowered to make decisions needed to support front line staff. Research conducted in 2001 by Baumann et al (Baumann, O’Brien-Pallas, Armstrong-Stassen, Blythe, Bourbonnais, Cameron, Doran, Kerr, McGillis Hall, Vezina, Butt, & Ryan, 2001a) identified that there was a decrease in organizational commitment with lower levels of management. Since employee perceptions and experiences are greatly affected by interactions with front-line managers, they concluded that organizations must invest in front-line managers to improve overall organizational performance.
Quality and accessibility of nursing leadership continues to be related to overall job satisfaction and nurse retention. One of the conclusions from the 2005 study An integrated strategy for Nursing Human Resources, Phase 1 Final Report identifies “cuts to nursing management” left nurses with few allies within the system. The authors recommend that a sufficient number of front line managers be on staff to allow reasonable contact with nurses in their setting. They further recommend that employers, educators, and governments work with nurses to develop succession plans that move nurses through management experiences and into formal leadership. (Torgerson, 2007)
For nursing leadership to have a positive impact on nurse retention requires giving nurse managers the ability to address job dissatisfaction, including a lack of professional support and recognition; inappropriate technical equipment and material; poor physical work environments; and ineffective problem solving related to the delivery of services from support departments.
Attempts to reduce nursing turnover should consider nursing leadership styles to enhance the quality of nursing work life. Doing so will reduce nursing turnover and improve patient health outcomes (Doran, McCutcheon, Evans, MacMillan, McGillis Hall, Pringle, Smith, & Valente, 2004).