Journal of Nursing Management, 2014
Factors influencing nurse managers’ intent to stay or leave: a quantitative analysis SARAH J. HEWKO R D , M H A 1, PAMELA BROWN R N , M N 2, KIMBERLY D. FRASER CAROL A. WONG R N , P h D 4 and GRETA G. CUMMINGS R N , P h D , F C A H S , F A A N 5
RN, PhD
3
,
1
Doctoral Student, 3Assistant Professor, 5Professor, Faculty of Nursing, University of Alberta, Edmonton, AB, Manager, Alberta Health Services, Edmonton, AB and 4Associate Professor, Arthur Labatt Family School of Nursing, Western University, London, ON, Canada
2
Correspondence Greta G. Cummings University of Alberta 5-110 Edmonton Clinic Health Academy 11405 87 Avenue Edmonton AB T6G 1C9 Canada E-mail: [email protected]
HEWKO S.J., BROWN P., FRASER K.D., WONG C.A. & CUMMINGS G.G.
(2014) Journal of Nursing Management Factors influencing nurse managers’ intent to stay or leave: a quantitative analysis
Aim To identify and report on the relative importance of factors influencing nurse managers’ intentions to stay in or leave their current position. Background Effective nurse managers play an important role in staff nurse retention and in the quality of patient care. The advancing age of nurse managers, multiple job opportunities within nursing and the generally negative perceptions of the manager role can contribute to difficulties in retaining nurse managers. Methods Ninety-five Canadian nurse managers participated in a web survey. Respondents rated the importance of factors related to their intent to leave or stay in their current position for another 2 years. Descriptive, t-test and MANCOVA statistics were used to assess differences between managers intending to stay or leave. Results For managers intending to leave (n = 28), the most important factors were work overload, inability to ensure quality patient care, insufficient resources, and lack of empowerment and recognition. Managers intending to leave reported significantly lower job satisfaction, perceptions of their supervisor’s resonant leadership and higher burnout levels. Implications for nursing management Organisations wishing to retain existing nurse managers and to attract front-line staff into leadership positions must create and foster an environment that supports nurse managers. Keywords: empowerment, health human resources, leadership, nurse manager, retention Accepted for publication: 17 June 2014
Background Effective nurse managers play an important role in staff nurse retention, and ultimately, in the quality of patient care (Mackoff & Triolo 2008). Few senior nurse leaders in Canada are under the age of 45, the average age being between 46 and 55 years. Only 8.5% of first-line and middle managers are between 25 and 35 years of DOI: 10.1111/jonm.12252 ª 2014 John Wiley & Sons Ltd
age (Laschinger et al. 2008). The advancing age of nurse managers and nursing directors, multiple job opportunities within nursing and the generally negative perceptions of the role of nurse manager all contribute to existing difficulties in recruiting and retaining nurse managers (Rudan 2002, Laschinger et al. 2004). Struggles to retain managers are further exacerbated in Canada by hospital restructuring, which, in the 1
S. J. Hewko et al.
1990s, led to a significant reduction in the number of nurse management positions (Laschinger et al. 2004). In Alberta, a 2009 province-wide restructure resulted in a loss of 100 managerial positions. As a result, the remaining nurse managers have increased spans of control and heavier workloads (Lang 2009). The retention of nurse managers is of widespread concern. A longitudinal Australian study reported that fewer managers intended to stay in nursing management positions (82.4% in 1989 vs. 72.7% in 1999), with many indicating plans to move to a clinical position (Duffield et al. 2001). In a recent prospective Swedish study, 40% of health-care managers had left their positions within 4 years (Skagert et al. 2011). In the United States, more than 67 200 nurse manager vacancies are predicted by the year 2020 (Shirey 2006). A recent national survey of Canadian nurses found that only 24% of direct care nurses were interested in pursuing a nurse management role; interest in the role declined steadily with age (Laschinger et al. 2013). This is our quandary – as more existing nurse managers leave their positions, whether to retire or to return to clinical practice, fewer direct care nurses have an interest in stepping into the role. Few quantitative studies have examined job retention among nurse managers (Skagert et al. 2011). The purpose of this study was to identify factors that influence nurse managers’ intentions to stay in or leave their current position.
Literature review Several theoretical models of staff nurse intent to stay or the determinants of nurse intention to remain employed are reported in the retention literature. Boyle et al. (1999) developed a research-based Conceptual Model of Intent to Stay that described four sets of predictor variables of intensive care unit staff nurses’ intention to stay employed. Five variables found directly to affect intention to stay were the managers’ position power, the presence of opportunities elsewhere, manager influence over work coordination, promotional opportunities and job satisfaction. Variables that were indirectly related to intent to stay included situational stress, control over nursing practice and characteristics of the manager including consideration and structuring expectations (Boyle et al. 1999, Tourangeau & Cranley 2006). Gilmartin (2013), in a recent review of the nursing turnover literature, concluded that, despite notable and significant prior work in the area, turnover research in the discipline of nursing has failed to keep pace 2
with theoretical and conceptual advances found in management-based turnover research. The tasks and duties of staff nurses differ significantly from those of nurse managers, as does the span of control and the level of personal accountability for unit-level performance. It is unreasonable to assume, prior to empirical investigation, that the factors that influence nurse managers’ intention to leave or stay will be the same factors that influence staff nurses’ turnover intentions. There are early empirical indications that factors related to turnover among staff nurses are not the same as those related to turnover among nurse managers – for example, in a recent quantitative study, job satisfaction, which has been established as a factor related to staff nurse turnover, was found to have a nonsignificant association with turnover among nurse managers (Warshawsky & Havens 2014). Several recent studies have explored the phenomenon of turnover among nurse managers. Skagert et al. (2011) concluded, following a 4-year prospective study of health-care managers (not exclusively nurse managers), that the primary predictors of manager turnover were work-related: job demands, job control, social support and frequency of contact with patients. Warshawsky and Havens (2014) reported, following a secondary analysis of electronic survey data (n = 291 nurse managers), that the top four reasons for manager leaving intentions were career change, burnout or stress, retirement and promotion. Retirement, as a reason for leaving, was more frequently reported among managers with high job satisfaction. Those managers intending to remain supervised fewer staff and reported both higher job satisfaction and greater satisfaction with the amount of time spent with staff (Warshawsky & Havens 2014). In a recent systematic review, Brown et al. (2013) evaluated the current knowledge of factors influencing nurse managers’ intentions to stay in or leave their current positions. In the 14 included studies, 25 factors were found to influence nurse managers’ intentions to stay or leave: factors were grouped into the categories of organisational, role and personal. Organisational or institutional factors – that is, those within an organisation’s power to change – include organisational values and culture, human and fiscal resources, effective administration and the presence of succession planning. Role or position factors were inherent to the nurse manager role and included the potential for work–life balance or work overload, the clarity of expectations and the regularity and content of feedback. Personal or individual factors were ª 2014 John Wiley & Sons Ltd Journal of Nursing Management
Factors influencing nurse manager retention
characteristics of the individual nurse manager such as their personal beliefs, personal life and life experience (Brown et al. 2013). Factors conceptualised as common to the organisational and role categories included empowerment, leadership style, support and communication. Factors common to role and individual categories included work–life balance and the ability to provide quality patient care. Factors conceptualised as shared among all three categories were work–life balance, job satisfaction and ability to provide high quality care. The results of this review indicate that nurse managers’ reasons for leaving or staying are multifactorial and interrelated (Brown et al. 2013). Based on the literature review and the authors’ managerial and research experience the following research questions were developed to guide the study: 1 Do nurse managers’ intentions to leave or stay differ based on demographics of age, gender, years of experience, years of experience as a manager, level of education and work environment? 2 Which factors were reported as important to forming intention decisions? 3 What organisational, role and individual factors are associated with the retention of nurse managers?
Methods Research design The Social Science and Humanities Research Foundation (SSHRC)-funded Quality Work Environment Study (QWEST 2007-2010) was a non-experimental, cross-sectional, three phase study. The primary purpose of QWEST was to examine the resonant leadership practices of first-line patient care managers in three health-care settings – acute care teaching hospitals, general hospitals and long-term care. Additional goals included assessment of the impact of manager leadership practices on workplace empowerment, nurse perceptions of their quality of work life and of the culture of patient safety. QWEST phase 1 consisted of individual interviews with managers from each study setting, followed by focus groups with staff nurses to gain additional contextual information about work life and the culture of patient safety. Phase 2 involved completion of a web-based survey by front-line nurse managers. Phase 3 included a paper-based survey for staff on the units of managers who had responded to the electronic survey. All data were linked by unit and de-identified. ª 2014 John Wiley & Sons Ltd Journal of Nursing Management
Sample The web-based survey was distributed to 290 frontline managers in a western Canadian city. The response rate was 33%, with 95 managers returning completed surveys; 36 in acute care hospitals, 33 in general hospitals and 26 in long-term care facilities. Simultaneous to survey distribution, regional health authority restructuring resulted in the elimination of 100 manager positions.
Measures The analysis reported here utilises only manager survey data collected in phase 2. The manager survey included questions within the following areas: work unit information, unit characteristics, unit staffing and resources, programmatic and structural changes, unit work environment, time spent on managerial tasks, work relationships, work life as a manager, relationship with work, professional development, number of staff supervised and demographic information such as age, sex, level of education and years of experience in the profession and as a manager. In addition, frontline managers were asked to rate the importance of a series of factors related to their reported intent to leave or stay in their current position for another 2 years. Additional contextual data were collected such as facility type, specialty area and inpatient vs. outpatient environment. Five managers participated in pilot testing the manager survey, which resulted in an estimated time to complete, clarification of wording and in elimination of some items. Intent to stay Respondents were asked the likelihood that they would stay in their current position for another 2 years. If the respondent indicated it was ‘very likely’ or ‘likely’ that they would stay they were categorised as managers intending to stay. If they reported that it was ‘very unlikely’ or ‘unlikely’ that they would stay, they were categorised as managers intending to leave. A branching method was utilised to direct managers intending to stay to rate the importance of 15 factors influencing intention to stay and managers intending to leave to rate the importance of 15 complementary factors influencing intention to leave. Possible responses ranged from ‘very important’ to ‘not important at all’. The 15 factors presented to each group (managers intending to stay and managers intending to leave), developed based on the results of phase 1 interviews 3
S. J. Hewko et al.
and focus groups, were to be written as complementary. For example, managers intending to stay were asked to rank the importance of sufficient job security in influencing their intent to stay, and managers intending to leave were asked to rank the importance of insufficient job security in influencing their intent to leave. For some factors, complementary statements were more difficult to derive. For example, managers intending to stay were asked to rank the importance of their Desire to finish the work I have started here, while managers intending to leave were asked to rank the importance of their Desire to extend career in a different direction.
Organisational factors Patient safety culture Previous studies have reported low Cronbach alpha scores for the Modified Stanford Instrument (MSI) Patient Safety Culture questionnaire and have noted problems with its psychometric cross-validation, resulting in unstable factor analysis (Ginsburg et al. 2009a,b). Therefore, given the length of the questionnaire (46 items), the QWEST team decided to use only 16 of the original 46 items scale; responses were on a 5-point scale ranging from ‘strongly disagree’ to ‘strongly agree’. For the purposes of this analysis, we chose to use three questions that best measured safety, resources and loss of staff. ‘Is patient safety a priority?’ ‘Is the ability to provide quality patient care negatively affected by loss of experienced personnel?’ and ‘Are there adequate resources to provide safe patient care?’ Cronbach’s alpha was 0.66.
Leadership The Resonant Leadership Scale (10-item), which focuses on emotionally intelligent leadership behaviour, yielded a Cronbach’s alpha score of 0.96 in the managerial context (Estabrooks et al. 2009), 0.94 among staff nurses (Laschinger et al. 2013) and 0.93 in this study. The managers were asked to rate their director/supervisor on a series of statements using a 5-point scale ranging from ‘strongly disagree’ to ‘strongly agree’. Global empowerment The Global Empowerment Scale-II is a 2-item scale, with known reliability of 0.86 (Laschinger et al. 2003) and 0.95 in this study, that measures nurses’ perceptions of empowerment in their workplace.
Individual factors Job satisfaction Two items from the Global Job Satisfaction Scale (Quinn & Shepard 1974) were used to measure job satisfaction: ‘How satisfied are you with your job?’ and ‘How much do you like your job?’ Responses were provided on a 5-point scale of 1 = not at all satisfied to 5 = completely satisfied. A previous reliability score was 0.92 for the full-5 item scale (Quinn & Shepard 1974) and 0.69 for the two items selected for analysis.
Programmatic changes Two multi-part questions examining programmatic and structural changes resulting from health system restructuring were developed based on the feedback received during phase 1 manager interviews. The questions asked if the wait times for decisions by senior management, turnover/vacancies in frontline management positions, restructuring of middle management positions and restructuring of senior management positions had changed in the past year. Respondents rated changes on a 5-point scale ranging from ‘decreased a lot’ to ‘increased a lot’.
Burnout The 9-item Maslach Burnout Inventory (MBI) was used to collect data to measure burnout, relationship with work, and emotional health and well being. The MBI contains three subscales: burnout, cynicism and efficacy (Leiter et al. 2007; Leiter & Shaughnessy 2006). Respondents were asked to rate a series of questions in terms of frequency (ranging from ‘never’ to ‘daily’). The MBI has been reported as a valid and reliable tool for measuring burnout in nurse leaders (Tourangeau & McGilton 2004) and yielded 0.65 alpha in this study. Previous alpha scores reported for MBI subscales by Leiter et al. (2007) and our study respectively are: emotional exhaustion (0.88 and 0.79), cynicism (0.69 and 0.75) and professional efficacy (0.68 and 0.71).
Role factors
Data analysis
Number of staff supervised Respondents were asked to report the number of nursing staff, both full-time and part-time, that worked on the largest unit they managed.
The data were analysed in a sequence of steps using SPSS version 17.0 (Chicago, IL, US: SPSS Inc.). To address Research Question 1, the demographic and personal characteristics of managers intending to
4
ª 2014 John Wiley & Sons Ltd Journal of Nursing Management
Factors influencing nurse manager retention
stay or leave were compared and contrasted using descriptive statistics. To address Research Question 2, the relative importance of factors to intention decisions was obtained by rank ordering within groups (managers intending to stay or leave). To address Research Question 3, we compared the responses of managers intending to stay or leave to survey items reflecting organisational, role and individual factors. For Likert scale items, the means were compared using t-test; relationships between multiitem predictors and intention decisions were analysed using MANCOVA.
Results Ninety-two percent of the 95 respondents were female. The mean age of the respondents was congruent with the existing literature (Laschinger et al. 2008), with 75% of the sample between the ages of 40 and 59. No significant differences were found in the means of managers intending to stay or leave for age, years of experience in their profession, number of years at their present place of employment or level of experience as a manager. Managers intending to leave were more likely to be employed in acute care (teaching hospitals), with only 56% reporting intent to stay in their current position for another 2 years, as compared with 82% of those working in general hospitals (P = 0.04). Of all respondents, 52% were diploma-prepared and 39% were baccalaureate-prepared. Thirty-two percent of diploma-prepared respondents vs. 54% of bachelor-prepared respondents indicated intent to leave (P = 0.08). Age, gender, level of education, years of experience and position title were not related to intent to remain for another 2 years. See Table 1 for a summary of sample demographics. The most important factor reported by managers intending to stay was work–life balance followed by sufficient support from their immediate supervisor and the ability to ensure quality of care. They also reported sufficient empowerment to do the job, congruence between their leadership style and their supervisor’s and job security as being important. The four most important factors for managers intending to leave were work overload/work–life balance, insufficient ability to ensure the quality of patient care, insufficient human/fiscal resources and insufficient empowerment to do the job. Of least importance were job security, family reasons and incongruence between their leadership style and their ª 2014 John Wiley & Sons Ltd Journal of Nursing Management
Table 1 Demographics of the manager sample Demographic
Total (n = 95)
Gender (%) Male 8 (8) Female 87 (92) Age (%) 25–29 4 (4) 30–34 4 (4) 35–39 8 (8) 40–44 20 (21) 45–49 14 (15) 50–54 19 (20) 55–59 18 (19) 60–64 7 (7) 65–70 1 (1) Education (%) Diploma 49 (52) Bachelors degree 37 (39) Masters 4 (4) Other 4 (4) Experience – mean years (SD) In profession 24.27 As front line manager 9.08 As manager in 5.74 current facility Employment at 12.36 current facility Managerial experience (%) New manager 14 (15) Some experience 22 (23) Experienced manager 27 (28) Very experienced 15 (16) Most experienced 13 (14) manager Position title (%) Patient care manager 21 (22) Nurse manager 3 (3) Coordinator 2 (2) Client care manager 2 (2) Unit manager 39 (44) Frontline manager 1 Other 25 (26) Two missing Type of facility (%) Acute 36 (38) General 33 (35) Long term care 26 (27)
Intending to leave (n = 28)
Intending to stay (n = 67)
4 (14) 24 (86)
4 (6) 63 (94)
3 2 3 8 1 4 5 2 0
(11) (7) (11) (29) (4) (14) (18) (7) (0)
1 2 5 12 13 15 13 5 1
(1) (3) (7) (18) (19) (22) (19) (7) (1)
9 15 2 2
(32) (54) (7) (7)
40 22 2 2
(61) (33) (3) (3)
21.93 7.89 5.50
25.24 9.58 5.85
11.18
12.85
5 6 9 5 2
(19) (22) (33) (19) (7)
9 16 18 10 11
(14) (25) (28) (16) (17)
6 0 1 1 17 0 2
(29) (0)
15 3 1 1 22 1 23
(71) (100)
(44) (8)
16 (44) 6 (18) 6 (23)
(56) (92)
20 (56) 27 (82) 20 (77)
supervisor’s. See Table 2 for the results of managers intending to stay or leave. Due to the relatively small sample size (n = 28), the results for managers intending to leave have been interpreted with caution.
Factors influencing retention of nurse managers Organisational factors The perceived adequacy of available resources (including space, budget, staff and practice support) did not differ significantly between managers intending to leave or stay. Overall, the respondents reported that their units had some to most of the resources required 5
S. J. Hewko et al.
Table 2 Relative importance of factors to intention decisions Intending to leave (n = 28)
Mean (SD)
Work overload or work–life balance Insufficient ability to ensure quality of care Insufficient fiscal/human resources Insufficient empowerment to do the job Insufficient recognition of value of contributions
4.00 3.96 3.68 3.46 3.36
(1.21) (1.13) (1.36) (1.45) (1.49)
Insufficient support for education Insufficient communication from the organisation Insufficient support from the organisation Desire to extend career in different direction Incongruence between organisational and personal values/cultures Insufficient remuneration Incongruence between my leadership style and my supervisor’s Insufficient support from immediate supervisor
3.32 3.25 3.18 3.18 3.18
(1.33) (1.29) (1.27) (1.38) (1.58)
Family reasons not related to work Insufficient job security
2.61 (1.59) 2.50 (1.26)
Mean (SD)
Work–life balance Sufficient support from immediate supervisor Sufficient ability to ensure quality of care Sufficient empowerment to do the job Congruence between my leadership style and my supervisor’s Sufficient job security Sufficient remuneration Sufficient support from the organisation Sufficient fiscal/human resources Desire to finish the work I have started here
4.55 4.52 4.52 4.37 4.37
(0.58) (0.58) (0.56) (0.67) (0.81)
4.31 4.27 4.27 4.24 4.22
(0.80) (0.68) (0.70) (0.69) (0.75)
3.14 (1.17) 3.07 (1.38)
Sufficient recognition of value of contributions Sufficient support for education
4.19 (0.78) 4.12 (0.74)
2.93 (1.24)
Congruence between organisational and personal values/cultures Sufficient communication from the organisation Family reasons not related to work
4.09 (0.79)
to provide the current level of service: the means ranged from 2.54 to 3.11 (none = 1 and all = 4). Both groups of managers perceived a small increase in wait time for decisions from senior management within the past year, higher turnover in front-line managers and greater restructuring of both middle management and senior management. Role factors Managers intending to stay reported their workplaces as being significantly more empowering than managers intending to leave (3.56 vs. 2.95; P < 0.00). Managers intending to stay also rated their supervisor as displaying significantly more resonant leadership practices than managers intending to leave (4.06 vs. 3.49; P < 0.00). Managers intending to stay also reported being more satisfied with the adequacy of their orientation to the job (P = 0.04). The mean number of staff supervised (full-time and part time) were not significantly different for managers intending to leave or stay (35.66 vs. 38.79). Individual factors Managers intending to leave reported greater cynicism (P < 0.00) and emotional exhaustion (P < 0.00) than managers intending to stay. Managers intending to stay reported significantly greater professional efficacy than did those intending to leave (5.64 vs. 5.08; P = 0.02.) Managers intending to stay were more satisfied with their job and liked their job more than managers intending to leave (P < 0.00). The group means for managers intending to leave, although lower than those 6
Intending to stay (n = 67)
3.99 (0.76) 3.82 (1.11)
for managers intending to stay, were not particularly low: the mean score for satisfaction among managers intending to leave was 2.89 and the mean score for ‘How much do you like your job?’ was 3.25. See Table 3 for a summary of means and significance.
Discussion These results provide valuable insight into which factors are important for nurse managers as they consider whether to remain in their current position. Our results align with Brown et al.’s (2013) systematic review findings, which concluded that job satisfaction, empowerment, work–life balance, leadership practices of senior management and the ability to ensure the quality of care are factors that influence nurse managers’ intent to stay or leave. The implications of these results are significant for health-care organisations and senior administrators, particularly as they relate to leadership practices. Health-care environments are increasingly complex, requiring leaders who can effectively manage multidisciplinary teams and successfully build and maintain relationships. Such relationships include not only those between managers and their staff, but also those of front-line managers with middle and senior managers and those between departments. Leaders with relational skills are described as transformational or resonant leaders; they inspire others to reach their own potential, work collaboratively and encourage employee investment in unit and organisational-level goals. A number of studies have reported strong ª 2014 John Wiley & Sons Ltd Journal of Nursing Management
Factors influencing nurse manager retention
Table 3 Factors associated with intentions to stay or leave Intending to leave (n = 28) Organisational factors Resources (adequate or sufficient) Space Budget Equipment Clinical staff Clerical staff Support staff Ongoing education support Professional practice support Patient safety Safety is high priority Loss of experienced staff has negatively affected ability to provide high quality patient care I have adequate resources to provide safe patient care Programmatic changes Wait time for decisions from senior management Turnover/vacancies in front line management positions Restructuring of middle management Restructuring of senior management Role factors Resonant leadership (10-item) Global empowerment (2-item) Adequate orientation Mentorship from senior management Number of full time and part time staff Individual factors Job satisfaction How satisfied are you with your job? How much do you like your job? Burnout Emotional exhaustion Cynicism Professional efficacy
2.54 2.64 2.79 2.96 3.11 2.73 2.64 2.61
(0.92) (0.68) (0.63) (0.58) (0.69) (0.78) (0.68) (0.74)
Intending to stay (n = 67)
2.68 2.85 3.00 3.05 3.00 2.82 2.80 2.67
P-value†
(0.81) (0.71) (0.66) (0.62) (0.88) (0.85) (0.75) (0.82)
4.14 (0.76) 2.82 (1.27)
4.34 (0.59) 2.70 (0.99)
3.14 (1.29)
3.21 (1.00)
3.40 3.64 3.56 3.88
(0.75) (0.91) (0.87) (1.03)
3.31 3.35 3.29 3.70
(0.81) (0.81) (0.51) (0.83)
3.49 2.95 2.25 3.07 35.66
(0.73) (0.96) (1.17) (1.18) (27.94)
4.06 3.56 2.85 3.43 38.79
(0.65) (0.81) (1.28) (1.23) (29.08)
2.89 (1.10) 3.25 (1.18)
3.93 (0.94) 4.15 (0.97)
3.57 (1.38) 3.58 (1.50) 5.08 (1.09)
2.73 (1.18) 2.52 (1.19) 5.64 (1.08)
Factors influencing nurse managers’ intent to stay or leave: a quantitative analysis SARAH J. HEWKO R D , M H A 1, PAMELA BROWN R N , M N 2, KIMBERLY D. FRASER CAROL A. WONG R N , P h D 4 and GRETA G. CUMMINGS R N , P h D , F C A H S , F A A N 5
RN, PhD
3
,
1
Doctoral Student, 3Assistant Professor, 5Professor, Faculty of Nursing, University of Alberta, Edmonton, AB, Manager, Alberta Health Services, Edmonton, AB and 4Associate Professor, Arthur Labatt Family School of Nursing, Western University, London, ON, Canada
2
Correspondence Greta G. Cummings University of Alberta 5-110 Edmonton Clinic Health Academy 11405 87 Avenue Edmonton AB T6G 1C9 Canada E-mail: [email protected]
HEWKO S.J., BROWN P., FRASER K.D., WONG C.A. & CUMMINGS G.G.
(2014) Journal of Nursing Management Factors influencing nurse managers’ intent to stay or leave: a quantitative analysis
Aim To identify and report on the relative importance of factors influencing nurse managers’ intentions to stay in or leave their current position. Background Effective nurse managers play an important role in staff nurse retention and in the quality of patient care. The advancing age of nurse managers, multiple job opportunities within nursing and the generally negative perceptions of the manager role can contribute to difficulties in retaining nurse managers. Methods Ninety-five Canadian nurse managers participated in a web survey. Respondents rated the importance of factors related to their intent to leave or stay in their current position for another 2 years. Descriptive, t-test and MANCOVA statistics were used to assess differences between managers intending to stay or leave. Results For managers intending to leave (n = 28), the most important factors were work overload, inability to ensure quality patient care, insufficient resources, and lack of empowerment and recognition. Managers intending to leave reported significantly lower job satisfaction, perceptions of their supervisor’s resonant leadership and higher burnout levels. Implications for nursing management Organisations wishing to retain existing nurse managers and to attract front-line staff into leadership positions must create and foster an environment that supports nurse managers. Keywords: empowerment, health human resources, leadership, nurse manager, retention Accepted for publication: 17 June 2014
Background Effective nurse managers play an important role in staff nurse retention, and ultimately, in the quality of patient care (Mackoff & Triolo 2008). Few senior nurse leaders in Canada are under the age of 45, the average age being between 46 and 55 years. Only 8.5% of first-line and middle managers are between 25 and 35 years of DOI: 10.1111/jonm.12252 ª 2014 John Wiley & Sons Ltd
age (Laschinger et al. 2008). The advancing age of nurse managers and nursing directors, multiple job opportunities within nursing and the generally negative perceptions of the role of nurse manager all contribute to existing difficulties in recruiting and retaining nurse managers (Rudan 2002, Laschinger et al. 2004). Struggles to retain managers are further exacerbated in Canada by hospital restructuring, which, in the 1
S. J. Hewko et al.
1990s, led to a significant reduction in the number of nurse management positions (Laschinger et al. 2004). In Alberta, a 2009 province-wide restructure resulted in a loss of 100 managerial positions. As a result, the remaining nurse managers have increased spans of control and heavier workloads (Lang 2009). The retention of nurse managers is of widespread concern. A longitudinal Australian study reported that fewer managers intended to stay in nursing management positions (82.4% in 1989 vs. 72.7% in 1999), with many indicating plans to move to a clinical position (Duffield et al. 2001). In a recent prospective Swedish study, 40% of health-care managers had left their positions within 4 years (Skagert et al. 2011). In the United States, more than 67 200 nurse manager vacancies are predicted by the year 2020 (Shirey 2006). A recent national survey of Canadian nurses found that only 24% of direct care nurses were interested in pursuing a nurse management role; interest in the role declined steadily with age (Laschinger et al. 2013). This is our quandary – as more existing nurse managers leave their positions, whether to retire or to return to clinical practice, fewer direct care nurses have an interest in stepping into the role. Few quantitative studies have examined job retention among nurse managers (Skagert et al. 2011). The purpose of this study was to identify factors that influence nurse managers’ intentions to stay in or leave their current position.
Literature review Several theoretical models of staff nurse intent to stay or the determinants of nurse intention to remain employed are reported in the retention literature. Boyle et al. (1999) developed a research-based Conceptual Model of Intent to Stay that described four sets of predictor variables of intensive care unit staff nurses’ intention to stay employed. Five variables found directly to affect intention to stay were the managers’ position power, the presence of opportunities elsewhere, manager influence over work coordination, promotional opportunities and job satisfaction. Variables that were indirectly related to intent to stay included situational stress, control over nursing practice and characteristics of the manager including consideration and structuring expectations (Boyle et al. 1999, Tourangeau & Cranley 2006). Gilmartin (2013), in a recent review of the nursing turnover literature, concluded that, despite notable and significant prior work in the area, turnover research in the discipline of nursing has failed to keep pace 2
with theoretical and conceptual advances found in management-based turnover research. The tasks and duties of staff nurses differ significantly from those of nurse managers, as does the span of control and the level of personal accountability for unit-level performance. It is unreasonable to assume, prior to empirical investigation, that the factors that influence nurse managers’ intention to leave or stay will be the same factors that influence staff nurses’ turnover intentions. There are early empirical indications that factors related to turnover among staff nurses are not the same as those related to turnover among nurse managers – for example, in a recent quantitative study, job satisfaction, which has been established as a factor related to staff nurse turnover, was found to have a nonsignificant association with turnover among nurse managers (Warshawsky & Havens 2014). Several recent studies have explored the phenomenon of turnover among nurse managers. Skagert et al. (2011) concluded, following a 4-year prospective study of health-care managers (not exclusively nurse managers), that the primary predictors of manager turnover were work-related: job demands, job control, social support and frequency of contact with patients. Warshawsky and Havens (2014) reported, following a secondary analysis of electronic survey data (n = 291 nurse managers), that the top four reasons for manager leaving intentions were career change, burnout or stress, retirement and promotion. Retirement, as a reason for leaving, was more frequently reported among managers with high job satisfaction. Those managers intending to remain supervised fewer staff and reported both higher job satisfaction and greater satisfaction with the amount of time spent with staff (Warshawsky & Havens 2014). In a recent systematic review, Brown et al. (2013) evaluated the current knowledge of factors influencing nurse managers’ intentions to stay in or leave their current positions. In the 14 included studies, 25 factors were found to influence nurse managers’ intentions to stay or leave: factors were grouped into the categories of organisational, role and personal. Organisational or institutional factors – that is, those within an organisation’s power to change – include organisational values and culture, human and fiscal resources, effective administration and the presence of succession planning. Role or position factors were inherent to the nurse manager role and included the potential for work–life balance or work overload, the clarity of expectations and the regularity and content of feedback. Personal or individual factors were ª 2014 John Wiley & Sons Ltd Journal of Nursing Management
Factors influencing nurse manager retention
characteristics of the individual nurse manager such as their personal beliefs, personal life and life experience (Brown et al. 2013). Factors conceptualised as common to the organisational and role categories included empowerment, leadership style, support and communication. Factors common to role and individual categories included work–life balance and the ability to provide quality patient care. Factors conceptualised as shared among all three categories were work–life balance, job satisfaction and ability to provide high quality care. The results of this review indicate that nurse managers’ reasons for leaving or staying are multifactorial and interrelated (Brown et al. 2013). Based on the literature review and the authors’ managerial and research experience the following research questions were developed to guide the study: 1 Do nurse managers’ intentions to leave or stay differ based on demographics of age, gender, years of experience, years of experience as a manager, level of education and work environment? 2 Which factors were reported as important to forming intention decisions? 3 What organisational, role and individual factors are associated with the retention of nurse managers?
Methods Research design The Social Science and Humanities Research Foundation (SSHRC)-funded Quality Work Environment Study (QWEST 2007-2010) was a non-experimental, cross-sectional, three phase study. The primary purpose of QWEST was to examine the resonant leadership practices of first-line patient care managers in three health-care settings – acute care teaching hospitals, general hospitals and long-term care. Additional goals included assessment of the impact of manager leadership practices on workplace empowerment, nurse perceptions of their quality of work life and of the culture of patient safety. QWEST phase 1 consisted of individual interviews with managers from each study setting, followed by focus groups with staff nurses to gain additional contextual information about work life and the culture of patient safety. Phase 2 involved completion of a web-based survey by front-line nurse managers. Phase 3 included a paper-based survey for staff on the units of managers who had responded to the electronic survey. All data were linked by unit and de-identified. ª 2014 John Wiley & Sons Ltd Journal of Nursing Management
Sample The web-based survey was distributed to 290 frontline managers in a western Canadian city. The response rate was 33%, with 95 managers returning completed surveys; 36 in acute care hospitals, 33 in general hospitals and 26 in long-term care facilities. Simultaneous to survey distribution, regional health authority restructuring resulted in the elimination of 100 manager positions.
Measures The analysis reported here utilises only manager survey data collected in phase 2. The manager survey included questions within the following areas: work unit information, unit characteristics, unit staffing and resources, programmatic and structural changes, unit work environment, time spent on managerial tasks, work relationships, work life as a manager, relationship with work, professional development, number of staff supervised and demographic information such as age, sex, level of education and years of experience in the profession and as a manager. In addition, frontline managers were asked to rate the importance of a series of factors related to their reported intent to leave or stay in their current position for another 2 years. Additional contextual data were collected such as facility type, specialty area and inpatient vs. outpatient environment. Five managers participated in pilot testing the manager survey, which resulted in an estimated time to complete, clarification of wording and in elimination of some items. Intent to stay Respondents were asked the likelihood that they would stay in their current position for another 2 years. If the respondent indicated it was ‘very likely’ or ‘likely’ that they would stay they were categorised as managers intending to stay. If they reported that it was ‘very unlikely’ or ‘unlikely’ that they would stay, they were categorised as managers intending to leave. A branching method was utilised to direct managers intending to stay to rate the importance of 15 factors influencing intention to stay and managers intending to leave to rate the importance of 15 complementary factors influencing intention to leave. Possible responses ranged from ‘very important’ to ‘not important at all’. The 15 factors presented to each group (managers intending to stay and managers intending to leave), developed based on the results of phase 1 interviews 3
S. J. Hewko et al.
and focus groups, were to be written as complementary. For example, managers intending to stay were asked to rank the importance of sufficient job security in influencing their intent to stay, and managers intending to leave were asked to rank the importance of insufficient job security in influencing their intent to leave. For some factors, complementary statements were more difficult to derive. For example, managers intending to stay were asked to rank the importance of their Desire to finish the work I have started here, while managers intending to leave were asked to rank the importance of their Desire to extend career in a different direction.
Organisational factors Patient safety culture Previous studies have reported low Cronbach alpha scores for the Modified Stanford Instrument (MSI) Patient Safety Culture questionnaire and have noted problems with its psychometric cross-validation, resulting in unstable factor analysis (Ginsburg et al. 2009a,b). Therefore, given the length of the questionnaire (46 items), the QWEST team decided to use only 16 of the original 46 items scale; responses were on a 5-point scale ranging from ‘strongly disagree’ to ‘strongly agree’. For the purposes of this analysis, we chose to use three questions that best measured safety, resources and loss of staff. ‘Is patient safety a priority?’ ‘Is the ability to provide quality patient care negatively affected by loss of experienced personnel?’ and ‘Are there adequate resources to provide safe patient care?’ Cronbach’s alpha was 0.66.
Leadership The Resonant Leadership Scale (10-item), which focuses on emotionally intelligent leadership behaviour, yielded a Cronbach’s alpha score of 0.96 in the managerial context (Estabrooks et al. 2009), 0.94 among staff nurses (Laschinger et al. 2013) and 0.93 in this study. The managers were asked to rate their director/supervisor on a series of statements using a 5-point scale ranging from ‘strongly disagree’ to ‘strongly agree’. Global empowerment The Global Empowerment Scale-II is a 2-item scale, with known reliability of 0.86 (Laschinger et al. 2003) and 0.95 in this study, that measures nurses’ perceptions of empowerment in their workplace.
Individual factors Job satisfaction Two items from the Global Job Satisfaction Scale (Quinn & Shepard 1974) were used to measure job satisfaction: ‘How satisfied are you with your job?’ and ‘How much do you like your job?’ Responses were provided on a 5-point scale of 1 = not at all satisfied to 5 = completely satisfied. A previous reliability score was 0.92 for the full-5 item scale (Quinn & Shepard 1974) and 0.69 for the two items selected for analysis.
Programmatic changes Two multi-part questions examining programmatic and structural changes resulting from health system restructuring were developed based on the feedback received during phase 1 manager interviews. The questions asked if the wait times for decisions by senior management, turnover/vacancies in frontline management positions, restructuring of middle management positions and restructuring of senior management positions had changed in the past year. Respondents rated changes on a 5-point scale ranging from ‘decreased a lot’ to ‘increased a lot’.
Burnout The 9-item Maslach Burnout Inventory (MBI) was used to collect data to measure burnout, relationship with work, and emotional health and well being. The MBI contains three subscales: burnout, cynicism and efficacy (Leiter et al. 2007; Leiter & Shaughnessy 2006). Respondents were asked to rate a series of questions in terms of frequency (ranging from ‘never’ to ‘daily’). The MBI has been reported as a valid and reliable tool for measuring burnout in nurse leaders (Tourangeau & McGilton 2004) and yielded 0.65 alpha in this study. Previous alpha scores reported for MBI subscales by Leiter et al. (2007) and our study respectively are: emotional exhaustion (0.88 and 0.79), cynicism (0.69 and 0.75) and professional efficacy (0.68 and 0.71).
Role factors
Data analysis
Number of staff supervised Respondents were asked to report the number of nursing staff, both full-time and part-time, that worked on the largest unit they managed.
The data were analysed in a sequence of steps using SPSS version 17.0 (Chicago, IL, US: SPSS Inc.). To address Research Question 1, the demographic and personal characteristics of managers intending to
4
ª 2014 John Wiley & Sons Ltd Journal of Nursing Management
Factors influencing nurse manager retention
stay or leave were compared and contrasted using descriptive statistics. To address Research Question 2, the relative importance of factors to intention decisions was obtained by rank ordering within groups (managers intending to stay or leave). To address Research Question 3, we compared the responses of managers intending to stay or leave to survey items reflecting organisational, role and individual factors. For Likert scale items, the means were compared using t-test; relationships between multiitem predictors and intention decisions were analysed using MANCOVA.
Results Ninety-two percent of the 95 respondents were female. The mean age of the respondents was congruent with the existing literature (Laschinger et al. 2008), with 75% of the sample between the ages of 40 and 59. No significant differences were found in the means of managers intending to stay or leave for age, years of experience in their profession, number of years at their present place of employment or level of experience as a manager. Managers intending to leave were more likely to be employed in acute care (teaching hospitals), with only 56% reporting intent to stay in their current position for another 2 years, as compared with 82% of those working in general hospitals (P = 0.04). Of all respondents, 52% were diploma-prepared and 39% were baccalaureate-prepared. Thirty-two percent of diploma-prepared respondents vs. 54% of bachelor-prepared respondents indicated intent to leave (P = 0.08). Age, gender, level of education, years of experience and position title were not related to intent to remain for another 2 years. See Table 1 for a summary of sample demographics. The most important factor reported by managers intending to stay was work–life balance followed by sufficient support from their immediate supervisor and the ability to ensure quality of care. They also reported sufficient empowerment to do the job, congruence between their leadership style and their supervisor’s and job security as being important. The four most important factors for managers intending to leave were work overload/work–life balance, insufficient ability to ensure the quality of patient care, insufficient human/fiscal resources and insufficient empowerment to do the job. Of least importance were job security, family reasons and incongruence between their leadership style and their ª 2014 John Wiley & Sons Ltd Journal of Nursing Management
Table 1 Demographics of the manager sample Demographic
Total (n = 95)
Gender (%) Male 8 (8) Female 87 (92) Age (%) 25–29 4 (4) 30–34 4 (4) 35–39 8 (8) 40–44 20 (21) 45–49 14 (15) 50–54 19 (20) 55–59 18 (19) 60–64 7 (7) 65–70 1 (1) Education (%) Diploma 49 (52) Bachelors degree 37 (39) Masters 4 (4) Other 4 (4) Experience – mean years (SD) In profession 24.27 As front line manager 9.08 As manager in 5.74 current facility Employment at 12.36 current facility Managerial experience (%) New manager 14 (15) Some experience 22 (23) Experienced manager 27 (28) Very experienced 15 (16) Most experienced 13 (14) manager Position title (%) Patient care manager 21 (22) Nurse manager 3 (3) Coordinator 2 (2) Client care manager 2 (2) Unit manager 39 (44) Frontline manager 1 Other 25 (26) Two missing Type of facility (%) Acute 36 (38) General 33 (35) Long term care 26 (27)
Intending to leave (n = 28)
Intending to stay (n = 67)
4 (14) 24 (86)
4 (6) 63 (94)
3 2 3 8 1 4 5 2 0
(11) (7) (11) (29) (4) (14) (18) (7) (0)
1 2 5 12 13 15 13 5 1
(1) (3) (7) (18) (19) (22) (19) (7) (1)
9 15 2 2
(32) (54) (7) (7)
40 22 2 2
(61) (33) (3) (3)
21.93 7.89 5.50
25.24 9.58 5.85
11.18
12.85
5 6 9 5 2
(19) (22) (33) (19) (7)
9 16 18 10 11
(14) (25) (28) (16) (17)
6 0 1 1 17 0 2
(29) (0)
15 3 1 1 22 1 23
(71) (100)
(44) (8)
16 (44) 6 (18) 6 (23)
(56) (92)
20 (56) 27 (82) 20 (77)
supervisor’s. See Table 2 for the results of managers intending to stay or leave. Due to the relatively small sample size (n = 28), the results for managers intending to leave have been interpreted with caution.
Factors influencing retention of nurse managers Organisational factors The perceived adequacy of available resources (including space, budget, staff and practice support) did not differ significantly between managers intending to leave or stay. Overall, the respondents reported that their units had some to most of the resources required 5
S. J. Hewko et al.
Table 2 Relative importance of factors to intention decisions Intending to leave (n = 28)
Mean (SD)
Work overload or work–life balance Insufficient ability to ensure quality of care Insufficient fiscal/human resources Insufficient empowerment to do the job Insufficient recognition of value of contributions
4.00 3.96 3.68 3.46 3.36
(1.21) (1.13) (1.36) (1.45) (1.49)
Insufficient support for education Insufficient communication from the organisation Insufficient support from the organisation Desire to extend career in different direction Incongruence between organisational and personal values/cultures Insufficient remuneration Incongruence between my leadership style and my supervisor’s Insufficient support from immediate supervisor
3.32 3.25 3.18 3.18 3.18
(1.33) (1.29) (1.27) (1.38) (1.58)
Family reasons not related to work Insufficient job security
2.61 (1.59) 2.50 (1.26)
Mean (SD)
Work–life balance Sufficient support from immediate supervisor Sufficient ability to ensure quality of care Sufficient empowerment to do the job Congruence between my leadership style and my supervisor’s Sufficient job security Sufficient remuneration Sufficient support from the organisation Sufficient fiscal/human resources Desire to finish the work I have started here
4.55 4.52 4.52 4.37 4.37
(0.58) (0.58) (0.56) (0.67) (0.81)
4.31 4.27 4.27 4.24 4.22
(0.80) (0.68) (0.70) (0.69) (0.75)
3.14 (1.17) 3.07 (1.38)
Sufficient recognition of value of contributions Sufficient support for education
4.19 (0.78) 4.12 (0.74)
2.93 (1.24)
Congruence between organisational and personal values/cultures Sufficient communication from the organisation Family reasons not related to work
4.09 (0.79)
to provide the current level of service: the means ranged from 2.54 to 3.11 (none = 1 and all = 4). Both groups of managers perceived a small increase in wait time for decisions from senior management within the past year, higher turnover in front-line managers and greater restructuring of both middle management and senior management. Role factors Managers intending to stay reported their workplaces as being significantly more empowering than managers intending to leave (3.56 vs. 2.95; P < 0.00). Managers intending to stay also rated their supervisor as displaying significantly more resonant leadership practices than managers intending to leave (4.06 vs. 3.49; P < 0.00). Managers intending to stay also reported being more satisfied with the adequacy of their orientation to the job (P = 0.04). The mean number of staff supervised (full-time and part time) were not significantly different for managers intending to leave or stay (35.66 vs. 38.79). Individual factors Managers intending to leave reported greater cynicism (P < 0.00) and emotional exhaustion (P < 0.00) than managers intending to stay. Managers intending to stay reported significantly greater professional efficacy than did those intending to leave (5.64 vs. 5.08; P = 0.02.) Managers intending to stay were more satisfied with their job and liked their job more than managers intending to leave (P < 0.00). The group means for managers intending to leave, although lower than those 6
Intending to stay (n = 67)
3.99 (0.76) 3.82 (1.11)
for managers intending to stay, were not particularly low: the mean score for satisfaction among managers intending to leave was 2.89 and the mean score for ‘How much do you like your job?’ was 3.25. See Table 3 for a summary of means and significance.
Discussion These results provide valuable insight into which factors are important for nurse managers as they consider whether to remain in their current position. Our results align with Brown et al.’s (2013) systematic review findings, which concluded that job satisfaction, empowerment, work–life balance, leadership practices of senior management and the ability to ensure the quality of care are factors that influence nurse managers’ intent to stay or leave. The implications of these results are significant for health-care organisations and senior administrators, particularly as they relate to leadership practices. Health-care environments are increasingly complex, requiring leaders who can effectively manage multidisciplinary teams and successfully build and maintain relationships. Such relationships include not only those between managers and their staff, but also those of front-line managers with middle and senior managers and those between departments. Leaders with relational skills are described as transformational or resonant leaders; they inspire others to reach their own potential, work collaboratively and encourage employee investment in unit and organisational-level goals. A number of studies have reported strong ª 2014 John Wiley & Sons Ltd Journal of Nursing Management
Factors influencing nurse manager retention
Table 3 Factors associated with intentions to stay or leave Intending to leave (n = 28) Organisational factors Resources (adequate or sufficient) Space Budget Equipment Clinical staff Clerical staff Support staff Ongoing education support Professional practice support Patient safety Safety is high priority Loss of experienced staff has negatively affected ability to provide high quality patient care I have adequate resources to provide safe patient care Programmatic changes Wait time for decisions from senior management Turnover/vacancies in front line management positions Restructuring of middle management Restructuring of senior management Role factors Resonant leadership (10-item) Global empowerment (2-item) Adequate orientation Mentorship from senior management Number of full time and part time staff Individual factors Job satisfaction How satisfied are you with your job? How much do you like your job? Burnout Emotional exhaustion Cynicism Professional efficacy
2.54 2.64 2.79 2.96 3.11 2.73 2.64 2.61
(0.92) (0.68) (0.63) (0.58) (0.69) (0.78) (0.68) (0.74)
Intending to stay (n = 67)
2.68 2.85 3.00 3.05 3.00 2.82 2.80 2.67
P-value†
(0.81) (0.71) (0.66) (0.62) (0.88) (0.85) (0.75) (0.82)
4.14 (0.76) 2.82 (1.27)
4.34 (0.59) 2.70 (0.99)
3.14 (1.29)
3.21 (1.00)
3.40 3.64 3.56 3.88
(0.75) (0.91) (0.87) (1.03)
3.31 3.35 3.29 3.70
(0.81) (0.81) (0.51) (0.83)
3.49 2.95 2.25 3.07 35.66
(0.73) (0.96) (1.17) (1.18) (27.94)
4.06 3.56 2.85 3.43 38.79
(0.65) (0.81) (1.28) (1.23) (29.08)
2.89 (1.10) 3.25 (1.18)
3.93 (0.94) 4.15 (0.97)
3.57 (1.38) 3.58 (1.50) 5.08 (1.09)
2.73 (1.18) 2.52 (1.19) 5.64 (1.08)
