ORIGINAL RESEARCH: EMPIRICAL RESEARCH – QUANTITATIVE

Praise matters: the influence of nurse unit managers’ praise on nurses’ practice, work environment and job satisfaction: a questionnaire study Herd
ıs Sveinsd
ottir, Erla D€ ogg Ragnarsd
ottir & Katr
ın Bl€ ondal Accepted for publication 15 September 2015

Correspondence to H. Sveinsd
ottir: e-mail: [email protected] Herd
ıs Sveinsd
ottir PhD RN Professor University of Iceland, Faculty of Nursing, and Landspitali University Hospital, Surgical Services, Reykjav
ık, Iceland Erla D€ ogg Ragnarsd
ottir MS RN Unit Manager Landspitali University Hospital, Surgical Services, Reykjav
ık, Iceland Katr
ın Bl€ ondal MS RN Clinical Nurse Specialist University of Iceland, Faculty of Nursing, and Landspitali University Hospital, Surgical Services, Reykjav
ık, Iceland


T I R H . , R A G N A R S D OT
T I R E . D . & B L ON € D A L K . ( 2 0 1 6 ) Praise matS V E I N S D OT ters: the influence of nurse unit managers’ praise on nurses’ practice, work environment and job satisfaction: a questionnaire study. Journal of Advanced Nursing 72(3), 558–568. doi: 10.1111/jan.12849

Abstract Aim. The aim of this study was to investigate the associations between praise from nurse unit managers and job satisfaction, professional practice, workload, work climate and organizational commitment of nurses caring for surgical patients. Background. Praise influences experiences of employees. Design. Web-based, cross-sectional explorative survey design. Methods. A structured questionnaire was used to measure praise given by nurse unit managers as perceived by nurses (n = 383; 49% response rate) working with surgical patients. Data were collected between December 2009–January 2010. Several variables assessed the major concepts under study. Binary logistic regression analysis was employed to compare nurses who receive praise very rarely/rarely as compared with very often/rather often. Results. Praise was received often/very often by 31
6% of participants. Compared with nurses receiving praise rarely/very rarely those who received it often/rather showed more job satisfaction, stated they had more opportunities to practice professionally, described a more positive work climate and were more committed to the organization such as being proud to work at and willing to make effort for the unit and hospital. There was no difference between the groups regarding workload. Main findings of the regression analysis were that nurses display their organizational commitment by not thinking about leaving the current workplace and those who value professional recognition are likelier to receive praise than their counterparts. Conclusion. Nurse unit managers should praise their staff in a realistic fashion. Such praise is cost-effective, takes short time, produces positive influences on members of their staff and may improve patient safety. Keywords: job satisfaction, nurse unit manager, nursing management, nursing practice, praise, recognition, servant leadership, surgical nursing, work environment

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Why is this research or review needed?  Praise is a simple, cost-free and effective way to reward employees. In the light of contemporary healthcare cost containment, it would seem extremely important for managers to be aware of the cost-saving significance of praise.  Recent research shows that praise influences nurses’ intention to stay at their workplace. However, limited knowledge exists about the general influence of praise on staff nurses’ practice, work environment and job satisfaction.

What are the key findings?  Praise matters to nurses and most importantly, from a managerial perspective, nurses who are praised tend to stay on at their job.  Praise has a positive relationship with nurses’ job satisfaction, how many opportunities nurses’ have to practice professionally, organizational commitment and work climate.  Praise has a mixed relationship on the importance of having opportunities to practice professionally indicating that nurses are, independently of others, conscious of the value of their profession.

How should the findings be used to influence policy/ practice/research/education?  Nurse unit managers should strive to establish and maintain good relationships with their nurses; to communicate to them that they are valued (e.g. by recognizing their input) and to provide them with every opportunity to discharge their duties in a professional manner.  Nurse unit managers should be trained in human resource management.  Future studies should focus on how to implement and sustain effective NUM management styles.

Primacy of praise

(NUMs), it influences their perception of their work. Dispensing praise is most effective when nurses know how their performance merits acknowledgement from their supervisors – that is, when praise is given in an honest, clear and meaningful way (Kimball 2004, Craig 2008, Murrey & Rusignuolo 2010). Conversely, dispensing praise becomes ineffective when nurses’ are not clear on when their performance is deserving of acknowledgement; and not dispensing praise at all can engender anger and sadness (Amabile & Kramer 2007). NUMs should therefore be aware that special recognition in the form of praise can inspire greater employee effort and that behaviour rewarded is behaviour repeated (Salmore 1990). Encouragement can also reduce anxiety in employees and improve their ability to function and supervisor support tends to make workers more productive and job-satisfied. Moreover, by generating a feeling of caring and camaraderie, a supervisor can increase employee morale and make the unit for which they are responsible a more pleasant environment to work in (Davidhizar & Shearer 1997). This study is a sub-study of a larger research project on working conditions of nurses caring for surgical patients. In a previous analysis, we found that the absence or presence of praise from NUMs is an important determinant in nurses’ intentions to stay or leave their workplace (Sveinsd
ottir & Bl€ ondal 2014). Earlier Icelandic findings show that supportive and empowering relationships with frontline managers lead to positive attitudes in nurses towards their positions and a feeling that they enhance their ability to provide good patient care (Gunnarsd
ottir et al. 2009). Praise is a simple, cost-free and effective way to reward an employee or employees. In the light of contemporary healthcare cost containment, it seems important for managers to be aware of the cost-saving significance of praise. In this study, we explore how praise from NUMs influences the work environment, job satisfaction and practice of nurses caring for surgical patients.

Introduction The Online Oxford Dictionary (n.d.) defines praise as ‘the act of making positive statements about a person, an object or idea, either publically or privately’. Praise plays a crucial role in leadership, empowerment, supervision, encouragement, mentoring, recognizing achievements and maintaining professional standards that influence employees’ welfare. Recent research shows that praise can have a marked influence on employee satisfaction, employee retention levels, improved patient outcomes and organizational performance (Amabile & Kramer 2007, Sherman & Pross 2010). When nurses receive praise from their nurse unit managers © 2015 John Wiley & Sons Ltd

Study setting The study took place at the Landspitali University Hospital (LUH) in Iceland where health services are primarily financed from public coffers. The LUH was established in 2000 following the cost-reducing merger of the country’s two largest state-run hospitals. After changes to the organizational structure of the hospital in 2009, the number of divisions was reduced from 11 to 5, with one chief executive responsible for each division instead of the previous physician or nurse team. The 2008 world economic collapse hit Iceland hard, compounding these organizational changes 559

H. Sveinsd ottir et al.

with cutbacks in funding and restrictions on hiring employees. The job description for NUMs was rewritten such that it now included managerial and financial responsibilities previously beyond the bounds of their duties. Their new responsibilities relate mainly to the management of staff and finances and to ensuring the provision of high quality nursing care. NUMs often experience these mixed responsibilities as onerous because of the sheer number of employees in each unit, with the average number of forty making the comparison to a medium-sized company with a fivemember board of directors not an unjustified one (Landspitali University Hospital 2009).

Background A significant part of human resource management from the manager’s point of view is the creation of a favourable work climate (Aiken et al. 2013) by facilitating professionalism across all work processes. Inner worklife, described as personal perceptions, emotions and motivation at work, can be seen as a part of a favourable work climate (Amabile & Kramer 2007). Studies on NUMs’ leadership styles show that this factor influences staffs’ inner worklife and that managerial support in the form of praise makes staff feel more valued, prompts them to regard their work environment as being healthier and reduces staff turnover (Sherman & Pross 2010). Organizational commitment may be defined as an individual’s attachment to, identification with and involvement in an organization, with staff turnover serving as one indicatior of organizational commitment (Mowday et al. 1979). Various studies have explored nurses’ intention to leave their workplace and the role of NUMs in the forging of this intention (De Gieter et al. 2010, Cowden et al. 2011, Duffield et al. 2011). One such study on nurses from 10 European countries found leadership to be one of seven factors associated with the intention to leave (Heinen et al. 2013). Other factors that seem to influence nurses’ intention to stay in their workplace include job satisfaction, the type of work processes created by NUMs and the sense of belonging to a peer group, especially when that group is stable and dependable, where its members exhibit trust in and respect for each other and where opportunities for socializing exist (De Gieter et al. 2010, Tourangeau et al. 2010, Duffield et al. 2011). It is notable that psychological rewards in the form of praise from a nurse manager not only impact nurse turnover, intention to stay or leave, job satisfaction and organizational commitment, but are even valued as more important than salary satisfaction (Stapleton et al. 2007, De Gieter et al. 2010). The conclusion that can thus be drawn is that 560

NUMs with strong leadership skills can create and foster a positive work environment (Rosengren et al. 2007, NSW Department of Health 2009) and influence nurse retention through their positive effect on job satisfaction (Tourangeau et al. 2010). The importance of the nurse retention is recognised in studies that show that medical errors are reduced (O’Brien-Pallas et al. 2010) and patients’ outcomes improved if nurses stay for some time at the same unit (Bartel et al. 2014). In this light, preventing high turnover should be a priority management task. Despite the overwhelming persuasiveness of the data, NUMs do not always seem to occupy such an influential role in their workplace. A study on staff conceptions of nursing leadership showed that nurses considered leadership to be successful when the leader is present and available, supports everyday practice and facilitates professional acknowledgement by giving feedback on daily activity. The NUMs were however described as being devastated by financial and administrative tasks such that they were prevented from improving care and supporting staff (Rosengren et al. 2007). In a similar vein are findings from an earlier study where the large majority of participating nurses ranked recognition as indispensable to job satisfaction. Nearly, half of the participating nurses found verbal feedback and the person meting it out – namely, the nurse manager – to be of paramount importance, with 28% feeling recognition was rarely or never meted out (Goode et al. 1993). NUMs occupy a prime position then in the provision of encouragement and feedback to nursing staff and by virtue of their role are actually the only persons capable of dispensing such acknowledgement. Australian NUMs have stated, however, that most of their work involves general management tasks and patient care activities but not leadership activities. This statement contradicts their opinion that leadership should involve activities such as empowering and supervising staff, encouraging teamwork, mentoring and recognizing staff achievements (NSW Department of Health 2009). The view of the Australian NUMs is supported by a systematic review that found 24 studies reporting that nurse manager leadership styles, which focused on people and relationships were associated with higher job satisfaction among nurses and ten studies reporting that leadership styles which focused on tasks alone were associated with lower job satisfaction among nurses (Cummings et al. 2010). Furthermore, a study that looked at the underlying factors driving the nursing shortage in US found the single positive element to be the realization that NUMs can make a significant difference to how nurses perceive and embrace their jobs (Kimball 2004). There is a strong argument to be made, therefore, that NUMs should be guided by leadership © 2015 John Wiley & Sons Ltd

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theories that emphasize the above-mentioned elements in their work. The theoretical framework guiding this study is the theory of servant leadership as developed by Parris and Peachey (2013). This theory concerns itself with the use of leadership opportunities in the development and appreciation of people through providing them with a service and recognizing and meeting their needs. Recognition for instance is thought to bestow confidence and positive energy, both of which in turn prove foundational for providing opportunities, fostering positive supportive relationships, encouraging autonomy and building a sense of connectedness in the community (Jackson 2007). Servant leadership is one way of managing people with respect, honesty and spirituality in a manner that encourages, empowers and inspires (Mahon 2011). A servant leader emphasizes the growth and well-being of people and the communities they belong to as NUMs should do.

The study Aim The aim of this study was to investigate the associations between praise from NUMs and job satisfaction, professional practice, workload, work climate and organizational commitment of nurses caring for surgical patients.

Design This study used a web-based, cross-sectional explorative survey design.

Participants Nurses working at the surgical division at LUH (n = 383) were invited to participate. The response rate was 49% (n = 189). The majority of the participants were married (79
6%) with children living at home (67
8%), were older than 40 years of age (66
3%) and worked rotating shifts with over 10 years of work experience since graduating (70
7%) and over 6 years at the present unit (63%) (Table 1).

Data collection Data were collected online using Outcome© software (outcomekannanir.is. Date accessed 02 October 2015) between December 2009—January 2010. Participants were assigned a code that they received via e-mail and that gave them access to the questionnaire. They were reminded of the © 2015 John Wiley & Sons Ltd

Primacy of praise

study twice via e-mail. Valid e-mail addresses of all eligible participants were obtained from NUMs at participating units. Participants were asked to think of their current job situation when answering the questionnaire.

Measures Praise in our study is defined as the subjective feeling of how individual nurses experience statements from the NUM that they themselves define as praise. It was measured with a single question that asked participants if NUMs offered them praise for doing their work well. Responses ranged from 1 (very rarely)-5 (very often). Job satisfaction was measured with the Job Satisfaction Scale (JSS), which asked participants about job satisfaction using 17 items that were rated on a Likert scale from 1 (very unsatisfied)-5 (very satisfied). Examples of these items include organization of nursing care, responsibility, staffing, participation in decisionmaking, flexibility in work schedule, shift load, salary and vacation. The JSS has three subscales (Table 2). Professional practice was measured with the Professional Practice Scale–Opportunities (PPS-O) and the Professional Practice Scale–Importance of Opportunities (PPS-IO) (Sveinsd
ottir & Bl€ ondal 2014). Each scale is composed of 25 questions that mirror each other so that the questions in each scale target the same aspects of professional practice. The PPS-O targets information on participants’ opportunities to practice different aspects of nursing’ and PPS-IO targets information on the importance of having these opportunities. An example question on the PPS-O is ‘How many or few opportunities do you have to develop new interventions on the unit?’ The mirror question on PPS-IO is ‘How important is it for you to develop new interventions on the unit?’ Examples of other aspects of professional practice that were targeted include doing research, teaching students, developing professionalism, providing care, working with new staff, working in a team, working with experienced nurses/physicians, making independent decisions and using various knowledge. Response options for the scales ranged from 0 (not important at all/no opportunity) to 10 (very important/very many opportunities). The PPS-O and PPS-IO have five subscales each (Table 2). Workload was measured with the Work Load Scale (WLS) that includes 15 items, with responses ranging from 1 (very rarely or never)-5 (very often). Examples of items on this scale include whether work is challenging in a positive way, requires maximum attention, is too difficult, is meaningful, is secretarial, does not require professional knowledge and is disturbed by interruptions. The WLS includes three subscales (Table 2) (Sveinsd
ottir & Bl€ ondal 2014). 561

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Table 1 Demographic characteristics of all participants (n = 189) and chi-square/Fisher’s exact statistics for statistically significant differences in those who received praise by NUMs very rarely/rarely (n = 66) and rather/very often (n = 59).

n (%) Age (n = 187)* ≤29 years 11 (5
9) 30-39 years 52 (27
8) 40-49 years 67 (35
8) ≥50 years 57 (30
5) Work experience since graduation (n = 184) 10 years 130 (70
7) Worked at present unit (n = 184) 10 years 63 (34
2) Marital status (n = 186) Married/in a relationship (n = 146) 148 (79
6) Single/divorced 37 (19
9) Widow/widower 1 (0
5) Children under 18 years living at home (n = 183) None 59 (32
2) 1 or more 124 (67
8) Working unit (n = 185) Day unit/walk in unit 13 (7
0) ICU 45 (24
3) Inpatient unit 76 (41
1) OR 32 (17
3) Anaesthetic unit 19 (10
3) Working hours (n = 188) Days 34 (18
1) Shifts 154 (81
9) Thought of leaving the current workplace (n = 183)* Yes 96 (51
3) No 91 (48
7)

Praised very rarely/rarely n (%)

Praised rather/very often n (%)

Chi-square/Fisher’s exact

5 10 32 19

(45
5) (19
6) (48
5) (33
3)

3 18 18 20

(27
3) (35
3) (27
3) (35
1)

ns+

2 6 10 45

(100
0) (27
3) (34
5) (34
9)

0 6 9 43

(0
0) (27
3) (31
0) (33
3)

ns

9 20 16 20

(69
2) (37
0) (30
2) (31
7)

2 16 20 19

(15
4) (29
6) (37
7) (30
2)

ns

52 (35
6) 13 (35
1) 0 (0
0)

47 (32
2) 11 (29
7) 1 (100
0)

ns

22 (37
3) 42 (34
4)

21 (35
6) 39 (32
0)

ns

1 22 23 10 9

6 14 26 8 5

(46
2) (31
1) (34
7) (25
0) (26
3)

ns

12 (36
4) 54 (35
3)

10 (30
3) 51 (33
3)

ns

47 (49
5) 18 (20
0)

17 (17
9) 42 (46
7)

P < 0
001

(7
7) (48
9) (30
7) (31
2) (47
4)

*Valid percentages are presented for all participants. + ns, not significant.

We measured work climate by asking participants if the work climate at their unit was characterized by: (1) competitiveness; (2) motivation and empowerment; (3) suspicion or no trust; (4) comfort and calmness or (5) stiffness and no flexibility. Responses range from 1 (not at all competitive/motivating/suspicious/comforting/stiff)-5 (highly competitive/motivating/suspicious/comforting/stiff). We merged these variables into one scale that we called ‘Relaxed and trusting atmosphere-scale’ after we had reversed relevant questions. Internal consistency of the scale was good (Cronbach’s a = 0
83). Other questions concerning work climate included (1) ‘Do you get information and guidance at work 562

as needed?’; (2) ‘Do you get support and encouragement from the NUM?’; (3) ‘Do you get support and encouragement from coworkers?’; (4) ‘Are employees at the workplace motivated to submit proposals for the betterment of practice?’; and (5) ‘Are the communications satisfying at the unit?’. Response options ranged from 1 (does not apply)-5 (applies perfectly). Organizational commitment was measured with the question, ‘Have you thought of leaving your current work place?’, with response options of either ‘yes’ or ‘no’ and by using the following items: ‘I am proud to work on this unit’; ‘I am proud to work at this hospital’; ‘I am willing to © 2015 John Wiley & Sons Ltd

JAN: ORIGINAL RESEARCH: EMPIRICAL RESEARCH – QUANTITATIVE

Primacy of praise

Table 2 Mean score on study variables for all participants and mean scores and t-test statistics for significant differences between participants who received praise very rarely/rarely and rather/very often.

N Job satisfaction (JSS) Professional recognition (8 items) 178 Flexibility at work (6 items) 160 Strings attached (3 items) 185 Professional Practice Scale-Opportunities (PPS-O) Professional opportunities (10 items) 178 Educational and supportive opportunities (4 items) 183 Collaborative opportunities (4 items) 177 Expanding opportunities (3 items) 180 Autonomy opportunities (4 items) 182 Professional Practice ScaleImportance of Opportunities (PPS-IO) Importance of diverse opportunities (10 items) 181 Importance of professional collaboration (5 items) 178 Importance of professional progress (5 items) 177 Importance of providing patients with support (3 items) 183 Importance of knowledge utilization (2 items) 182 Work Load Scale (WLS) Work booster (6 items) 182 Work constraints (4 items) 182 Unprofessional work (5 items) 181 Work climate Relaxed and trusting atmosphere-scale (5 items) 173 Do you get information and guidance at work as needed 186 Do you get support and motivation from your NUM? 187 Do you get support and motivation from coworkers? 187 Are communications satisfying at the unit? 186 Are employees motivated to propose better practice? 185 Organizational commitment I am proud to work on this unit 185 I am proud to work at this hospital 186 I am willing to make more effort for this unit 184 I am willing to make more effort for this hospital 185 I have little connection to this unit 185 I have little connection to this hospital 184

Very rarely/ rarely

Rather/very often

M (SD)

N

M (SD)

N

M (SD)

t-test

3.8 (0.8) 3.5 (0.8) 2.6 (0.9)

63 56 66

3.3 (0.8) 3.5 (0.8) 2.5 (0.8)

56 51 59

4.4 (0.5) 3.9 (0.8) 2.9 (0.9)

t(117) = t(105) = t(123) =

5.1 7.4 6.3 3.3 6.8

(2.3) (2.1) (2.0) (2.4) (1.9)

62 64 62 64 65

3.7 6.7 5.4 2.4 6.1

(1.9) (2.4) (2.2) (2.3) (2.2)

57 58 58 57 57

6.3 8.2 7.1 4.3 7.5

(2.1) (1.1) (1.9) (2.3) (1.7)

t(118) t(120) t(118) t(119) t(120)

6.0 8.4 8.4 8.3 9.2

(1.9) (1.2) (1.4) (1.7) (0.9)

65 62 62 65 64

5.6 8.3 8.2 8.2 9.3

(2.2) (1.4) (1.7) (1.8) (0.9)

57 57 58 58 59

6.5 8.7 8.7 8.6 9.2

(1.7) (0.9) (1.2) (1.3) (1.0)

t(120) = t(117) = ns ns ns

3.9 (0.5) 2.3 (0.6) 3.1 (0.7)

66 65 64

3.9 (0.6) 2.3 (0.7) 3.0 (0.7)

56 58 59

4.0 (0.4) 2.2 (0.6) 3.0 (0.6)

ns ns ns

3.8 4.2 4.0 4.3 3.5 3.5

(0.7) (0.7) (1.1) (0.7) (1.0) (1.0)

63 66 66 66 66 66

3.5 4.0 3.2 4.1 3.0 3.0

(0.8) (0.8) (1.2) (0.9) (1.1) (1.0)

55 59 59 59 59 58

4.1 4.5 4.8 4.6 4.0 4.0

(0.1) (0.6) (0.5) (0.6) (0.8) (0.8)

t(116) t(121) t(123) t(123) t(123) t(122)

= = = = = =

4.2 3.6 3.7 3.0 1.9 2.3

(0.8) (1.0) (1.0) (1.0) (1.1) (1.1)

65 66 65 65 65 65

3.9 3.3 3.3 2.8 2.2 2.7

(0.9) (0.9) (0.9) (1.0) (1.0) (1.1)

59 59 59 59 59 59

4.5 4.0 4.1 3.5 1.8 2.0

(0.7) (0.9) (0.8) (0.9) (1.2) (1.0)

t(122) t(123) t(122) t(122) t(122) t(122)

= 4
186; P < 0
001 = 4
188; P < 0
001 = 4
805; P < 0
001 = 4
326; P < 0
001 = 2
133; P < 0
05 = 3
599; P < 0
001

= = = = =

8
555; P < 0
001 2
475; P < 0
05 2
963; P < 0
01 6
914; 4
331; 4
317; 4
401; 4
073;

P P P P P

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