16 July 2019 • Nursing Management Nursingmanagement.Com Copyright

16 July 2019 • Nursing Management nursingmanagement.com

OPEN Nurse manager job satisfaction and retention: A home healthcare perspective

By Coleen Arlette Cox, DHA, MS, MSN/Ed, RN, CCM

urse managers are essential for the success of organizational missions and objectives.1,2 The expectation is that nurse managers are adept at financial management, negotiation, N staff recruitment and development, conflict resolution, technologic advancements, and leadership.3 Nurse managers have a primary responsibility of ensuring that adequate nursing staff members are available to provide quality patient care.4 Supportive behaviors to promote clinical nurse autonomy and development, enhance nurse-physician relationships, and improve nursing competence are also expectations.5 Despite the essential role of nurse managers, increasingly complex and demanding healthcare environments are contributing to their overwork, stress, and dissatisfaction.6

Significance Demand for nursing services is expected to increase by 15% between 2016 and 2026 because of the ris- ing needs of an aging population, growing numbers of individuals with chronic conditions, and the increasing focus on preventive care. RNs practice as frontline caregivers and are in leadership roles in nearly all healthcare settings, including home care agencies.7 The need for nursing services is greater for home healthcare because the older population pre- fers to receive treatment in their homes.8

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Clinical nurse satisfaction and extrinsic factors as the theoretical also associated with organiza- retention are central responsibili- framework,11 the general research tional policies.13 Two hundred ties of nurse managers; however, question that guided the study and ninety-one nurse managers nurse manager job satisfaction was: “How do nurse manag- who worked in various US hos- and retention are low. There’s ers perceive their experience of pitals participated in a study to also a lack of understanding job satisfaction and retention?” help describe nurse manager job about what contributes to nurse Three subquestions supported satisfaction and intent to leave. manager job satisfaction and and directed the central question: Results revealed that burnout retention.9 The increasing pref- “What experiences contribute to or stress were among the most erence for home care services nurse manager job satisfaction in frequently cited reasons nurse may intensify nurse managers’ home healthcare organizations?,” managers gave for their intent responsibilities for ensuring that “What experiences contribute to to leave their positions. Despite adequately prepared clinical nurse manager job retention in the stressors and workload bur- nurses are available to coordinate home healthcare organizations?,” den, 52% of the nurse managers care for patients in their homes. and “What do nurse managers reported being satisfied or very Clinical nurse satisfaction also perceive that home healthcare satisfied in their roles.14 affects patient satisfaction.10 organizations can do to improve Lack of leadership support is Nurse manager job satisfaction their job satisfaction and reten- another factor that contributes to and retention can influence the tion?” (See Research box.) nurse manager job satisfaction success of home care agencies and intent to leave an organiza- faced with a projected demand Supporting literature tion. This was a major factor to provide services to the grow- The literature indicates a need for revealed in a study that included ing older population. research on the job satisfaction 12 nurse managers from three This qualitative phenomeno- and retention of nurse managers Magnet® hospitals. The researcher logic study explored the lived in home healthcare. A study con- recommended that senior lead- experiences of nurse managers ducted in the home healthcare ers should provide support and to determine what contributed setting during 2004 wasn’t solely the infrastructure to assist nurse to their job satisfaction and focused on nurse managers.12 managers to be successful and motivated them to remain in The greatest job dissatisfiers enhance their job satisfaction. their positions. Using Herzberg’s reported by 16 nurse managers Organizational leaders should two-factor theory that satisfac- in a long-term-care facility were also create initiatives to minimize tion is associated with motivat- pay, organizational policies, and nurse manager stress levels, such ing or intrinsic work factors and interaction. A relationship with as shared on-call responsibilities dissatisfaction with hygiene or nurse manager retention was and smaller spans of control.15

Study design and demographics Research box Nurse managers in their current • The purpose of this study was to gather a general understanding of nurse positions for at least 5 years at a manager job satisfaction and retention. large home healthcare organiza- • Twenty nurse managers who were employed in their positions for at least 5 years at a large nonprofit home healthcare organization in New York, N.Y., tion in New York, N.Y., were were interviewed. asked to participate in this quali- • The participants included 17 females and 3 males. tative phenomenologic study. • Seventy-five percent of the participants were with the agency for longer than After Institutional Review Board 10 years. approval, communication with • Ninety-five percent of the participants had a bachelor’s degree or higher. • Twenty- to 40-minute interviews were conducted face-to-face using a the home healthcare organiza- semistructured interview protocol with open-ended questions. tion’s human resources depart- • Computer-assisted data analysis software and the Van Kaam method of analysis ment assisted with identifying for phenomenologic data revealed four core themes: the nurse manager and potential participants who met staff relationship, organizational and leadership support, care for patients in the the selection criteria. A purposive home environment, and focus on nurse manager responsibilities. sampling of 20 nurse managers

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Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved. was selected because the geographic location allowed for con- Table 1: Participant characteristics ducting face-to-face interviews. Characteristic Percent Validation strategies applied to Sex this study included triangula- Female 85% tion, member checking, and Male 15% thick descriptions of participant Years as an RN responses. 10 to 15 years 5% The 20 voluntary participants, Greater than 15 years 95% identified as study nurse manager Years with the current agency 1 to study nurse manager 20, had 5 to 10 years 25% the following demographic char- 10 to 15 years 30% acteristics: 17 (85%) were female Greater than 15 years 45% and 3 (15%) were male; years in Educational level their current position ranged from Associate degree 5% 5 to 20 years, with an average of BSN 40% 9 years; 11 (55%) were in previous MSN 30% nurse manager positions ranging MS 15% MPH 5% from 1 to 15 years, with an aver- Doctorate 5% age of 5 years; 9 (45%) were with the current agency longer than 15 Hours worked per week years, 6 (30%) for 10 to 15 years, 36 to 40 hours 50% 41 hours or greater 40% and 5 (25%) for 5 to 10 years; and 35 hours or less 10% 19 (95%) were RNs for more than 15 years, with 1 (5%) for 10 to 15 years. (See Table 1.) Table 2: Alignment of research subquestions with Participants’ educational interview questions level included 1 (5%) with an associate degree, 8 (40%) with Research subquestions Interview questions a bachelor of science in nursing What experiences contribute to • What experiences make you satisfied in degree, 6 (30%) with a master nurse manager job satisfaction in your role as a nurse manager? of science in nursing degree, 3 home healthcare organizations? • Reflecting on your time with the organization (15%) with a master of science in the nurse manager role, what was one of the most satisfying experiences for you? degree, 1 (5%) with a master of • What experiences contribute to your satis- public health degree, and 1 (5%) faction with the organization? with a doctoral degree. Ten par- What experiences contribute to • What experiences contribute to your stay- ticipants (50%) worked 36 to 40 nurse manager job retention in ing in the nurse manager role for at least hours per week, 8 (40%) worked home healthcare organizations? 5 years? 41 hours or more, and 2 (10%) • What experiences contribute to your decision worked 35 hours or less. Several to stay with a home healthcare organization? of the participants who selected What do nurse managers perceive • What can home healthcare organizations do 41 hours per week or greater that home healthcare organizations to improve nurse manager job satisfaction? indicated that this choice was can do to improve their job satisfac- • What can home healthcare organizations made because of additional time tion and retention? do to improve nurse manager job retention? worked to accomplish job tasks. interviews. Semistructured protocol form with seven open- Data collection and analysis interviews were conducted ended questions was used for Data collection involved contact- with 22 (2 pilot and 20 study the interviews. (See Table 2.) The ing study participants by email participants) nurse managers. A interviews lasted between 20 and or phone to arrange face-to-face researcher-developed interview 40 minutes using open-ended www.nursingmanagement.com Nursing Management • July 2019 19

questions until data saturation responsibilities assigned to nurse Organizational and occurred. managers. (See Table 3.) leadership support During the final phase of data Participants’ responses revealed collection, approximately 10 Nurse manager and that nurse managers’ perceptions hours of audio-recorded inter- staff relationship of organizational and leadership views were transcribed; hand- The foremost theme that support were essential to their written notes were also reviewed. emerged from participants’ job satisfaction. Nurse manag- After transcription, the partici- responses centered on the nurse ers described the organization pants were given the transcript manager and staff relationship. as supportive and engaging. of their interview for review and Some of the participants indi- One manager emphasized that feedback as a means of member cated that they couldn’t specify the reason for still working with checking to establish credibility. one experience that was most the organization was the current Data were analyzed using the satisfying; however, their experi- supervisor, stating, “I like who I seven-step modified Van Kaam ences were associated with their work for and I have confidence method to reveal final themes.16 staff. Regarding what kept them in that person.” in the role for at least 5 years, the Results nurse managers again empha- Care for patients in the Participants discussed and sized their staff. One participant home environment described their lived experi- stated, “When I say, ‘What can I Participants were also asked ences related to nurse manager do for you?’ and when they say about what experiences contrib- job satisfaction and retention in ‘thank you’ or when an email uted to their continuing to work a home healthcare agency. They comes that says ‘thank you for in the home healthcare setting. also offered candid and positive taking the time,’ I appreciate The prevalent theme identified recommendations to improve that.” Another shared, “I guess was caring for patients in the nurse manager job satisfaction the thing that always stands home environment. One par- and retention. Four core themes out for me is when the nurses ticipant stated, “I’m so commit- emerged from the interviews: have those ‘a-ha’ moments of ted, I can’t explain it. I was so significance of the nurse man- clarity and connecting what enamored by the idea of keeping ager and staff (nurses, clinicians, they learned in school with how people at home. It just seemed so nonclinicians) relationship, they’re doing their job. It’s a sat- right to me.” importance of organizational isfying thing when you have a and leadership support, care for nurse who’s really good at that Focus on nurse manager patients in the home environ- and you’ve participated in get- responsibilities ment, and need to focus on the ting the person to that level.” Participants were asked what home healthcare organizations Table 3: Core themes and descriptions could do to improve nurse manager job satisfaction and Theme Description retention. Nurse managers Nurse manager and staff The significance of the nurse manager and staff emphasized a need to focus relationship (nurses, clinicians, nonclinicians) relationship to on the amount of responsibili- nurse manager job satisfaction and retention ties assigned to their role. They felt overwhelmed with cleri- Organizational and The importance of organizational and leadership leadership support support to nurse manager job satisfaction and cal work and preferred to give retention more attention to the clinical aspects of the role. One nurse Care for patients in the The value of caring for patients in the home home environment environment related to nurse manager job manager stated, “I think we’re satisfaction and retention really bogged down with a lot of clerical duties. At least I find Focus on nurse manager A need to focus on the responsibilities assigned to that in this organization [there responsibilities nurse managers are] a lot of clerical duties that

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Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved. really take away from our focus video feedback and reflection ership techniques to improve on the clinical aspects.” Another as a technique to improve nurse nurse manager job satisfaction expressed, “I think to improve a managers’ relationship-focused and retention.22 Nurse managers manager’s satisfaction it would leadership approaches. Video may also learn transformational be to really utilize that person’s feedback and reflection entails leadership techniques and talents for the role, rather than the recording of real-time inter- apply the same approach with having them fill in gaps in the actions of the nurse manager their staff.23 missing pieces that need to get with staff or in meetings after Nurses primarily obtain cer- done in the organization.” permission is obtained from all tification in clinical specialty employees.19 Use of real-time areas; however, nurse managers Discussion video is an emerging best prac- should also be encouraged to Nurse managers working in tice to improve clinical practice, pursue manager certification. home healthcare organizations interprofessional communica- Despite a focus on nurse man- have various responsibilities, tion, and patient safety in hospi- agers working with hospital including managing resources, tal settings. organizations, home healthcare clinical support, and effectively Administrative support is one leadership should recommend communicating with staff mem- of the strongest predictors of job that nurse managers prepare bers who provide patient care satisfaction.20 One participant for and take the Certified throughout broad geographic emphasized that the people are Nurse Manager and Leader regions.17 The information the organization and the sup- exam.24 Nurse managers who obtained in this study about port received was very satisfy- achieve certification should

Administrative support is one of the strongest predictors of job satisfaction. nurse managers’ perceptions ing. Interpersonal relationships be recognized and financially of factors contributing to their with nursing administrators had rewarded. Senior leader- job satisfaction and longevity a greater effect on nurse man- ship should restructure nurse is beneficial to leadership in ager engagement and proactive manager work processes and home healthcare organizations. behavior than interpersonal rela- provide adequate clerical sup- To enhance the nurse manag- tionships with peers or physi- port. Home healthcare leader- ers’ leadership skills, home cians.21 Senior leadership should ship should also explore the healthcare leaders should con- schedule one-to-one informal feasibility of creating an online sider using a relationship- or meetings with nurse manag- portal for nurse managers.25 people-focused approach instead ers to promote a culture that The online portal should be of a task-focused leadership supports quality interpersonal designed to ensure easy naviga- style. The relationship-focused relationships between nurse tional access to well-organized leadership style helps create a managers and their supervisors. electronic resources to support healthy work environment and Transformational leadership nurse managers in performing increase nursing workforce satis- practices foster nurse manager their roles and include informa- faction.18 empowerment and effectiveness tion for leadership develop- Home healthcare organiza- in accomplishing organization ment. tion development staff mem- goals. Senior leaders should Nurses are frequently pro- bers should explore the use of practice transformational lead- moted and expected to per- www.nursingmanagement.com Nursing Management • July 2019 21

form the same in a nurse man- Recommendations for 2. Regan LC, Rodriguez L. Nurse ager position without formal future research empowerment from a middle- management perspective: management and leadership The first recommendation for nurse managers’ and assistant 26 training. Home healthcare future research is replication of nurse managers’ workplace leadership can collaborate with this study because findings may empowerment views. Perm J. academic institutions to support be validated if similar themes 2011;15(1):e101-e107. nurse manager enrollment and emerge from future studies in 3. Cathcart EB, Greenspan M, Quin M. The making of a nurse manager: the attendance in nursing manage- different geographic locations role of experiential learning in lead- ment and leadership programs. with samples sharing similar ership development. J Nurs Manag. To accommodate nurse manag- demographics. A qualitative, 2010;18(4):440-447. ers’ schedules, courses can be instrumental case study is a 4. Fry BJ. Fast Facts for the Clini- offered in the traditional class- second recommendation for cal Nurse Manager: Managing a Changing Workplace in a Nutshell. room setting or online. future research. The case study 2nd ed. New York, NY: Springer; approach should allow for data 2016. Limitations collection from multiple sources, 5. Schmalenberg C, Kramer M. Nurse A limitation noted was the such as interviews, documents, manager support: how do staff small sample size; however, and observations that may con- nurses define it? Crit Care Nurse. 2009;29(4):61-69. despite the small sample size, tribute to eliciting more emer- 6. Shirey MR, McDaniel AM, Ebright 28 the results may be beneficial to gent themes. The final recom- PR, Fisher ML, Doebbeling BN. healthcare leaders’ understand- mendation is a cross-sectional Understanding nurse manager ing of factors that contribute survey design that may capture stress and work complexity: factors to nurse manager satisfaction a larger sample of participants to that make a difference. J Nurs Adm. 2010;40(2):82-91. and retention. Other study compare nurse manager job sat- 7. US Bureau of Labor Statistics. limitations were the volun- isfaction and retention in home Registered nurses: summary. 2019. tary method, the participants’ healthcare organizations. www.bls.gov/ooh/healthcare/regis honesty, and the possibility of tered-nurses.htm. response bias even with the Moving forward 8. US Bureau of Labor Statistics. Registered nurses: job outlook. assurance of confidentiality. In Nurse managers are key to the 2019. www.bls.gov/ooh/healthcare/ addition, participants may not achievement of the home health- registered-nurses.htm#tab-6. have provided thick descrip- care mission to provide quality 9. Warshawsky NE. Promote nurse tions of their experiences and care while keeping patients safe manager job satisfaction and reten- this might limit the transferabil- in the community. This study’s tion. Am Nurse Today. 2018;13(8): 33-34. ity of study results. themes and recommendations 10. Zori S, Nosek LJ, Musil CM. Critical Another possible limita- can provide a framework for thinking of nurse managers related tion may have been researcher home healthcare leaders to to staff RNs’ perceptions of the bias. A strategy used to mini- include nurse managers in the practice environment. J Nurs mize researcher bias before creation of innovative strategies Scholarsh. 2010;42(3):305-313. 11. Herzberg F, Mausner B, Snyder- initiating interviews included to enhance nurse manager job man BB. The Motivation to Work. application of a transcendental satisfaction and retention. Suc- New Brunswick, NJ: Transaction; approach to set aside personal cessful implementation may con- 1959/1993. beliefs and ideas about the tribute to improved satisfaction 12. Navaie-Waliser M, Lincoln P, phenomenon.27 Utilization and retention of nurse managers, Karuturi M, Reisch K. Increasing job satisfaction, quality care, and of the modified Van Kaam succession planning for the nurse coordination in home health. J Nurs method during the data analy- manager role, and better patient Adm. 2004;34(2):88-92. sis process and the use of data experiences. NM 13. Pagliei P. Nurse managers job sat- analysis software to assist isfaction and retention in long term with identifying themes from REFERENCES care. Masters Abstr Int. 2008;47:149. 1. Codier E, Kamikawa C, Kooker BM. 14. Warshawsky NE, Havens DS. participants’ responses were The impact of emotional intelligence Nurse manager job satisfaction and additional techniques used to development on nurse managers. intent to leave. Nurs Econ. 2014; minimize researcher bias. Nurs Adm Q. 2011;35(3):270-276. 32(1):32-39.

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Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved. 15. Loveridge S. Straight talk: nurse 22. Lee H, Cummings GG. Examining tional Technology Research, School manager role stress. Nurs Manage. relationships between director of Advanced Studies, University of 2017;48(4):20-27. leadership practices and manager Phoenix for supporting the preparation 16. Moustakas C. Phenomenological worklife and burnout. J Leadersh of this article. Portions of this study Research Methods. Thousand Oaks, Stud. 2008;2(2):47-62. have been presented in abstract form CA: Sage; 1994. 23. Choi SL, Goh CF, Adam MB, Tan OK. at the American Organization for Nurs- 17. Rosenfeld P, Pyc LS, Rosati RJ, Mar- Transformational leadership, empow- ing Leadership (formerly the American ren JM. Developing a competency erment, and job satisfaction: the medi- Organization of Nurse Executives) tool for home health care nurse ating role of employee empowerment. Meeting and Exposition, Orlando, managers. Home Health Care Hum Resour Health. 2016;14(1):73. Florida, March 12-15, 2014. Manage Pract. 2011;24(1):5-12. 24. American Organization for Nursing 18. Laschinger HK, Wong CA, Cummings Leadership. Certified nurse man- Coleen Arlette Cox is a professor at GG, Grau AL. Resonant leadership ager and leader certification. www. Herzing University in Orlando, Fla. and workplace empowerment: the aonl.org/initiatives/cnml.shtml. value of positive organizational cul- 25. Parry J. An online portal to sup- Copyright © 2019 The Author. Pub- tures in reducing workplace incivil- port the role of the nurse manager. lished by Wolters Kluwer Health, ity. Nurs Econ. 2014;32(1):5-15,44. Nurs Econ. 2012;30(4):230-232. Inc. This is an open-access article 19. Crenshaw JT. Use of video- 26. Kelly LA, Wicker TL, Gerkin RD. distributed under the terms of the feedback, reflection, and interac- The relationship of training and Creative Commons Attribution-Non tive analysis to improve nurse education to leadership practices in Commercial-No Derivatives License leadership practices. Nurs Adm Q. frontline nurse leaders. J Nurs Adm. 4.0 (CCBY-NC-ND), where it is permis- 2012;36(3):260-267. 2014;44(3):158-163. sible to download and share the work 20. Richmond PA, Book K, Hicks M, 27. Wojnar DM, Swanson KM. Phe- provided it is properly cited. The work Pimpinella A, Jenner CA. C.O.M.E. nomenology: an exploration. J cannot be changed in any way or be a nurse manager. Nurs Manage. Holist Nurs. 2007;25(3):172-180. used commercially without permission 2009;40(2):52-54. 28. Creswell JW. Qualitative Inquiry & from the journal. 21. Warshawsky NE, Havens DS, Knafl Research Design: Choosing Among G. The influence of interpersonal Five Approaches. 2nd ed. Thousand The author and planners have dis- relationships on nurse managers’ Oaks, CA: Sage; 2007. closed no potential conflicts of interest, work engagement and proac- financial or otherwise. tive work behavior. J Nurs Adm. Acknowledgment: The author thanks 2012;42(9):418-425. the Center for Educational and Instruc- DOI-10.1097/01.NUMA.0000558512.58455.68 ▲ For more than 142 additional continuing-education articles related to management topics, go to NursingCenter.com/CE. ▲

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INSTRUCTIONS Nurse manager job satisfaction and retention: A home healthcare perspective TEST INSTRUCTIONS PROVIDER ACCREDITATION • Read the article. The test for this CE activity is to be taken online at Lippincott Professional Development will award 1.0 contact hour for this http://nursing.ceconnection.com. continuing nursing education activity. • You’ll need to create (it’s free!) and login to your personal CE Planner Lippincott Professional Development is accredited as a provider of account before taking online tests. Your planner will keep track of all your continuing nursing education by the American Nurses Credentialing Lippincott Professional Development online CE activities for you. Center’s Commission on Accreditation. • There’s only one correct answer for each question. A passing score for This activity is also provider approved by the California Board of this test is 13 correct answers. If you pass, you can print your certificate of Registered Nursing, Provider Number CEP 11749 for 1.0 contact hour, earned contact hours and access the answer key. If you fail, you have the and the District of Columbia, Georgia, and Florida CE Broker #50-1223. option of taking the test again at no additional cost. • For questions, contact Lippincott Professional Development: 1-800-787-8985. Payment: The registration fee for this test is $12.95. • Registration deadline is June 4, 2021.