- Top of page
- Source of funding
- Ethical approval
Nursing managers are known to be at risk of experiencing burnout and job dissatisfaction because of having to manage complex and challenging situations in environments characterised by the need to strive for high-quality care provision under the burden of constrained budgetary circumstances and staff shortages (Laschinger & Finegan 2008, Lee et al. 2010, Shirley et al. 2010). Other sources of work-related stress for nursing managers include dealing with negative people and organisational politics, a heavy workload, concerns about operational efficiencies and staff retention (Shirley et al. 2010). It has also been recognised that nursing managers who are poorly prepared for their roles, or are unsupported in their roles, are at an increased risk of high levels of stress, burnout and job dissatisfaction (Paliadelis et al. 2007, Lee & Cummings 2008, Shirley et al. 2010). In New South Wales (NSW), Australia, it has recently been highlighted that unclear and ambiguous role expectations of the Nursing Unit Manager (NUM) is also likely to affect the job satisfaction and retention of individuals in this role (Peregrina 2009).
Leadership development in nursing managers can reduce burnout and increase job satisfaction by strengthening support systems and promoting healthy work environments through enabling congruence between values held by managers’ and their organisations (Lee et al. 2010). Nursing managers, being influential to workplace cultures, have been recognised as individuals required to lead rather than just manage professionals (Fennimore & Wolf 2011). Effective leadership behaviours in front-line nurse managers have been associated with staff satisfaction and retention (Chiok Foong Loke 2001, Duffield & O'Brien-Pallas 2003, Kleinman 2004, Duffield et al. 2009, Cummings et al. 2010), reduced staff burnout (Kanste 2008), and increased staff productivity and organisational commitment (McNeese-Smith 1995, Chiok Foong Loke 2001). An Australian study of 23 NUMs and 58 Registered Nurses (RNs) employed in a tertiary hospital in NSW found a positive correlation between the self-reported and observed leadership practices of NUMs, measured using the Leadership Practices Inventory, and the job satisfaction and empowerment of RNs (Peregrina 2009).
A number of programmes aimed at supporting nursing managers in their role have been reported on in the literature. In Australia, Duffield (2005) implemented a Master Class in leadership development course for 18 NUMs in NSW that involved expert facilitation to encourage reflective learning and guide experiential learning strategies in a 12-month peer group-based programme. The evaluation of this course, undertaken using a Likert scale-based university tool, revealed that networking, having the opportunity to express their opinion, and reflection on their experiences were highly rated aspects of the programme by participants (Duffield 2005). Similarly, in an US study of front-line nursing managers engaged in facilitated narrative-based groups aimed at leadership development, articulation and reflection on complex leadership challenges was found to be a source of experiential learning for the individual and the group (Cathcart et al. 2010). The nursing managers in this study participated in peer-groups over a two-year period to discuss their critical learning experiences. However, no formal evaluation on the effects of engagement in the narrative-based groups on the participants’ development or learning was undertaken. Both these studies highlighted the benefits of nursing managers reflecting on the challenges they face and the sharing of perspectives and management strategies with peers.
A Leadership Development Initiative aimed at improving transformational leadership practices of 179 healthcare managers in Canada used a curriculum-based approach (Lee et al. 2010). Qualitative data collected through focus group and individual interview methods indicated that participants’ of the Leadership Development Initiative benefited from networking with other managers and having the opportunity to share challenges experienced and to learn from other managers (Lee et al. 2010). However, the curriculum-based focus of the Leadership Development Initiative was potentially limiting to the participants ability to translate the transformational leadership theory that they obtained from the initiative into their practice. This was reflected in qualitative feedback provided by participants who found the theoretical mode of the initiative to be ‘removed from workplace realities’ (Lee et al. 2010, p. 1036).
The present study was motivated by the identified need to strengthen local nursing leadership. In 2009, an organisation-wide Staff Climate Survey was undertaken to examine workplace culture and a ‘Culture Improvement Survey Action Team’ was instigated in 2010 to undertake state-wide consultations with staff to better understand staff perspectives on areas within the organisation that needed improvement and to develop core organisational values. An outcome of this process was an insight that nursing managers, both Nursing Unit Managers (responsible for the day-to-day operational management of a unit) and Nurse Managers (responsible for the management and coordination of a cluster of units), would benefit from targeted skill development opportunities in leadership and management. In particular, skill development related to the management of workplace behaviour, grievance and mediation. The need to support nursing managers in applying new skills and behaviours learnt through NSW Health leadership development initiatives, and organisational developmental days, was also recognised (Justice Health 2011).
The current study aimed to engage local nursing leaders, NUMs and NMs, to develop a support and challenge framework that allowed managers an avenue to engage in structured critical dialogue and reflect on practice. This study aimed to embed leadership development in the realities of the workplace through providing nursing managers with the opportunity to engage in facilitated discussion groups using context-laden real-life scenarios of situations they face in the unique context of correctional and forensic health. Critical thinking within the context of nursing management has been defined as, ‘to engage in processes of reflection, judgment, evaluation, and criticism that leads to decisiveness that is vital to achievement of intentioned outcomes’ (Zori & Morrison 2009, p. 77). The development of critical thinking skills is enhanced when the individuals have the opportunity to exercise independent thoughts in relation to their own problems or issues that they have to deal with (Bowerman 2003). Therefore the support and challenge framework valued knowledge, skill, experience and culture as it focused on issues and challenges faced by participants in their nursing management role.
- Top of page
- Source of funding
- Ethical approval
There was statistically no significant difference between baseline and follow-up data on the MBI (see Table 2). There was however a slight increase in the mean score for both exhaustion and cynicism and the mean score for professional efficacy decreased slightly at follow-up for the total participant group (both NMs and NUMs combined) and for the NUM group. The mean score for cynicism decreased slightly at follow-up for the NM group.
Table 2. Pre-Post comparison of (MBI), NWSQ and LPI scores using Wilcoxon's test
|NM or NUM||Measure||Domain||Baseline Mean (SD)||Follow-up Mean (SD)||Wilcoxon test z (Significance)||Effect size r|
|NM & NUM||MBI||Exhaustion||11.51 (6.6)||12.23 (7.3)||−0.047 (0.962)||0.004|
|Cynicism||8.67 (7.7)||9.43 (7.6)||−0.013 (0.990)||0.001|
|Professional Efficacy||29.87 (5.1)||28.74 (4.9)||−0.518 (0.604)||0.04|
|NWSQ||Intrinsic||11.06 (5.4)||12.53 (4.5)||−1.975 (0.048a)||0.18|
|Extrinsic||20.23 (3.8)||20.19 (3.2)||−0.265 (0.791)||0.23|
|Relational||8.65 (2.9)||8.26 (2.6)||−0.773 (0.440)||0.06|
|Total||39.88 (10.5)||40.76 (7.3)||−0.803 (0.422)||0.07|
|LPI||Model the way||48.68 (7.9)||48.07 (7.5)||−0.689 (0.491)||0.06|
|Inspire a shared vision||43.06 (10.8)||42.33 (11)||−0.390 (0.697)||0.03|
|Challenge the process||42.94 (9.6)||43.67 (8.9)||−0.115 (0.909)||0.01|
|Enable others to act||49.78 (7.2)||48.72 (7.7)||−1.272 (0.203)||0.01|
|Encourage the heart||47.33 (10)||46.93 (8.8)||−0.282 (0.778)||0.02|
|NM||MBI||Exhaustion||9.68 (6.1)||10.29 (7.5)||−1.061 (0.289)||0.16|
|Cynicism||8.77 (9)||7.64 (7.9)||−1.371 (0.171)||0.21|
|Professional Efficacy||30.0 (6.6)||28.92 (5.3)||−0.633 (0.527)||0.09|
|NWSQ||Intrinsic||11.68 (7.3)||11.93 (4.8)||−1.355 (0.176)||0.21|
|Extrinsic||19.55 (4.7)||19.62 (2.3)||−0.847 (0.397)||0.13|
|Relational||8.00 (3.6)||7.71 (3)||−0.211 (0.833)||0.03|
|Total||39.60 (15.3)||38.46 (5.3)||−0.356 (0.722)||0.05|
|LPI||Model the way||49.95 (4.7)||49.57 (4.8)||−0.314 (0.753)||0.05|
|Inspire a shared vision||43.59 (9.9)||43.79 (9.9)||−0.031 (0.975)||0.004|
|Challenge the process||43.95 (8.8)||44.14 (8.6)||−0.126 (0.900)||0.02|
|Enable others to act||51.18 (4.7)||49.57 (4.8)||−0.599 (0.549)||0.09|
|Encourage the heart||48.36 (7.6)||48.14 (6.4)||−0.754 (0.451)||0.01|
|NUM||MBI||Exhaustion||12.49 (6.7)||13.17 (7.2)||−0.063 (0.950)||0.006|
|Cynicism||8.61 (7)||10.32 (7.4)||0.000 (1.0)||0|
|Professional Efficacy||29.80 (4.2)||28.66 (4.7)||−0.980 (0.327)||0.1|
|NWSQ||Intrinsic||10.73 (4.1)||12.83 (4.5)||−2.468 (0.014a)||0.27|
|Extrinsic||20.56 (3.2)||20.45 (3.6)||−0.084 (0.933)||0.009|
|Relational||9.00 (2.4)||8.52 (2.5)||−0.652 (0.515)||0.07|
|Total||40.03 (7.3)||41.79 (7.9)||−1.358 (0.174)||0.1|
|LPI||Model the way||48.00 (9.2)||47.34 (8.5)||−0.998 (0.318)||0.11|
|Inspire a shared vision||42.78 (11.4)||41.62 (11.6)||−0.144 (0.885)||0.01|
|Challenge the process||42.39 (10)||43.45 (9.2)||−0.547 (0.584)||0.06|
|Enable others to act||49.02 (8.1)||48.31 (8.8)||−0.319 (0.750)||0.03|
|Encourage the heart||46.78 (11.1)||46.34 (9.8)||−0.191 (0.849)||0.02|
Nursing Workforce Satisfaction Questionnaire data for the total participant group showed that the combined NM and NUM group were statistically significantly (z = −1.975, P = 0.048, r = 0.18) less satisfied in their intrinsic domain of job satisfaction at follow-up. No significant difference was found between baseline and follow-up scores in the extrinsic and relational domains of job satisfaction for the total participant group at follow-up (see Table 2). For the NM group, no significant difference was found between baseline and follow-up scores in all three domains of job satisfaction (see Table 2). Baseline and follow-up data for the NUM group only showed that NUMs were statistically significantly (z = −2.468, P = 0.014, r = 0.27) less satisfied in their intrinsic domain of job satisfaction at follow-up. No significant difference was found between baseline and follow-up scores in the extrinsic and relational domains of job satisfaction for the NUM group (see Table 2).
There was statistically no significant difference between baseline and follow-up data on the LPI (see Table 2). Data for the total participant group showed that the score for the leadership practice of enabling others declined slightly from baseline to follow-up, although this difference was not significant (z = −1.272, P = 0.2, r = 0.01). No significant difference between baseline and follow-up scores for the total participant group was found for the remaining leadership practices. Baseline and follow-up data for the NM group only showed a slight decrease, although not significant, in the mean score in the leadership practice of enabling others to act (z = −0.599, P = 0.549, r = 0.09). For the NM group, there was no significant difference between baseline and follow-up in the remaining leadership practices. Baseline and follow-up data for the NUM group only showed, although not statistically significant, a slight decrease in means score for the leadership practice modelling the way (z = −0.998, P = 0.318, r = 0.11), and a slight increase in mean score for the leadership practice challenging the process (z = −0.547, P = 0.584, r = 0.06). No significant difference between baseline and follow-up scores for the NUM group was found in the remaining leadership practices.
Reported benefits of participation in the discussion groups by participants was categorised into the following themes: Networking, Personal Development and Role development.
Networking for participants related to having the opportunity to network (‘an opportunity to meet with other NMs in a safe environment’), receiving peer support (‘Guaranteed support from my peers’, ‘The support felt within the group’), being able to feel that they weren't alone (‘We are all experiencing the same issues’, ‘It's good to know others are feeling the same’), and being able to share information, ideas and challenges experienced with their peers (‘Listening to colleagues and the issues they face on a daily basis’, ‘sharing of stories, situations, ideas and solutions by other managers’). For both NUMs and NMs the sharing of information, ideas and challenges experienced with their peers dominated this theme, and the feeling that they were not alone was prominent for NUMs.
Personal development for participants related to reflection (‘Allowed me to reflect on situations both good and bad that I had managed’), identifying strengths and areas for improvement (‘identifying some of my strengths in my role’, ‘identifying areas that need improvement’) and skill development (‘consolidating the skills needed for leadership’ “Learning coping mechanisms for change’). NMs also identified experiencing increased self-confidence (‘gaining confidence in my abilities’), whereas NUMs identified experiencing increased knowledge (‘my knowledge has increased’). NUMS additionally identified benefiting from goal setting as an outcome of the discussion groups (‘learning the value of goal setting’, ‘ways of improving achieving goal setting’).
Role development for participants related to the articulation and understanding of their role as a NM or NUM (‘Articulating the nature and responsibility of being a nurse manager’, ‘to be able to verbalise the way we work’, ‘helped me to focus on the basic requirements of what a NUM should have’).
- Top of page
- Source of funding
- Ethical approval
Qualitative data collected at follow-up indicated that participants experienced benefits from their participation in the support and challenge framework. As participants of this study were geographically isolated from their peers, owing to the state-wide nature of the organisation, it was not surprising that networking was the most prominent benefit identified by both NMs and NUMs in their qualitative feedback. Perceived benefits associated with networking identified by both NMs and NUMs included feeling supported and being able to share challenges and ideas with peers. Similar findings in relation to networking have been presented in the literature. For example, in an Australian study in which 20 NUMs were individually interviewed using a qualitative feminist approach to explore their experiences, participants identified that while formal organisational support was lacking, they received benefits from informal peer networking (Paliadelis et al. 2007). Being able to feel that they were not alone in the challenges they faced in their roles was also consistently highlighted by both NMs and NUMs in the present study. Similarly, in the Australian study by Duffield (2005), NUMs that participated in a 12-month leadership development programme found comfort in knowing that their fellow NUMs were confronted with similar issues and challenges.
Leadership development opportunities for nursing managers that foster networking have been identified to be of particular benefit to NUMs who are often in their first management position. It has been highlighted that these NUMs have little or no targeted support to assist their transition from a clinical to management role (Duffield 2005). Nursing Unit Managers in the present study not only spoke of feeling unprepared for their role during discussion groups, but qualitative feedback at the end of study indicated that their participation in the discussion groups enabled them to articulate their work and to better understand the work that NUMs do. This suggests that NUMs, at least, are unsure of their role. It is of interest that in Peregrina's (2009) study of 23 NUMs, employed in the same Australian state as the participants in the current study, role ambiguity and unclear role expectations were highlighted by participants as factors affecting their ability to develop in their role. Therefore, the support and challenge framework has the potential to promote role development through engagement in critical conversations around role expectations with peers in a supportive environment.
A further benefit of participating in the discussion groups, identified by both NMs and NUMs, related to the reflection on their practice and the challenges they face in their role. In a supportive peer-group environment participants were able to use and share their experiences to critically think about the skills, knowledge, behaviours and resources required in the situations they manage. Critical thinking positively influences nursing managers’ ability to problem solve and make decisions and is therefore necessary for them to effectively function in their role and as a transformational leader (Zori & Morrison 2009). Increased awareness of their practice, in terms of strengths and areas for improvement, was also identified by both NMs and NUMs as a benefit to their participation in the discussion groups. Self-awareness of one's strengths, limitations and values has been described as the ‘foundation for reflection’ (Horton-Deutsch & Sherwood 2008, p. 949). Self-awareness enables nursing managers to critically analyse situations, to challenge their own assumptions and to transform their behaviour (Horton-Deutsch & Sherwood 2008). It is therefore plausible that this aspect of the support and challenge framework was associated with the increase in perceived problem-solving skills, as reported by participants in qualitative feedback, and with the slightly improved leadership practice of challenging the process at the end of study period for both NMs and NUMs as measured using the LPI.
While the benefits of engagement in the support and challenge framework were indicated in qualitative feedback, little evidence of change relating to burnout, job satisfaction and leadership practices were supported by quantitative measures used. However, quantitative findings have provided an indication of the current level of burnout and workplace satisfaction experienced by this participant group. These findings, in addition to the self-reported leadership behaviours of nursing managers, are useful in order to situate the experiences of this participant group within the wider experiences of nursing managers presented in the international literature. Also, data collected from the MBI, NWSQ and LPI provide a baseline measurement for future comparison. This will be invaluable for further studies involving the evaluation of the support and challenge framework with this participant group.
The mean MBI scores for the total participant group in the present study indicated that participants were potentially more exhausted, more cynical and had less professional efficacy at follow-up. This potentially reflects an increasing level of frustration experienced by participants as the study period progressed. It is plausible that the experience of frustration may have been partly related to an increase in self-awareness concerning the effectiveness of their work place leadership practices, developed as a consequence of their engagement in the support and challenge framework. However it is important to note that nursing managers in the present study sample were less burnt-out than both nursing mangers and nurses working in forensic and non-forensic settings presented in the international literature. For example, Happell et al. (2003) examined burnout and job satisfaction of 51 forensic psychiatric nurses and 78 psychiatric nurses from mainstream mental health services in Victoria, Australia. For exhaustion, the baseline mean score of the total participant group in the present study was comparable to the forensic group (11.51 vs. 12.9) and less than the mainstream mental health group (11.51 vs. 17.4). The baseline mean score for cynicism was higher in the present study sample than the forensic group (8.67 vs. 4.7), and the baseline mean score for professional efficacy was lower than the forensic group (29.87 vs. 34.5). In a US study of 40 nurse managers, while comparable mean scores of cynicism to the total participant group of the current study at baseline were reported (9.11 vs. 8.67), higher levels of both exhaustion and professional efficacy were reported (23.78 vs. 11.51 and 38.68 vs. 29.87, respectively) (Browning et al. 2007). It is of note that nurse practitioners and emergency nurses also completed the MBI for this study. Emergency nurses experienced the highest exhaustion and cynicism scores, while nurse practitioners experienced burnout levels lower than both nurse managers and emergency nurses (Browning et al. 2007).
The NWSQ is a relatively new measure; therefore, there are little published findings in the literature for comparison with the present study sample. In the validation process of this tool, however, Fairbrother et al. (2009) published the findings from a large hospital-wide study of 459 nurses in NSW who completed the NWSQ. While the mean scores of the intrinsic and relational domains presented were comparable to the findings of the total participant group of the present study at follow-up (13.4 vs. 12.53 and 7.5 vs. 8.26 respectively), there is a noticeable difference in the mean score in the extrinsic domain. The mean score in this domain for the total participant group of the present study at follow-up was greater than what was found in Fairbrother et al.'s sample (20.19 vs. 12.3) suggesting that the participants in the present study were more satisfied with their working environment than the hospital-based nurses. This is contradictory to the findings of the Australian study that found psychiatric nurses working in the forensic setting were generally more satisfied in their job than psychiatric nurses working in mainstream mental health services (Happell et al. 2003), and literature relating to nurse burnout which indicate non-forensic hospital-based nurses have the greatest burnout levels (Browning et al. 2007).
In the present study, the NUM group were significantly (P > 0.014) less satisfied in the intrinsic domain of the NWSQ at follow-up. This is indicative of these respondents feeling less content about working in their role at follow-up in comparison to how they felt at the commencement of the study. This finding is not surprising as, during their engagement in the support and challenge framework, NUM participants expressed a shared lack of clarity in the NUM role and an absence of infrastructure to support role orientation and development. Furthermore, in the midst of supporting NUMs to engage in dialogue around this uncertainty, the organisation commenced a restructure. The restructure included changes to the grading of roles and the requirement for NUMs to reapply for their positions. The increasing frustrations felt by NUMs associated with the forthcoming restructuring of their positions are likely to have left them feeling undervalued, as supported by the mean-score decrease in the intrinsic (within-nurse) NWSQ domain. This may plausibly also explain the slight decrease in the mean scores for the LPI leadership practices inspiring a shared vision and modelling the way for the NUM group as they struggled to envision a future amongst the uncertainty of their roles. The NUM group did, however, score themselves slightly higher on the leadership practice of challenging the process at follow-up; an outcome potentially attributable to their engagement in the support and challenge framework.
The self-rated leadership practices of the participants in the present study are comparable to the self-reported leadership practices of 23 NUMs in NSW (Peregrina 2009). When the mean score for each leadership practice for the NUMs in the present study at follow-up is converted to match the reporting method by Peregrina (2009) (Peregrina reported means within a range of 1–10. Therefore, for the purpose of comparison with Perengrina's study, the mean scores for the present study were divided by the number of questions per leadership practice, n = 6, to create a mean score within a range of 1–10), there was little difference in mean scores reported on all leadership practices between the two samples. The greatest difference was seen in the leadership practice inspiring a shared vision (7.72 vs. 6.94 in the present study sample), and the least difference was seen in the leadership practice modelling the way (8.03 vs. 8.05 in the current sample).
In the international literature, Martin et al. (2012) reported on the self-reported LPI scores of 14 nursing ward managers in Switzerland before and after they completed a clinical leadership development programme. Prior to the ward managers undertaking the programme the mean scores for all leadership practices were lower than the reported mean score of the participants in the present study, but were comparable to the self-reported scores undertaken 6 months after the completion of the clinical leadership programme (Martin et al. 2012). Also similar to the findings presented by Martin et al. (2012) in the present study the leadership practice of inspiring a shared vision and challenging the process were rated lowest by both NMs and NUMs at baseline. For the NMs in the present study, there was little difference (<0.2) in mean scores at follow-up for these leadership practices, and for NUMs while the mean score for challenging the process increased slightly the mean score for inspiring a shared vision decreased, although neither change was significant. This differed from the participants of the study by Martin et al. (2012) where significant increases were seen in the score of both inspiring a shared vision and challenging the process after completion of the programme. The leadership programme implemented in the study by Martin et al. (2012) entailed 147 h over a 12-month period of leadership development-specific lectures in addition to individual coaching, action learning sets and workshops. The reported post-programme LPI scores were comparable to this study's participant's baseline LPI scores. It is of note that the participants in the present study had previous opportunities to partake in NSW Health Leadership Development Initiatives prior to the commencement of this study. This suggests that comprehensive leadership development initiatives/programmes play an important foundational role in the development of nursing manager's leadership practices. However, it also supports exploring strategies that will enable continuous reflection, critique and dialogue that will sustain and extend leadership development beyond the formal programme and into the workplace.
Findings should be considered in light of attendance at discussions groups. Nurse Unit Managers had the greatest decline in attendance over the three groups from 88% for the first discussion group to just 39% for the final discussion group, whereas the attendance of NMs declined from 64% for the first discussion group to 50% for the final discussion group. It is of note that 32% of participants withdrew their participation from the study over the study period. Reasons for study withdrawal included leaving the organisation, leaving a nursing management role and being unable to attend any of the discussion groups held. Overall, in spite of this decline in numbers, attendance at groups was considered good in light that attendance was completely voluntary. However, including an aspect to the study that specifically evaluated participant engagement in the support and challenge framework would have been fruitful.
From the pattern of attendance at groups it became apparent that the context-related background to each participant influenced the level at which they could engage in critical dialogue with their fellow group members. There was significant variation in places of work for participants; each of which presented varying challenges to the nursing managers. It became clear that groups which consisted of context-alike workplaces for participants were more effective, and nursing managers allocated to groups with the wider variance of work-type locations experienced a greater number of disengaged participants and poorer attendance at subsequent groups. It is presumed that this may be related to not being able to share contextual-related experiences with fellow group members.
Last, the study was limited by the minimal number of discussion groups able to be held within the relatively short study period. For the majority of nursing manager groups the three discussion groups held enabled the articulation of their frustrations and the opportunity to form peer networks. It became apparent however that for the majority of nursing manager groups further meetings were required in order for participants to engage fully in the support and challenge framework. Therefore the continuation of participant discussion groups over a longer study period may yield more noticeable changes in self-rated burnout, job satisfaction and leadership practices scores using the validated tools.
Conclusion and implications for nursing managers
This study demonstrates the benefits of applying qualitative and quantitative measures when determining the impact of leadership development initiatives on workplace behaviours. The present study provides an insight into the level of burnout and workplace satisfaction experienced by nursing managers as they develop as leaders within the context of the JH & FMHN organisational climate. From qualitative feedback, it was clear that nursing managers recognised benefits in participating in facilitated peer discussion groups that enabled contextually specific critique of their practice. The importance of incorporating participant contextual realities into leadership development initiatives was also highlighted by this study. However, in order to fully understand the value of this leadership development initiative further research is required to investigate the impact of nursing manager engagement with the support and challenge framework over an extended period of time.