Nurse managers in perioperative settings and their reasons for remaining in their jobs: A qualitative study

Aim: The study describes what helps nurse managers maintain the strength to keep going as leaders. Background: Good leadership is important for the quality of patient care, patient satisfaction in care and efficiency. Many nurse managers stay on despite challenges at work. Methods: Twelve nurse managers were interviewed. Data were analysed by systematic text condensation according to Malterud. Results: The results were as follows: A—Walking side


| INTRODUC TI ON
The management role in surgical departments requires high skills and competence, including providing health care, leading staff, organising workload and handling ethical and legal questions.Nurses' work performance and creativity is dependent on caritative leadership (Bondas, 2003;Gu, Hempel, & Yu, 2019).Caritative leadership may affect nurses' intentions to remain in their jobs (Arakelian, Rudolfsson, Rask-Andersen, Runeson-Broberg, & Walinder, 2019a); nurse and patient satisfaction; and outcomes in care (Wong, Cummings, & Ducharme, 2013).Nurses describe their nurse manager both as a facilitator (Arakelian et al., 2019a) and as someone who betrays or is dismissive (Logde et al., 2018).Furthermore, the nurse manager's behaviour towards his/her employees has a significant impact on the employees' perception of formal and informal power as well as on their professional skill development (Laschinger, Wong, McMahon, & Kaufmann, 1999).Moreover, nurse managers affect their employees, and clarity in management structure also means lower levels of work tension among employees and increased efficiency at work (Gunawan, Aungsuroch, Nazliansyah, & Sukarna, 2018).
Furthermore, studies point to the challenges and complexity of nursing management as it contains both the rules and regulations of administration and the more personal but less defined aspects of human caring, both of which represent very specific demands.Laschinger et al. (1999) indicated that nurse managers present a link between caring for staff and an administrative responsibility.The nurse managers' leadership sometimes includes a conflict between being clinicians and at the same time being distanced from clinical practice.When priority was given to clinical practice, leadership tasks often came second (Sorensen, Delmar, & Pedersen, 2011).Furthermore, despite their clinical expertise, many nurse managers are exposed to a management role without leadership training (McCallin & Frankson, 2010).There are great demands on nurse managers, who must harmonize the demands of management, unions and staff.They are expected to be strategic planners, representatives of the human resources (HR) department, quality specialists and clinical experts (McCallin & Frankson, 2010).Nurse managers are also responsible for ensuring a good, healthy work environment for their employees and excellent care for their patients (Anthony et al., 2005).Gunawan et al. (2018) indicated that nurse managers are high achievers who struggle with conflicting feelings: on the one hand, being a nurse manager is a positive challenge, while on the other hand, nurse managers have negative experiences due to the personal conflict of being removed from their front-line care job, which consequently makes them want to leave their unit.According to Adriaenssens, Hamelink, and Bogaert (2017), job demands, job control and social support from team managers were predictors of well-being in nurse managers, which in turn included job satisfaction, work engagement, less psychosomatic distress and fewer turnover intentions.
To meet and include all dimensions of nursing management, the idea of caritative leadership was developed to combine nurse managers' administrative responsibilities with caring based on human mercy and love.Caritative leadership was derived from Eriksson's theory of caritative caring (Eriksson, 1992(Eriksson, , 1997) ) and was further developed as the theory of caritative leadership (Bondas, 2003).Caring administration means seeing the uniqueness of the employees and their abilities to 'minister to' or help the patients (Bondas, 2003).To expand the conceptual understanding of caring in nursing leadership using a meta-ethnographic analysis, five relation-based rooms were identified in 'the house of leadership', each representing one aspect of leadership.Nurse leaders move back and forth between these rooms.The rooms are the patients' room, the staff room, the organisational room, the superior's room and the secret room.The superior's room is about peer relationships, and the secret room is a place where the manager can be alone to reflect and think things over.
The discussion regarding caring in nursing leadership indicates that caring is a conscious movement between the different rooms mentioned above (Solbakken, Bergdahl, Rudolfsson, & Bondas, 2018).
Therefore, it can be assumed that the opportunity of metaphorically walk between different rooms indicates the development of a caring atmosphere, which influences the desire to continue as a nurse manager.Consequently, our study focuses on the elements that lead to the perioperative nurse manager's wish to remain in the job.

| Aim
The study describes what helps nurse managers maintain the strength to keep going as leaders.

| Design
A qualitative prospective design was used.

| Study participants
The inclusion criteria were as follows: nurse managers with more than one year's experience in perioperative settings, that is anaesthesia or surgical departments.Fifty-five nurse managers (four men, 51 women) were invited to participate, of whom 12 accepted, all women, between 35 years and 63 years of age (mean age 53 years).
The participants had one to 18 years of experience as nurse managers.Six of the participants were from university hospitals, three from small hospitals, two from central hospitals and one from a regional hospital, all from different parts of Sweden.In Sweden, university hospitals are large hospitals that, in addition to health care, also include medical research and education.County hospitals offer highly specialized care in comparison with local and rural hospitals.
Convenience sampling was used to enable participants from different age groups and work experiences to be included.

| Procedure
The human resources departments of 12 hospitals (five university hospitals and seven county and minor care hospitals) in Sweden were contacted for information about nurse managers in perioperative settings who met the inclusion criteria.The participants were contacted and invited to take part in the study via their work mail address.A reminder was sent one week later to those who did not answer the invitation the first time.After receiving their informed consent, contact was made to schedule an interview session.
Interviews were conducted via telephone in nine cases due to the long distance to the participants' workplaces and homes, and faceto-face in three cases upon requests from the participants.The interviews lasted between 54 and 74 min (mean 63 min).There were no differences between the two interview techniques or quality.
After the first interview, we deliberated on the interview guide regarding whether we had received the answers we sought using the questions in the guide.No changes were made to the interview guide after that interview.

| The interview guide
A semi-structured interview guide was used with main questions such as the reasons and prerequisites for working as a nurse manager, plus follow-up questions concerning the driving force and challenges of the position, followed by narratives regarding successful days and days not so successful.Probing questions such as 'Could you explain more?' or 'What do you mean by that?' were also used to deepen the interview.
People's life-world experiences form the focus of this method.The analysis was conducted according to the following steps: a-interviews were transcribed verbatim and were read several times for our team to grasp the whole picture; b-preliminary themes were identified and meaning units (sections of text that were about the topic of interest) were coded; c-condensation, the codes that were about the same topic were grouped together followed by the meaning units; d-re-contextualization consisted of creating the final themes and writing the content for these themes.Finally, the interview text from each interview was read through again with regard to the themes.
No new information was found after seven interviews.However, the rest of the interviews were analysed to make sure that no further information could be identified.Authors EA and GR conducted all the steps in the analysis independently.Authors ARA and RW each read half of the interviews and the results to confirm the results.
The final themes were a result of several discussions between the authors.

| Ethical considerations
The study follows the regulations in Declaration of Helsinki (World Medical Association, 2013)

TA B L E 1
The themes and their contents

| Findings
Five themes were identified (Table 1), which are presented below with citations.

| Walking side by side with my employees
To create a sense of togetherness, a conversation 'room' was created.
Appointments were booked for these discussions, or spontaneous conversations were held with the employees.Many talked about 'con- To let the employees formulate their own ideas was another source of empowerment, as Nurse Manager 6 stated: 'These (the employees) are incredibly wise people…with their own driving force, bringing their own ideas so I am motivated and stimulated to continue… Had it not been for a group of employees, I probably would not have been here (if it were not for them)'.

| Knowing that I mean something to my employees
Being honest and fair, the participants talked about receiving their employees' confidence almost as an honour, giving them the strength to go on.They always felt welcomed to their workplace both by their employees and by the physicians or anaesthesiologists with whom they worked.Nothing meant more than having an employee tell his/ her nurse manager that 'I wanted to come to this surgical department because you are here' (Nurse Manager 3).As one of the participants explained, 'It gives one such joy to know that one can actually mean something to someone' and that 'It is impossible to put a price on that' (Nurse Manager 3).Nurse managers learned more about their employees' personal lives, which they tried to encourage to the best of their ability.They often served as support for their employees in their personal lives, which was also confirmed by the employees.
This, in turn, gave a feeling of warmth and joy to the nurse managers.

| Talking to myself-asking myself tough questions
Participants in this study indicated that they gathered strength by having an internal dialog with themselves, asking themselves tough questions or pondering things while they were jogging, taking long walks, travelling by train to their workplace or exercising longer at the gym, to 'process' as Nurse Manager 4 expressed it.
…I personally have a rather tough internal dialog with myself…this was no good; in this I could have done better… I have very little time to think, which is a big challenge… it is a part of my mission to keep my head up and think ahead … That's why it works for me to commute.It's really nice to sit on the train… to have time to think and plan… so the time on the train is really important to me.
(Nurse Manager 8) This was a way of preparing oneself for difficult situations, for example if a decision was to be communicated to employees that 'I might not support 100% but we don't have any choice but to go along with it…' (Nurse Manager 7).Looking ahead and looking forward were important tasks as a nurse manager, that is not to sit still in the same place but to move forward and 'drag' or develop the enterprise.Other forms of preparation were also described such as 'mind mapping', thinking about different scenarios and results before, for example delivering a tough decision to one's employees or having a difficult conversation.The nurse managers were their own critics, questioning whether they were their best self in their meetings with their employees or not.Thus, being one's best self or doing one's best was discussed frequently during the interviews.The participants were aware that they were not best at doing everything but they always, wholeheartedly, wanted to 'at least do my best' (Nurse Manager 10).

| Having someone to talk to, to decrease the feeling of being alone
The participants said that having the support of co-nurse managers and having someone to talk to were important prerequisites for building their inner strength.They needed to talk about everyday topics or specific cases, and ask for advice.
… I need to have somebody to talk to and to know that she is there … I think it is important for me as a firstline manager that I don't end up in a vacuum between my staff and myself… (Nurse Manager 5) All of the participants were very well aware that their position meant that they were 'not a part of the group', which created a need to have someone to talk to.
…You can feel lonely at the top…mostly at lunch hour or when it's time for a coffee break… (Nurse Manager 8) The support group often included other nurse managers from the same perioperative settings or other organisations in the hospital.
However, not everyone had a network of co-nurse managers to whom they could turn with their questions or problems.A few had a coach or a mentor or a psychologist.
… these three (co-nurse managers) who are health care managers, plus my superior manager, we have a strategy meeting every week where she (superior manager) helps us with our questions.Had she not been in that position, I would not have applied for the job here.

| Leading and managing in my own way-the fear of not succeeding is my motivation
The nurse managers expressed that they were strong and confident in their position as leaders and managers.Having life and work experience, and knowing the health care business, they now had authority and were respected.
… My role carries a lot of weight with the surgeons, I can lean on my co-workers for support, I am confident in myself and I am confident in my life and I am confident in my role as manager.
(Nurse Manager 3) Many also talked about being successful in making changes or in 'putting one's foot down' (Nurse Manager 7) against authorities, taking responsibility for their employees' rights or ensuring that what they did was 'good enough'.They also had the courage to put their own mark on their leadership, in many cases by watching and learning from their own former managers and leaders.How to act or not to act as a nurse manager was discussed frequently and focused on their feelings back when they were employees themselves.
… an incredible number of demands from so many places; you are pulled in too many directions…you set a goal that is so high that you never reach up to it … you always try to run a little faster and do much more… you have to dare to slow down… go easy on yourself about what is good enough… (Nurse Manager 9) The fear of failure was another driving force mentioned by one of the participants.Several participants mentioned that they were trying to satisfy their employees, their superior managers and themselves, and that all three were connected.The relationship with the superior manager and gaining his/her confidence and trust, and having that trust returned, was an essential source of empowerment to the participants.
… I have set up a goal, I'll get there… I think it's probably the fear of failure that motivates me… (Nurse Manager 8) A goal was set and a promise was made, a promise that the nurse manager would not betray.
…The goal is to become XXX's best surgical department.Together with my four managers (this person is Head Nurse Manager of four first-line managers), we are natural drivers, together with the employees.
This is not a one-man show; it is something we do together… (Nurse Manager 8)

| D ISCUSS I ON
The findings of this study are discussed through the lens of the caritative leadership theory presented by Bondas (2003) and the meta-synthesis of caritative leadership resulting in the metaphors of different rooms in the 'house of leadership' by Solbakken et al. (2018).
The first theme of this study concerned doing good for one's employees, as described by Bondas (2003), recognizing their uniqueness and their potential for ministering to the patients.According to Bondas (2003), nurse managers are responsible for caring for both the patients and their employees' dignity.Furthermore, studies suggest that good leadership affects nurses' work performance (Gu et al., 2019), thus affecting patient care (Bender, Williams, Su, & Hites, 2017).Good leadership also means that specialist nurses in perioperative settings want to remain in their positions (Arakelian et al., 2019b).In their journey of doing good, the nurse managers go back and forth between the 'staff room' and their 'secret room' (Solbakken et al., 2018).
In the 'staff room' (Solbakken et al., 2018), nurse managers helped their employees to see and believe in their own capacity.
They also learned more about their employees' personal lives.
They were anxious to be on their employees' side, and walk together with them, meaning that the employees' wishes and stories were recognized by Bondas (2003).Being strong and fair, and receiving the employees' trust were seen as important sources of strength for the nurse managers.A nurse manager's reward was when employees chose to work where they knew a certain nurse manager worked.
In this study, the participants stressed the importance of showing their employees respect and being a facilitator.Arakelian et al. (2019a), Bondas (2009), Uhrenfeldt and Hall (2009) all indicated that by knowing their employees and their competencies, nurse managers were able to make individual plans for their employees' development.Honkavuo, Sivonen, Eriksson, and Nåden (2018) pointed out the sense of togetherness, which was also one of the findings in our study, and discussed the concept of 'ministering' in nursing administration.This was described as a mutual and two-way relationship between the leaders and their employees, helping and benefitting both parties.
Three of the themes in the current study are based on the concept of being in the 'secret room'.The 'secret room' is used as a way of preparing oneself for difficult situations and is a place to be with oneself to gather strength and to have an honest dialog with oneself.Reflecting on things or preparing oneself for difficult tasks was described as a way of moving forward.Moving forward implies not standing still, but it also means trying to develop oneself as a leader both emotionally and professionally.This movement was confirmed by Raelin (2016) who stated that leadership accrues in relationships with employees and that leadership and reality are mobile and changeable.
Working hard to satisfy both the leadership above and their employees, the study participants agonized about whether their goals were set too high or whether their performance was good enough.Edmondson, Higgins, Singer, and Weiner (2016) pointed out that individuals tend to alter their performance due to engagement in their work and that this is common in organisations with both theoretical and practical orientations, such as in health care.Adriaenssens et al. (2017) showed that support from one's superior manager was one of the predictors of well-being among nurse managers.
Since nurse managers may struggle with the inner conflict caused by being administrators, caring for staff and being clinicians (Gunawan et al., 2018;Laschinger et al., 1999;McCallin & Frankson, 2010;Sorensen et al., 2011), and the fact that some of the participants in this study became managers with no initial training and education, it is even more important to have training and support from superior managers (Laschinger et al., 1999).Furthermore, Hagerman, Engstrom, Haggstrom, Wadensten, and Skytt (2015) described the importance of having structural, supportive conditions as nurse managers, but also stressed that nurse managers must believe in their own competence and abilities.
The importance of operating according to the core of caritative leadership and commuting between the 'staff room' and the 'secret room' in the house of leadership (Bondas, 2003;Solbakken et al., 2018) was obvious findings of this study.These elements gave nurse managers the strength to go on as leaders.In addition, they wanted to be offered continuous support in different forms, both administrative and emotional, along with proper education and training throughout their time as leaders (Gundrosen, Thomassen, Wisborg, & Aadahl, 2018).

| Limitations
Credibility and transferability were guaranteed by describing the procedure and the data analysis as clearly as possible.Authors EA and GR had a pre-understanding of perioperative settings, which led to increased credibility and confirmability, thus improving the researchers' understanding of the phenomenon being studied (Nakkeeran & Zodpey, 2012).The topic of pre-understanding was discussed by all authors ensuring that the authors' pre-understanding did not interfere with the interpretation of the results.In this study, both face-to-face interviews and telephone interviews were used.No differences were found between the two interview methods, and they were all included in the study.No male participants were included in the study: this mirrors reality, as most nurse managers in surgical departments are woman.
bringing us closer together' (Nurse Manager 9), having an opendoor policy.One of the participants had created structured 'walking employee dialogs', which she undertook with every employee annually, walking side by side and outside the operating room.… It's the best management training, to talk …We have co-worker walks.We usually walk for between one and two hours… it's great because you think much better and much more is said when you walk than when sitting behind a desk… (Nurse Manager 4) At the same time, the nurse managers were to be 'the engine' (Nurse Manager 10) motivating what their employees did, and treating them with respect.… Together we can do something good….I like to meet people with respect.You usually get so much back…… (Nurse Manager 8)The nurse managers described a journey within oneself as a leader, learning how one chose to communicate with one's employees, or how one acted when meeting with one's employees, acknowledging their own power.This was expressed as 'one should be very humble with the power that one has (as a leader) affecting other people's lives…' (Nurse Manager 9).A sense of satisfaction or a 'cool feeling' (Nurse Manager 1) was experienced 'seeing the strengths of those you worked with' (Nurse Manager 9), helping them to believe in their own knowledge, ability and capacity, and seeing how several of them grew and achieved greater positions, and became proud of themselves.…it is one of the greatest joys as a manager to work with all employees and see them develop and take new roles and reach places when they hadn't really believed in themselves…I create the conditions for those I lead… (Nurse Manager 9) …private matters….several have said "If you hadn't been there for me back then, I do not know what I would have done; you were my greatest support in my separation… and it is absolutely amazing that you get such trust from employees… (Nurse Manager 3) Receiving responses from the employees made the nurse managers learn to improve themselves and to 'grow in my role', as one of them stated (Nurse Manager 1).

I
start to mind map what this meeting/issue is about, what do I think is its focus, what do the employees think is the focus and what are the various parts that are included… and so I begin to try to structure my thoughts … where I should begin, in order to end in the right place… (Nurse Manager 10) and local ethical guidelines and regulations (Centrum for Research Ethics & Bioethics, 2018).