Job Satisfaction and Retention of Nursing Staff: The Impact of Nurse Management Leadership

Key Implications for Decision Makers

For Policy Makers

  • To improve professional development strategies for nurse managers, increase financial resources invested in action learning programs designed to improve their leadership and management skills while implementing organizational changes that improve nurses' professional practice environment and psychological experience at work. These changes would include evidence-based factors that impact retention of nurses. The key characteristic of such a program is that the learning comes from the actions participants take to solve real problems.

For Nursing Decision Makers

  • To increase retention and the likelihood that younger and better-educated nurses who leave will return, nursing leaders should work with human resources departments and union representatives to develop policies and strategies that better fit younger nurses' work and career expectations.
  • To increase nurses' retention, put in place strategies and daily practices that ensure positive perception of nurse managers' leadership, affective commitment, and job satisfaction.
  • To increase positive perception of nurse managers' leadership, focus on the following development issues: managing performance issues; involving others in the process; managing conflict; communicating a long-term vision; making clear and specific plans; delegating adequately; and giving feedback on performance.
  • To increase affective commitment, increase time invested by nurse managers in participative change management processes using evidence-based diagnosis and action plans developed with the nursing team, and including shared responsibility for implementing changes and measuring impacts.
  • To increase job satisfaction, focus on professional support and recognition; balanced workload; appropriateness and quality of technical equipment, material resources, and physical work environment; nurses' participation in hospital affairs; and systems problem-solving related to the delivery of services from support services.
  • To increase the number of nurses having the firm intent to stay (only 50 percent in our samples), put emphasis on professional development opportunities and improve scheduling, team dynamics, leadership and communication, and job characteristics ("hassles" linked to systems issues).
  • To deal more systematically with systems problems ("operational failures"), put in place permanent forums of clinical and non-clinical directors and associate directors that would focus on three priorities: (1) to network key people with regard to the implementation of system problem-solving processes; (2) to develop shared values regarding the clinical mission of the university hospital; and (3) to put in place feedback systems that will make support services employees more aware of the importance of their job regarding the quality of care and the security of patients. The main goal is to implement permanent multilevel processes that will address the structural as well as the cultural causes of systems problems.

Executive Summary

Motivated by the nursing shortage, an action research project was conducted in a recently merged teaching hospital in the province of Quebec, referred to in this report as the university hospital). Research questions were related to (1) the key factors associated with the intent to stay or to leave; (2) the impact of leadership style on the nurses' perception of the practice environment and the psychological experience at work (empowerment, job satisfaction, and organizational commitment); (3) the "system problems" affecting care units; and (4) the impact of an "action learning" intervention on nurse managers' leadership development, nurses' perceptions of the work environment, and intent to stay or leave and retention rates.

Between 2003 and 2006, 21 nurse managers started the program and 11 completed all steps. The project, done by seven units, unfolded in three phases: diagnostic, intervention (action learning), and evaluation one year later. The diagnostic phase was composed of two main activities: (1) nursing staff completed a questionnaire and participated in focus groups; and (2) nurse managers participated in a 360º feedback process that evaluated their leadership. The intervention phase included (1) discussion of the diagnostic report based on staff survey and focus groups analysis and recommendations; (2) a program of 10 action learning workshops of four hours each; and (3) individual coaching sessions with the nurse managers. We assessed the outcomes by repeating the staff surveys, focus groups, and the 360º leadership evaluation three months after the completion of the action learning workshops.

Results

Key factors of intent to stay or to leave and the role of leadership
In the pre-test and post-test samples, the same proportion of nurses intended to leave (16 percent), and approximately one-third were uncertain about staying or leaving. This means that only 50 percent of nurses in our samples had the firm intent to stay. Those intending to leave were younger, better-educated, and less-experienced. The analysis of reasons given by the uncertain nurses and by those who intended to leave showed that, about 40 percent of the time, the organization could do something about the intention to leave, namely by addressing issues of professional development, schedules, team dynamics, leadership and communication, and job characteristics ("hassles" linked to systems issues). We observed that global satisfaction at work, affective organizational commitment, and a positive perception of the nurse manager's leadership differentiated nurses who intended to stay from those who intended to leave. With regard to job satisfaction, the main sources of dissatisfaction were lack of professional support and recognition; nurse/patient ratio and overload; lack of technical equipment and material resources; poor physical work environment; and poor relationships with support services. We also found that, in the same work environment, nurses characterized by "internal" work motivation tended to have higher global job satisfaction, stronger affective commitment, and a better perception of the nurse manager's leadership than nurses who had "external" work motivation.

Results show moderate to strong significant relationships between nurses' perception of the nurse manager's leadership and support ability and their perception of the practice environment and psychological experience at work. These results clearly suggest that investments in developing nurse managers' leadership and support abilities have a positive impact on nurses' perceptions and psychological experience at work. Analysis of 16 360º feedback reports showed the following leadership and management behaviours were in greater need of development: managing performance issues; involving others in the process; managing conflict; communicating a long-term vision; making clear and specific plans; delegating adequately; and giving feedback on performance.

Systems issues

Sources of job dissatisfaction mentioned above are a mix of "nursing department problems" (lack of resources, etc.) and systems problems. When nurse managers talked about systems issues, they referred to the many "day-to-day hassles" they experienced with support services (housekeeping, pharmacy, transport, human resources, finance, etc.). Systems problems were viewed by most participant nurse managers as chronic, pernicious, and unsolvable. They generated feelings of powerlessness and helplessness regarding finding productive ways to deal with them. Our observations confirm what recent research results have shown: healthcare organizations do not prioritize the improvement of the performance of their support services towards their nursing clients, since the nursing staff generally finds ways to provide these services to preserve the patients' security and quality of care. We recommend decision makers put in place systemic and structured approaches, at the global and local levels, to solve cross-boundary problems.

Impacts

Self-reported learning by participants (particularly related to visionary, coach, facilitator, and negotiator roles), and some statistical results, tend to confirm that action learning is a more effective way to foster professional development and knowledge transfer than classical approaches such as academic courses or in-house training seminars with external consultants. The evaluation of the project showed many significant positive impacts on the nurses' perception of nurse managers' leadership and support ability, staffing and resource adequacy, and leadership and human resources management satisfaction for all units and, in some units, on the perceptions of the nursing foundations for quality of care, affective commitment, and global organizational commitment.

This study did not reveal a short-term impact on the intent to stay and turnover rates, but it clearly showed that action learning approaches are effective, not only for professional development but also for the implementation of concrete improvements in the work environment related to nurses' job satisfaction, organizational commitment, and perception of professional practice environment. We recommend the implementation of leadership and management development programs, based on action learning principles and strategies, that assist nurse managers to be more effective problem solvers in complex settings, including developing the ability to influence the resolution of systems issues.