A Profile of the Structure and Impact of Nursing Management in Canadian Hospitals

Key Implications for Decision Makers

  • There is an immediate need for succession planning to ensure the future of nursing leadership. There is a cadre of very experienced and skilled nurse leaders across Canada who hold enormous responsibility for patient care within the healthcare system, but the average age of nurse leaders at all levels is between 47-51 years.
  • Regardless of structure, senior nurse leaders viewed themselves as influential members of the senior management team with high levels of decisional involvement in both traditional (distinct professional departments) and program management structures. Key facilitators of role effectiveness included being part of the senior executive structure, a reporting relationship to the chief executive officer, and the inclusion of chief nursing officer in their title.
  • Organizational structure had an impact on the quality of nurse leader work environments. Senior nurse leaders who felt they were more involved in decision-making and were involved earlier in the process felt more empowered, valued within the organization, supported for professional nursing practice and, ultimately, perceived a higher quality of patient care in their organizations. Senior nurse leaders’ role satisfaction and influence in senior management team decisions likewise had an impact on the role satisfaction and perceptions of patient care quality experienced by middle and first-line managers.
  • Nurse managers at all levels have adapted to large spans of control, but a majority recognize the need to reduce this level of responsibility. First-line managers averaged 71 direct reports (median 63, range five-264), far exceeding the benchmark found in other work settings. Despite very large spans of control, nurse leaders were very positive about their work and their abilities to be effective in their roles.
  • Working relationships between all levels of management were critical to both role effectiveness and satisfaction. Transformational leadership behaviours, perceived organizational support and quality communication had an impact on the satisfaction and quality of care for each subsequent level of manager.
  • Organizations have undergone significant and ongoing restructuring, which has produced barriers to role effectiveness for nurse leaders through broadened roles and functions, increased organizational size and complexity and the accompanying time and financial constraints. Access to adequate resources remains a key issue.

Executive Summary

The purpose of this study was to profile nursing leadership structures in Canadian hospitals in relation to organizational and structural characteristics of nursing management roles. Data were collected in 10 provinces from acute care inpatient units within 28 academic health centres and 38 community hospitals. Of the original 2,015 surveys, 1,164 surveys were returned for an overall response rate of 58 percent.

KEY FINDINGS

Overall, nurse leaders across the country were very experienced individuals with enormous responsibility for patient care within the healthcare system. A notable finding was the high average age (47-51 years) of nurse leaders at all levels, suggesting the immediate need for succession planning to ensure the future of nursing leadership. Despite very large spans of control, nurse leaders were very positive about their work and abilities to be effective in their roles. Roles at all levels have expanded to include responsibility for non-nursing personnel.

Senior nurse leaders felt they were influential members of the senior management team. Their decisional involvement was high in both traditional (distinct professional departments) and program management structures. Senior nurse leaders with operational/line authority were viewed by all levels of management as having higher senior management team status and greater decisional involvement in senior management decisions than those with staff authority. Perceived organizational support was an important factor at all levels of management. In addition, transformational leadership styles and satisfactory supervisor communication had an impact on lower-level managers’ satisfaction and patient care quality.

NURSING LEADERSHIP STRUCTURES

The predominant senior nurse leader role configuration was operational/line authority for clinical programs with a direct report to the chief executive officer or senior vice-president (84 percent). Senior nurse leaders in academic health centres were more likely to have responsibilityfor allied health than senior nurse leaders in community hospitals. A smaller number of senior nurse leaders (16 percent) had staff authority, reporting directly to the chief executive officer or senior vice-president. Professional practice leader-type roles were found in 68 percent of academic health centres and 25 percent of community hospitals. Traditional distinct nursing departments were rare (20 percent) and were found primarily in Quebec and in community hospitals.

SPAN OF CONTROL

Overall, managers reported very large spans of control with considerable variation in each level. First-line managers averaged 71 direct reports, with 20 percent reporting more than 100 reports. Middle managers averaged 12 direct reports, with the majority having less than 20 reports. Senior nurse leaders also averaged 12 direct reports, with a range from two to 47. More than 50 percent of the organizations were considering a decrease in managers’ span of control.

SENIOR NURSE LEADER ROLE FUNCTIONS: CHANGES, FACILITATORS AND BARRIERS TO EFFECTIVENESS

Senior nurse leaders identified four key role facilitators: part of senior executive structure; direct report to chief executive officer; inclusion of chief nursing officer in title; and operational/line authority. The main barriers to an effective role included financial and time constraints as well as increased organizational size and complexity. The most frequently reported changes during the past three years included (a) organizational restructuring and/or merging of facilities, (b) additions to the portfolio, (c) addition of the chief nursing officer role, and (d) changes in chief executive officer incumbents.

RELATIONSHIPS AMONG STRUCTURAL AND PROCESS CHARACTERISTICS AND WORK OUTCOMES

All levels of management reported moderate to high levels of:

  • transformational leadership behaviour used by senior nurse leader and themselves;
  • job and role satisfaction and job security;
  • empowerment and organizational support;
  • support for professional nursing practice;
  • satisfaction with supervisor communication;
  • influence in staff and policy decisions; and
  • patient care quality.

Overall, nurse leaders rated these characteristics higher than those in leadership roles below them (senior nurse leaders were greater than middle managers who were greater than first-line managers). Nurse leaders at all levels agreed that access to resources was limited.

SENIOR NURSE LEADERS’ FUNCTIONS AND DECISION-MAKING INVOLVEMENT AND INFLUENCE

Senior nurse leaders reported being integral members of the senior management team with high levels of involvement and influence in senior management decisions with a title and salary comparable to other executives in their organization. Those who reported more influence in senior management decisions and higher quality of senior management decisions were more likely to feel empowered and valued by the organization. They also felt greater support for professional nursing practice with a higher quality of care in their organizations.

Overall, senior nurse leaders felt that senior management decisions were compatible with existing constraints, timed to gain maximum benefit, based on an optimal amount of information, appropriately balanced between risks and rewards, with an understanding of the basis and implications of the decision by the senior team.

IMPACT OF ORGANIZATIONAL STRUCTURE ON OUTCOMES

Traditional versus Program Management
Senior nurse leaders and middle managers working within program management structures felt more organizational support, job security and support for professional nursing practice structure. In comparison, nurse leaders working in organizations with traditional departmental structures were more empowered with greater influence in staff and policy decisions and more confidence in the patient’s ability to manage care after discharge.

Line versus Staff Authority
Compared to senior nurse leaders with staff authority, those with line authority felt they had a higher status (title and salary) within their organization, with not only more involvement in decisions but earlier involvement in the process as well. They were also more satisfied with their role and the quality of senior management team decisions. Middle and first-line managers in these organizations also felt that their senior nurse leaders were more involved in senior management team decisions with a higher status and, in addition, provided more support for a professional practice environment.

Senior nurse leaders with staff authority were more likely to use an enabling or “encouraging the heart” leadership style. As a result, middle managers in these organizations felt more empowered and valued by the organization. Both middle and first-line managers felt more involved in decisions than their counterparts in line authority organizations.

EFFECTS OF SENIOR NURSE LEADER WORK CONDITIONS ON LOWER-LEVEL MANAGERS’ WORKLIFE

Effects of Senior Nurse Leader Variables on Middle and First-Line Manager Variables
Middle managers were more likely to report a higher quality of patient care if their senior nurse leader was satisfied with her role. First-line managers were more likely to report higher quality of patient care if their senior nurse leader reported more influence in senior management team decisions and used transformational leadership behaviours.

Effects of Middle Manager Variables on First-Line Managers
Higher middle manager perceptions of organizational support were significantly related to greater first-line manager empowerment, job and role satisfaction, organizational support and ratings of patient care quality. Middle manager self-ratings of their leadership style were significantly related to higher first-line manager perceptions of a supportive professional practice environment in the organization and higher patient care quality. Greater middle manager communication satisfaction with their supervisor was significantly related to first-line manager job satisfaction.