Nurse 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, 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 rising 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 prefers to receive treatment in their homes.8
Clinical nurse satisfaction and retention are central responsibilities of nurse managers; however, nurse manager job satisfaction and retention are low. There's also a lack of understanding about what contributes to nurse manager job satisfaction and retention.9 The increasing preference for home care services may intensify nurse managers' responsibilities for ensuring that adequately prepared clinical nurses are available to coordinate care for patients in their homes. Clinical nurse satisfaction also affects patient satisfaction.10 Nurse manager job satisfaction and retention can influence the success of home care agencies faced with a projected demand to provide services to the growing older population.
This qualitative phenomenologic study explored the lived experiences of nurse managers to determine what contributed to their job satisfaction and motivated them to remain in their positions. Using Herzberg's two-factor theory that satisfaction is associated with motivating or intrinsic work factors and dissatisfaction with hygiene or extrinsic factors as the theoretical framework,11 the general research question that guided the study was: "How do nurse managers perceive their experience of job satisfaction and retention?" Three subquestions supported and directed the central question: "What experiences contribute to nurse manager job satisfaction in home healthcare organizations?," "What experiences contribute to nurse manager job retention in home healthcare organizations?," and "What do nurse managers perceive that home healthcare organizations can do to improve their job satisfaction and retention?" (See Research box.)
Supporting literature
The literature indicates a need for research on the job satisfaction and retention of nurse managers in home healthcare. A study conducted in the home healthcare setting during 2004 wasn't solely focused on nurse managers.12 The greatest job dissatisfiers reported by 16 nurse managers in a long-term-care facility were pay, organizational policies, and interaction. A relationship with nurse manager retention was also associated with organizational policies.13 Two hundred and ninety-one nurse managers who worked in various US hospitals participated in a study to help describe nurse manager job satisfaction and intent to leave. Results revealed that burnout or stress were among the most frequently cited reasons nurse managers gave for their intent to leave their positions. Despite the stressors and workload burden, 52% of the nurse managers reported being satisfied or very satisfied in their roles.14
Lack of leadership support is another factor that contributes to nurse manager job satisfaction and intent to leave an organization. This was a major factor revealed in a study that included 12 nurse managers from three Magnet(R) hospitals. The researcher recommended that senior leaders should provide support and the infrastructure to assist nurse managers to be successful and enhance their job satisfaction. Organizational leaders should also create initiatives to minimize nurse manager stress levels, such as shared on-call responsibilities and smaller spans of control.15
Study design and demographics
Nurse managers in their current positions for at least 5 years at a large home healthcare organization in New York, N.Y., were asked to participate in this qualitative phenomenologic study. After Institutional Review Board approval, communication with the home healthcare organization's human resources department assisted with identifying potential participants who met the selection criteria. A purposive sampling of 20 nurse managers was selected because the geographic location allowed for conducting face-to-face interviews. Validation strategies applied to this study included triangulation, member checking, and thick descriptions of participant responses.
The 20 voluntary participants, identified as study nurse manager 1 to study nurse manager 20, had the following demographic characteristics: 17 (85%) were female and 3 (15%) were male; years in their current position ranged from 5 to 20 years, with an average of 9 years; 11 (55%) were in previous nurse manager positions ranging from 1 to 15 years, with an average of 5 years; 9 (45%) were with the current agency longer than 15 years, 6 (30%) for 10 to 15 years, and 5 (25%) for 5 to 10 years; and 19 (95%) were RNs for more than 15 years, with 1 (5%) for 10 to 15 years. (See Table 1.)
Participants' educational level included 1 (5%) with an associate degree, 8 (40%) with a bachelor of science in nursing degree, 6 (30%) with a master of science in nursing degree, 3 (15%) with a master of science degree, 1 (5%) with a master of public health degree, and 1 (5%) with a doctoral degree. Ten participants (50%) worked 36 to 40 hours per week, 8 (40%) worked 41 hours or more, and 2 (10%) worked 35 hours or less. Several of the participants who selected 41 hours per week or greater indicated that this choice was made because of additional time worked to accomplish job tasks.
Data collection and analysis
Data collection involved contacting study participants by email or phone to arrange face-to-face interviews. Semistructured interviews were conducted with 22 (2 pilot and 20 study participants) nurse managers. A researcher-developed interview protocol form with seven open-ended questions was used for the interviews. (See Table 2.) The interviews lasted between 20 and 40 minutes using open-ended questions until data saturation occurred.
During the final phase of data collection, approximately 10 hours of audio-recorded interviews were transcribed; handwritten notes were also reviewed. After transcription, the participants were given the transcript of their interview for review and feedback as a means of member checking to establish credibility. Data were analyzed using the seven-step modified Van Kaam method to reveal final themes.16
Results
Participants discussed and described their lived experiences related to nurse manager job satisfaction and retention in a home healthcare agency. They also offered candid and positive recommendations to improve nurse manager job satisfaction and retention. Four core themes emerged from the interviews: significance of the nurse manager and staff (nurses, clinicians, nonclinicians) relationship, importance of organizational and leadership support, care for patients in the home environment, and need to focus on the responsibilities assigned to nurse managers. (See Table 3.)
Nurse manager and staff relationship
The foremost theme that emerged from participants' responses centered on the nurse manager and staff relationship. Some of the participants indicated that they couldn't specify one experience that was most satisfying; however, their experiences were associated with their staff. Regarding what kept them in the role for at least 5 years, the nurse managers again emphasized their staff. One participant stated, "When I say, 'What can I do for you?' and when they say 'thank you' or when an email comes that says 'thank you for taking the time,' I appreciate that." Another shared, "I guess the thing that always stands out for me is when the nurses have those 'a-ha' moments of clarity and connecting what they learned in school with how they're doing their job. It's a satisfying thing when you have a nurse who's really good at that and you've participated in getting the person to that level."
Organizational and leadership support
Participants' responses revealed that nurse managers' perceptions of organizational and leadership support were essential to their job satisfaction. Nurse managers described the organization as supportive and engaging. One manager emphasized that the reason for still working with the organization was the current supervisor, stating, "I like who I work for and I have confidence in that person."
Care for patients in the home environment
Participants were also asked about what experiences contributed to their continuing to work in the home healthcare setting. The prevalent theme identified was caring for patients in the home environment. One participant stated, "I'm so committed, I can't explain it. I was so enamored by the idea of keeping people at home. It just seemed so right to me."
Focus on nurse manager responsibilities
Participants were asked what home healthcare organizations could do to improve nurse manager job satisfaction and retention. Nurse managers emphasized a need to focus on the amount of responsibilities assigned to their role. They felt overwhelmed with clerical work and preferred to give more attention to the clinical aspects of the role. One nurse manager stated, "I think we're really bogged down with a lot of clerical duties. At least I find that in this organization [there are] a lot of clerical duties that really take away from our focus on the clinical aspects." Another expressed, "I think to improve a manager's satisfaction it would be to really utilize that person's talents for the role, rather than having them fill in gaps in the missing pieces that need to get done in the organization."
Discussion
Nurse managers working in home healthcare organizations have various responsibilities, including managing resources, clinical support, and effectively communicating with staff members who provide patient care throughout broad geographic regions.17 The information obtained in this study about nurse managers' perceptions of factors contributing to their job satisfaction and longevity is beneficial to leadership in home healthcare organizations. To enhance the nurse managers' leadership skills, home healthcare leaders should consider using a relationship- or people-focused approach instead of a task-focused leadership style. The relationship-focused leadership style helps create a healthy work environment and increase nursing workforce satisfaction.18
Home healthcare organization development staff members should explore the use of video feedback and reflection as a technique to improve nurse managers' relationship-focused leadership approaches. Video feedback and reflection entails the recording of real-time interactions of the nurse manager with staff or in meetings after permission is obtained from all employees.19 Use of real-time video is an emerging best practice to improve clinical practice, interprofessional communication, and patient safety in hospital settings.
Administrative support is one of the strongest predictors of job satisfaction.20 One participant emphasized that the people are the organization and the support received was very satisfying. Interpersonal relationships with nursing administrators had a greater effect on nurse manager engagement and proactive behavior than interpersonal relationships with peers or physicians.21 Senior leadership should schedule one-to-one informal meetings with nurse managers to promote a culture that supports quality interpersonal relationships between nurse managers and their supervisors. Transformational leadership practices foster nurse manager empowerment and effectiveness in accomplishing organization goals. Senior leaders should practice transformational leadership techniques to improve nurse manager job satisfaction and retention.22 Nurse managers may also learn transformational leadership techniques and apply the same approach with their staff.23
Nurses primarily obtain certification in clinical specialty areas; however, nurse managers should also be encouraged to pursue manager certification. Despite a focus on nurse managers working with hospital organizations, home healthcare leadership should recommend that nurse managers prepare for and take the Certified Nurse Manager and Leader exam.24 Nurse managers who achieve certification should be recognized and financially rewarded. Senior leadership should restructure nurse manager work processes and provide adequate clerical support. Home healthcare leadership should also explore the feasibility of creating an online portal for nurse managers.25 The online portal should be designed to ensure easy navigational access to well-organized electronic resources to support nurse managers in performing their roles and include information for leadership development.
Nurses are frequently promoted and expected to perform the same in a nurse manager position without formal management and leadership training.26 Home healthcare leadership can collaborate with academic institutions to support nurse manager enrollment and attendance in nursing management and leadership programs. To accommodate nurse managers' schedules, courses can be offered in the traditional classroom setting or online.
Limitations
A limitation noted was the small sample size; however, despite the small sample size, the results may be beneficial to healthcare leaders' understanding of factors that contribute to nurse manager satisfaction and retention. Other study limitations were the voluntary method, the participants' honesty, and the possibility of response bias even with the assurance of confidentiality. In addition, participants may not have provided thick descriptions of their experiences and this might limit the transferability of study results.
Another possible limitation may have been researcher bias. A strategy used to minimize researcher bias before initiating interviews included application of a transcendental approach to set aside personal beliefs and ideas about the phenomenon.27 Utilization of the modified Van Kaam method during the data analysis process and the use of data analysis software to assist with identifying themes from participants' responses were additional techniques used to minimize researcher bias.
Recommendations for future research
The first recommendation for future research is replication of this study because findings may be validated if similar themes emerge from future studies in different geographic locations with samples sharing similar demographics. A qualitative, instrumental case study is a second recommendation for future research. The case study approach should allow for data collection from multiple sources, such as interviews, documents, and observations that may contribute to eliciting more emergent themes.28 The final recommendation is a cross-sectional survey design that may capture a larger sample of participants to compare nurse manager job satisfaction and retention in home healthcare organizations.
Moving forward
Nurse managers are key to the achievement of the home healthcare mission to provide quality care while keeping patients safe in the community. This study's themes and recommendations can provide a framework for home healthcare leaders to include nurse managers in the creation of innovative strategies to enhance nurse manager job satisfaction and retention. Successful implementation may contribute to improved satisfaction and retention of nurse managers, succession planning for the nurse manager role, and better patient experiences.
Research box
* The purpose of this study was to gather a general understanding of nurse manager job satisfaction and retention.
* 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., were interviewed.
* The participants included 17 females and 3 males.
* Seventy-five percent of the participants were with the agency for longer than 10 years.
* 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 semistructured interview protocol with open-ended questions.
* Computer-assisted data analysis software and the Van Kaam method of analysis for phenomenologic data revealed four core themes: the nurse manager and staff relationship, organizational and leadership support, care for patients in the home environment, and focus on nurse manager responsibilities.
INSTRUCTIONS Nurse manager job satisfaction and retention: A home healthcare perspective
TEST INSTRUCTIONS
* Read the article. The test for this CE activity is to be taken online at http://nursing.ceconnection.com.
* You'll need to create (it's free!) and login to your personal CE Planner account before taking online tests. Your planner will keep track of all your Lippincott Professional Development online CE activities for you.
* There's only one correct answer for each question. A passing score for this test is 13 correct answers. If you pass, you can print your certificate of earned contact hours and access the answer key. If you fail, you have the option of taking the test again at no additional cost.
* For questions, contact Lippincott Professional Development: 1-800-787-8985.
* Registration deadline is June 4, 2021.
PROVIDER ACCREDITATION
Lippincott Professional Development will award 1.0 contact hour for this continuing nursing education activity.
Lippincott Professional Development is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.
This activity is also provider approved by the California Board of Registered Nursing, Provider Number CEP 11749 for 1.0 contact hour, and the District of Columbia, Georgia, and Florida CE Broker #50-1223.
Payment: The registration fee for this test is $12.95.
REFERENCES