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

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2. 2 Research Team Co-Investigators Judith Ritchie, McGill University Health Centre Danielle D’Amour, University of Montreal Leslie Vincent, Mount Sinai Hospital Marjorie Armstrong Stassen, University of Windsor  Piotr Wilk, University of Western Ontario  Sue Matthews, Victorian Order of Nurses Marcy Saxe-Braithwaite, Providence Continuing Care Centre  Michael Kerr, University of Western Ontario, and Institute of Work & Health Jerry White, University of Western Ontario  Decision Maker Partners Judith Shamian, VON  Doris Grinspun, Registered Nurses Association of Ontario  Amy McCutcheon, Vancouver Coastal Health Authority Sandra Macdonald-Rencz, Office of Nursing Policy, Health Canada Consultants Barbara Oke, Executive Director, Office of Nursing Services, FNIHB Donna Denney, Provincial Nursing Policy Advisor, Nova Scotia Dept of Health  Joseph Mapa, President and Chief Executive Officer, Mount Sinai Hospital Thomas Ward, Consultant Project Advisory Committee Patricia O’Connor, McGill University Health Centre Joan Tranmer, Kingston General Hospital Clemence Dallaire, Laval University Mary Ellen Gurnham, Capital District Health Authority Anne Cooke, Prince George Regional Hospital

3. 3 Background to Project Dramatic changes in leadership roles over past decade Wider scope of responsibility and span of control Managerial positions significantly reduced (31% since 1992) Reduced visibility and availability for mentoring Few studies have examined how roles differ across country or effect on professional nursing services Several reports emphasize importance of strong nursing leadership (Baumann, et al., 2001; CNAC, 2002) All warn about the impending shortage of nurse leaders in Canada

4. 4 Objectives Provide descriptive analysis of nursing leadership/ management structures at senior, middle, and first line levels of management across Canada Examine relationships among structural and process characteristics of nurse leader roles and work-related outcomes Examine the effect of senior nurse leader role characteristics on middle and first line managers’ work 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. The project had three objectives: (1) describe nursing leadership structures; (2) examine the impact of structural and process characteristics of nurse leader roles and work-related outcomes; and 3) examine the effect of senior nurse leader role characteristics on middle and first-line managers’ work. 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. The project had three objectives: (1) describe nursing leadership structures; (2) examine the impact of structural and process characteristics of nurse leader roles and work-related outcomes; and 3) examine the effect of senior nurse leader role characteristics on middle and first-line managers’ work.

5. 5 Conceptual Framework A conceptual model was developed based on a review of the nursing, health services, and organizational theory literature. In the model, we posit two sets of propositions. First, structural characteristics of SNL roles affect their own outcomes. Second, structural and individual leadership characteristics of each level of management (SNL, MM, and FLM) affect their own outcomes through integrative mechanisms, such as effective coordination and communication Third, structural and individual characteristics of SNLs affect the outcomes of lower level managers – MM and FLM. The overall organizational and management structures are seen as the context that moderates these relationships. A conceptual model was developed based on a review of the nursing, health services, and organizational theory literature. In the model, we posit two sets of propositions. First, structural characteristics of SNL roles affect their own outcomes. Second, structural and individual leadership characteristics of each level of management (SNL, MM, and FLM) affect their own outcomes through integrative mechanisms, such as effective coordination and communication Third, structural and individual characteristics of SNLs affect the outcomes of lower level managers – MM and FLM. The overall organizational and management structures are seen as the context that moderates these relationships.

6. 6 Methods Data Collection Procedures: Mail surveys and interviews Sample: Acute care settings within Academic Health Centres (AHC) and Community Hospitals (CH) with > 100 beds Number of sites in each province: British Columbia: 12 Hospitals within 5 RHAs Alberta: 11 Hospitals within 6 RHAs Saskatchewan: 6 Hospitals within 3 RHAs Manitoba: 6 Hospitals within 2 RHAs Ontario: 22 Hospitals Quebec: 11 Hospitals New Brunswick: 5 Hospitals within 5 RHAs Nova Scotia: 5 Hospitals within 3 RHAs Newfoundland: 5 Hospitals within 3 RHAs Prince Edward Island: 1 Hospital Total: 84 Hospitals within 66 organizations (50 Hospitals within 27 RHAs) Data were collected through mail surveys and telephone interviews with SNLs in each province. Data collected in 10 provinces from acute care inpatient units within 28 Academic Health Centres and 38 community hospitals. Only hospitals with greater than 100 beds were chosen. Total of 66 sites which included stand alone hospitals as well as regional health authorities (RHA)Data were collected through mail surveys and telephone interviews with SNLs in each province. Data collected in 10 provinces from acute care inpatient units within 28 Academic Health Centres and 38 community hospitals. Only hospitals with greater than 100 beds were chosen. Total of 66 sites which included stand alone hospitals as well as regional health authorities (RHA)

7. 7 Participants included nurse leaders defined this way: Senior Nurse Leader (SNL): nurse who holds the most senior nursing leadership position with direct responsibility for nursing Middle Manager (MM): nurse/non-nurse with line responsibility for nursing; at least one level of management below and above level First-Line Manager (FLM): nurse/non-nurse with line responsibility for nursing; no level of management below them; may have charge nurses or supervisors reporting directly to them Professional Practice Leaders (PPL): staff position responsible for nursing within organization Chief Executive Officer (CEO): CEO of entire organization CEOs included in study but data not presented hereParticipants included nurse leaders defined this way: Senior Nurse Leader (SNL): nurse who holds the most senior nursing leadership position with direct responsibility for nursing Middle Manager (MM): nurse/non-nurse with line responsibility for nursing; at least one level of management below and above level First-Line Manager (FLM): nurse/non-nurse with line responsibility for nursing; no level of management below them; may have charge nurses or supervisors reporting directly to them Professional Practice Leaders (PPL): staff position responsible for nursing within organization Chief Executive Officer (CEO): CEO of entire organization CEOs included in study but data not presented here

8. 8 Of the original 2015 surveys, 1164 surveys were returned for an overall response rate of 58%. The final sample consisted of: 63 out of 66 SNLs (95.5%) 231 out of 384 middle managers (60.2%) 788 out of 1461 first-line managers (53.9%) 30 out of 40 professional practice leaders (75%) 52 out of 64 CEOs (81%)Of the original 2015 surveys, 1164 surveys were returned for an overall response rate of 58%. The final sample consisted of: 63 out of 66 SNLs (95.5%) 231 out of 384 middle managers (60.2%) 788 out of 1461 first-line managers (53.9%) 30 out of 40 professional practice leaders (75%) 52 out of 64 CEOs (81%)

9. 9 Education: SNLs – 54% Masters; 6% PhD MMs – 54% BSN; 38% Masters FLMs – 68% BSN; 18% Masters Sector study: 13.5% masters or doctorate; 47% had BSN Mass study: 40% Masters at middle level, 85% at SNL A notable finding was the high average age (47-50 years) of nurse leaders at all levels, with little variation across levels suggesting the immediate need for succession planning to ensure the future of nursing leadership. There were no regional differences Sector study: average age was 49.6Education: SNLs – 54% Masters; 6% PhD MMs – 54% BSN; 38% Masters FLMs – 68% BSN; 18% Masters Sector study: 13.5% masters or doctorate; 47% had BSN Mass study: 40% Masters at middle level, 85% at SNL A notable finding was the high average age (47-50 years) of nurse leaders at all levels, with little variation across levels suggesting the immediate need for succession planning to ensure the future of nursing leadership. There were no regional differences Sector study: average age was 49.6

10. 10 Study by Mass with 34 middle managers, and 33 SNLs – all but two were over 40, then over 50 (33% of middle managers and 66% SNLs)Study by Mass with 34 middle managers, and 33 SNLs – all but two were over 40, then over 50 (33% of middle managers and 66% SNLs)

11. 11 Manager vacancy rate low (38%=0, 50%=1-2) CHSRF report Sept 2006 - 50 Canadian leaders met to explore nursing workforce issues and discuss ways to share information and opportunities for collaboration and integration to address nursing challenges. Priorities in the area of leadership included promotion of movement between roles (clinician to manager), and encouraged succession planning for nurse leaders Mass et al’s study 2006, ACEN Report from 2002, and CNAC Report: Recommended Need to build in succession planningManager vacancy rate low (38%=0, 50%=1-2) CHSRF report Sept 2006 - 50 Canadian leaders met to explore nursing workforce issues and discuss ways to share information and opportunities for collaboration and integration to address nursing challenges. Priorities in the area of leadership included promotion of movement between roles (clinician to manager), and encouraged succession planning for nurse leaders Mass et al’s study 2006, ACEN Report from 2002, and CNAC Report: Recommended Need to build in succession planning

12. 12 Sector study: nursing experience 27.5; years in current role – 5.7Sector study: nursing experience 27.5; years in current role – 5.7

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15. 15 Span of Control by Management Level and Region Doran and McCutcheon – mean 77, median 67 – Range was 36 to 258 but 258 deemed an outlier, therefore high number 151 Sector study: Averaged 49 direct reports with a higher number (104.6) reported for Chief Nursing Officers working in hospitals. CNAC Report: Recommended Number of first line managers should be sufficient to allow reasonable levels of contact with nurses and should be an experienced nurse with strong leadership abilities; Reasonable, manageable span of control to allow managers to complete assigned functions and be present to meet nurses’ and patients’ needs; Supported with human and technical resources that allow them to do the required work within reasonable hours of work Doran and McCutcheon – mean 77, median 67 – Range was 36 to 258 but 258 deemed an outlier, therefore high number 151 Sector study: Averaged 49 direct reports with a higher number (104.6) reported for Chief Nursing Officers working in hospitals. CNAC Report: Recommended Number of first line managers should be sufficient to allow reasonable levels of contact with nurses and should be an experienced nurse with strong leadership abilities; Reasonable, manageable span of control to allow managers to complete assigned functions and be present to meet nurses’ and patients’ needs; Supported with human and technical resources that allow them to do the required work within reasonable hours of work

16. 16 An overall picture of the SNL role was determined by reviewing the organizational charts of all 66 participating organizations. Sector study: 70% hospitals, and 50% Regional Health Authorities - Chief Nursing Officers in line positions. Senior Nurse Leaders reported high levels of involvement and in influence in senior management decisions. A title and salary comparable to other executives with similar responsibilities SNLs’ involvement in senior management team decisions was evaluated according to 5 types of strategic decisions: planning organizational goals and methodologies operational management (excluding direct patient care) resource decisions (including fiscal and human resources) professional practice issues clinical care An overall picture of the SNL role was determined by reviewing the organizational charts of all 66 participating organizations. Sector study: 70% hospitals, and 50% Regional Health Authorities - Chief Nursing Officers in line positions. Senior Nurse Leaders reported high levels of involvement and in influence in senior management decisions. A title and salary comparable to other executives with similar responsibilities SNLs’ involvement in senior management team decisions was evaluated according to 5 types of strategic decisions: planning organizational goals and methodologies operational management (excluding direct patient care) resource decisions (including fiscal and human resources) professional practice issues clinical care

17. 17 Interviews were completed with SNLs in each province - Identified the following facilitators and barriers to the effectiveness of their role: Similar to the study by Heather Mass, et al who interviewed 34 senior nurse leaders and 33 middle-level positions across Canada. Facilitators: identified a clear link between professional leadership and operations – senior nurse leader should have both operations management and professional leadership authority. Barriers identified were system changes, lack of role clarity, workload, structural barriers (reporting structures, union regulations)Interviews were completed with SNLs in each province - Identified the following facilitators and barriers to the effectiveness of their role: Similar to the study by Heather Mass, et al who interviewed 34 senior nurse leaders and 33 middle-level positions across Canada. Facilitators: identified a clear link between professional leadership and operations – senior nurse leader should have both operations management and professional leadership authority. Barriers identified were system changes, lack of role clarity, workload, structural barriers (reporting structures, union regulations)

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19. 19 Despite very large spans of control, nurse leaders were very positive about their work and their abilities to be effective in their roles. K & P transformational leadership behaviours Enabling others to act Modeling the way Challenging the process within organizations Encouraging the heart of others through praise Inspiring a shared vision 2) Support for professional nursing practice: NWI support for staff nurse autonomy positive nurse/physician relationships control over practice Sample items: ‘Adequate support services allow nurses to spend time with patients’, ‘Physicians and nurses have good relationships’, ‘Enough staff to provide quality care’. 3) Communication Satisfaction: Listening, honesty, and understanding between themselves and their immediate supervisor 4) Nurse assessed quality of patient care – Aiken NWI Sector study: 70% were very satisfied with reporting relationship to senior management, also satisfied with scope of decision-making Despite very large spans of control, nurse leaders were very positive about their work and their abilities to be effective in their roles. K & P transformational leadership behaviours Enabling others to act Modeling the way Challenging the process within organizations Encouraging the heart of others through praise Inspiring a shared vision 2) Support for professional nursing practice: NWI support for staff nurse autonomy positive nurse/physician relationships control over practice Sample items: ‘Adequate support services allow nurses to spend time with patients’, ‘Physicians and nurses have good relationships’, ‘Enough staff to provide quality care’. 3) Communication Satisfaction: Listening, honesty, and understanding between themselves and their immediate supervisor 4) Nurse assessed quality of patient care – Aiken NWI Sector study: 70% were very satisfied with reporting relationship to senior management, also satisfied with scope of decision-making

20. 20 Empowerment related to NWI in sector study for staff nursesEmpowerment related to NWI in sector study for staff nurses

21. 21 Quality of senior management decisions asked about compatibility of decisions with existing constraints, timing of decisions to maximize advantage or benefits, optimal use of information, balance of risks and rewards, decision creating a conflict of interest. Quality of senior management decisions asked about compatibility of decisions with existing constraints, timing of decisions to maximize advantage or benefits, optimal use of information, balance of risks and rewards, decision creating a conflict of interest.

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24. 24 If SNLs were satisfied with their role…..their middle managers reported higher quality of patient care. If SNLs felt they were influential in senior team decisions, and were frequent users of transformational leadership behaviours……their first line managers reported higher quality of patient care. Mass et al: SNLs were expected to provide leadership to other nurses by mentoring, coaching and role modelling; to articulate a vision and be a voice for nursing and communicate it effectively to all levelsIf SNLs were satisfied with their role…..their middle managers reported higher quality of patient care. If SNLs felt they were influential in senior team decisions, and were frequent users of transformational leadership behaviours……their first line managers reported higher quality of patient care. Mass et al: SNLs were expected to provide leadership to other nurses by mentoring, coaching and role modelling; to articulate a vision and be a voice for nursing and communicate it effectively to all levels

25. 25 Study by Diane Doran and Amy McCutcheon with 41 nurse managers: Nurse managers with positive leadership styles, based on a series of exchanges or interactions between leader and followers, had more-satisfied staff, lower levels of staff turnover and higher patient satisfaction. Nurse managers with negative leadership styles, who take action only when required or when issues become serious or who avoid leadership responsibilities, had less-satisfied staff. Units with managers with large span of control had higher levels of staff turnover and lower patient satisfaction. Large spans of control reduced the positive effect of managers’ leadership styles on staff satisfaction and patient satisfaction. 2005 National Survey of the Work and Health of Nurses: low support from supervisor related to fair or poor healthStudy by Diane Doran and Amy McCutcheon with 41 nurse managers: Nurse managers with positive leadership styles, based on a series of exchanges or interactions between leader and followers, had more-satisfied staff, lower levels of staff turnover and higher patient satisfaction. Nurse managers with negative leadership styles, who take action only when required or when issues become serious or who avoid leadership responsibilities, had less-satisfied staff. Units with managers with large span of control had higher levels of staff turnover and lower patient satisfaction. Large spans of control reduced the positive effect of managers’ leadership styles on staff satisfaction and patient satisfaction. 2005 National Survey of the Work and Health of Nurses: low support from supervisor related to fair or poor health

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