Measuring the Impact of High-Performing Nurse Managers on Nurse Outcomes Across Clinical Settings

Abstract

OBJECTIVE

The purpose of this article was to compare nurse outcomes between high-performing and low-performing nurse managers (NMs) across clinical settings and discuss financial savings associated with high-performing NMs.

BACKGROUND

When NMs are provided with an environment that allows them to perform at a high level, their impact can be measured in terms of their nursing unit outcomes. Understanding the differences achieved between high-performing and low-performing NMs may provide insights on the return on investment in redesigning the NM role.

METHODS

Data from the 2022 National Database of Nursing Quality Indicators annual RN survey were used to examine the relationships among variables across care settings.

RESULTS

High-performing NMs across clinical settings achieved significantly higher RN intent to stay, higher quality of care, and lower missed nursing care, compared with low-performing NMs.

CONCLUSIONS

High-performing NMs achieved superior nurse outcomes with implications for the quality of nursing care and patient outcomes. Although coaching underperforming NMs is intuitive, mentoring high-performing NMs may yield greater benefit.

Nurse managers (NMs) play a critical role in realizing strategic organizational goals. Their job performance is based on their performance on key metrics such as staff retention, patient safety measures, resource utilization, and cost containment targets set by senior leaders.¹ Nurse managers are not fully in control of these key metrics; rather, they create environments that influence the actions of their teams to achieve unit goals. Some NMs are able to excel while others struggle because of factors that challenge their likelihood of success.^2,3 Those who achieve strong outcomes despite the complexities of the job are considered high performers. By comparison, those who are less proficient and less adept at overcoming barriers to performance are considered low performers.² Nurse executives need NMs who excel despite the complexities of the current environment; thus, they are seeking strategies to redesign NMs' work to help them adapt to current reality.³

There are mounting concerns over the expanding workload of NMs as the clinical environment, regulatory requirements, and financial targets evolve in a post–COVID-19 era.^3,4 For example, NMs have broad responsibilities. They often lead multiple patient care areas with large, complex teams of nursing personnel.⁴ These nursing teams possess a range of skill sets, licensure, and experience. More recently, nursing teams may include nurses providing care virtually in tandem with traditional bedside care.⁵ The complex demands create stressful work conditions and negatively impact the effectiveness of NMs' influence over clinical operations. In response, the American Organization for Nursing Leadership (AONL) has championed project teams over the past 2 years to identify solutions aimed at reducing the demands placed on NMs.^6,7 The AONL also partnered with the Healthcare Management Academy to identify the key drivers of NM workload.⁸ The sample consisted of 1700 NMs. Of 20 possible factors, the number of employees reporting directly to NMs was identified as the top driver of NM workload.⁸ A critical finding was that, on average, NMs are responsible for over 100 employees. The authors concluded that despite the influence of the other 19 factors, reducing headcount should be the top strategy to alleviate NM workload.

Reducing headcount is a complex endeavor to implement. An alternative approach to alleviating workload burden on NMs is to provide support in the form of support roles and functional tasks.⁹ Support roles such as assistant NMs, clinical educators, and administrative assistants have demonstrated positive effects on NMs' perceptions of stress, boosting their intentions to remain in their roles. Functional support with payroll, scheduling, and staffing have also yielded positive impacts on NMs' workload.² Research demonstrates that although providing support for NMs with large teams is helpful, it does not fully counter the negative effects of burdensome scopes of responsibility for NMs.¹⁰

This leaves nurse executives with an interesting challenge. What is the right balance between NM workload in terms of scope of responsibility offset by support positions and functions?^4,11 Previous research to understand the impact of effective NMs shows us that NMs are the chief architects of healthy work environments supporting professional nursing practice.^4,10,12 They are the key determinants of job satisfaction and retention among clinical nurses. Nurse managers also influence the quality of nursing care, which in turn affects the quality of patient outcomes (Figure 1). Factors that help NMs achieve these important outcomes include experience and competence for the role and a span of control of less than 60 full-time–equivalent direct reports.²

Figure 1.

Conceptual model: NM performance.

Although the AONL work groups identified factors that serve as a foundation for action,^6,7 quantifying the financial implications has not been well established. When NMs are provided with an environment that allows them to perform at a high level, their impact can be measured in terms of their nursing unit outcomes.⁴ Understanding the differences achieved between high-performing and low-performing NMs may provide insights on the return on investment in redesigning the NM role.⁴ The purpose of this study was to provide chief nursing officers with preliminary evidence to quantify the impact of high-performing NMs on measurable nurse outcomes as reported through a national nursing database. Using reported differences in outcomes, financial savings will be discussed.

Methods

Data were extracted from the 2022 National Database of Nursing Quality Indicators (NDNQI) Annual RN Survey. Press Ganey client hospitals voluntarily participate in the annual RN survey to collect data on nurse outcomes, work environment, and individual RN characteristics. The NDNQI database was established in 1988 by the American Nurses Association and acquired by Press Ganey in 2014. These researchers chose to analyze 2022 data as 2022 NDNQI RN Survey data became fully available at the end of Q1 2023. The NDNQI data management procedures were reviewed by the Advarra Institutional Review Board (IRB) and deemed exempt from IRB oversight.

Sample

Data from all 4861 units across 283 completing the 2022 NDNQI RN Survey with unit-level response rates of 50% or greater and who completed the Practice Environment Scale (PES)¹² option were eligible to be included in the analysis. Nursing units, including adult acute care (n = 1099), pediatric acute care (n = 890), ambulatory care (n = 197), and emergency care settings (n = 165), were stratified according to mean unit scores on the NM Ability, Leadership and Support (NMALS) subscale scores. The final study sample was composed of nursing units in the top 10% to 25% (defined as highest performers) and bottom 10% to 25% (defined as lowest performers) of NMALS scores, based on acuity type setting, for comparison of the highest and lowest performing units.

Measures

Measures used in the current study were obtained from the 2022 NDNQI RN Survey. Nurse manager leadership was measured using the average score of the NMALS subscale of the PES. Direct care nurses score their NM using 5 items that represent the quality of their NM's leadership ability and support. The NMALS subscale has demonstrated strong reliability (α = 0.84) and construct validity, supported by significant associations with nurse-reported outcomes and patient outcomes.^13,14

RN Outcomes

These were measured using the following 3 RN survey items: missed nursing care. Missed nursing care is the unit-level average of important activities that nurses report were left undone because of time constraints. Participants are asked “Which of the following activities were necessary but left undone because of time constraints?”, where they are then instructed to check all applicable items from a list. Sample response options included “adequately document nursing care, treatments and procedures,” “coordinate patient care,” and “administer medications on time.” Each nurse reported the total number of missed nursing activities that occurred during their last shift, with a possible of 0 to 15 missed nursing activities. For the current study, missed nursing care was calculated as the average unit-level score of the total reported missed care events across nurses on that unit during their last shift. Missed nursing care is a widely used and validated indicator of nursing care delivery, with previous research linking it to nurse staffing levels and adverse patient outcomes.¹⁵

Unit-Level Perceived Quality of Care

This was measured using the following item in the NDNQI RN Survey: “In general, how would you describe the quality of nursing care delivered to patients on your unit?” Response options included the following: “poor” (1), “fair” (2), “good” (3), and “excellent” (4). The single-item measure of perceived quality of care is widely used in nursing research and has been validated in studies examining unit-level care quality.¹⁶

Retention was measured as intention to stay employed on the unit, in the form of the percentage of nurses who plan to remain in direct patient care on the same unit. The NDNQI RN survey items on job plans have demonstrated validity though their consistent use in nursing workforce studies examining intent to stay in the profession or their current role.^17-19 More recent applications of these items to evaluate unit-level retention outcomes²⁰ further support their relevance for measuring frontline nurses' job intentions.

Nurse Characteristics

Nurse characteristics included RN education and certification. Education was calculated as the percentage of unit RNs with a BSN degree or higher. Registered nurse specialty nursing certification was calculated as the percentage of unit RNs holding certification in a specialty area of nursing practice granted by a national accredited nursing certification program.

Data Analysis

Subgroups of acuity setting types were created based on unit type. For each subgroup, descriptive statistics of the NMALS subscale and RN survey items for both highest and lowest performing NMs were calculated. t Tests were calculated to identify significant differences in the mean average RN survey items and nurse characteristics based on high-performing and low-performing NMs.

Results

Table 1 outlines the final subsample composition, detailing the number of nursing units and corresponding mean NMALS scores for high-performing and low-performing groups within each acuity setting. These stratified groupings formed the basis for subsequent comparative analyses. Unit-level NMALS scores for highest-performing NMs ranged from 3.45 to 3.75 on a 4-point scale, whereas unit-level NMALS scores for lowest-performing NMs ranged from 2.38 to 2.70. The differences between highest-performing and lowest-performing NM unit-level NMALS scores ranged from 0.88 and 1.37 points across acuity settings.

Table 1.

Sample Size Descriptives

Unit Type	Total No. Units	% Compared for High and Low	Total Units Per NM Category	High-Performing NMALS Score	Low-Performing NMALS Score
Adult acute care	1099	10%	116	3.59	2.43
Ambulatory care	890	10%	89	3.75	2.38
Emergency care	197	25%	50	3.58	2.70
Pediatric acute care	165	25%	42	3.49	2.54

High-performing NMs across acuity settings achieved significantly higher unit-level RN intent to stay, higher quality of care, and lower missed nursing care, compared with low-performing NMs (Table 2). Units with high-performing NMs reported between 21% and 32% more nurses reporting an intent to stay compared with units with low-performing NMs. Units with high-performing NMs reported a 0.39-to-0.68 increase in nurse-reported quality of care compared with units with low-performing NMs. Units with high-performing NMs reported between 0.72 and 2.05 fewer missed nursing care activities, per nurse, per shift compared with units with bottom-performing NMs.

Table 2.

Nurse Outcomes by High-Performing and Low-Performing NMs Across Clinical Settings

	Units With Low-Performing NMs		Units With High-Performing NMs		t	P	95% CI	Mean Difference
	Mean	SD	Mean	SD
Adult acute care (n = 232)
Quality of care	2.91a	0.37	3.59a	0.21	−17.19	<0.001	[−0.76 to −0.60]	0.68
Missed care	4.00a	1.49	1.96a	1.02	12.26	<0.001	[1.72-2.38]	−2.04
Percentage planning to remain	46.40a	18.11	78.49a	13.74	−15.21	<0.001	[−36.25 to −27.93]	32.09
Percentage with BSN or higher	71.69a	19.91	65.89a	21.15	2.95	0.003	[1.94-9.67]	−5.80
Percentage with certification	13.58a	13.56	19.39a	16.49	−3.90	<0.001	[−8.74 to −2.88]	5.81
Pediatric acute care (n = 84)
Quality of care	3.34a	0.36	3.73a	0.22	−5.99	<0.001	[−0.52 to −0.26]	0.39
Missed care	1.76a	1.22	1.04a	0.89	3.08	0.003	[0.25-1.18]	−0.72
Percentage planning to remain	67.61a	19.43	88.70a	10.04	−6.25	<0.001	[−27.84 to −14.34]	21.09
Percentage with BSN or higher	76.92	17.58	80.71	17.86	−1.45	0.149	[−8.95 to 1.36]	3.79
Percentage with certification	18.23a	22.41	34.64a	22.91	−4.83	<0.001	[−23.11 to −9.70]	16.41
Emergency care (n = 100)
Quality of care	3.12a	0.35	3.68a	0.24	−9.39	<0.001	[−0.68 to −0.44]	0.56
Missed care	3.23a	1.45	1.45a	1.03	7.08	<0.001	[1.28-2.29]	−1.78
Percentage planning to remain	62.80a	17.01	84.74a	10.05	−7.85	<0.001	[−27.49 to −16.37]	21.94
Percentage with BSN or higher	63.79a	24.40	71.21a	16.18	−2.69	<0.001	[−12.85 to −1.99]	7.42
Percentage with certification	19.17a	19.45	28.44a	20.33	−3.30	0.001	[−14.80 to −3.73]	9.27
Ambulatory care (n = 178)
Quality of care	3.40a	0.33	3.91a	0.13	−13.59	<0.001	[−0.59 to −0.44]	0.51
Missed care	1.41a	1.20	0.39a	0.44	7.58	<0.001	[0.76-1.30]	−1.02
Percentage planning to remain	64.19a	19.46	92.13a	11.69	−11.61	<0.001	[−32.70 to −23.18]	27.94
Percentage with BSN or higher	72.76	18.95	72.06	23.58	0.24	0.814	[−5.13 to 6.53]	−0.70
Percentage with certification	28.79	20.52	34.41	32.50	−1.47	0.142	[−13.15 to 1.91]	5.62

“Mean difference” represents mean difference in the high-performing NM group vs the low-performing NM group.

^aSignificant difference found in the mean average (P < 0.05).

Greater variation in nurses with a BSN degree or higher across NM performance was observed across acuity settings. Units with high-performing NMs had a significantly lower percentage of RNs with a BSN degree or higher in adult acute care settings, whereas a higher percentage of RNs with a BSN degree or higher were observed in emergency care settings compared with units with low-performing NMs. In addition, units with high-performing NMs had a significantly higher percentage of nurses with a specialty nursing certification in adult acute care, emergency care, and pediatric care settings compared with units with low-performing NMs. The difference between high-performing NMs in ambulatory care in the percentage of nurses with a specialty nursing certification or percentage of RNs with a BSN degree or higher were not significantly different from units with low-performing NMs.

Discussion

Across all acuity settings, high-performing NMs scored significantly higher compared with low-performing NMs using the NMALS subscale of the PES. This score reflects the ratings of NMs by the direct care nurses reporting to them. The items reflect the NMs' ability to create environments where nurses feel supported in decision making. In these environments, nurses feel respected and are recognized for their work. Nurses' perceptions of their NM are critical to nurse retention.²¹ In fact, this effect is reflected by the differences observed in nurses' intention to stay in their same positions for the next year between high-performing and low-performing NMs. Across all acuity settings, high-performing NMs outperformed low-performing NMs by 21% to 32%. This difference represents a significant opportunity for cost savings related to decreased avoidable turnover. For every nurse retained, an organization saves an estimated $56 000.²² The cost savings are substantial when multiplied by the difference between top-performing and low-performing NMs across hospital units.

The impact of high-performing NMs is also reflected in nurses' completion of essential nursing care activities. Nurses working with high-performing NMs reported missing 2 fewer activities per shift. This observed difference can be multiplied across the number of nurses working on a given shift and units. The published literature reveals the critical role of completing essential nurse care and patient safety outcomes such as patient experience, falls with injury, urinary tract infections, and readmissions.²³ Completion of essential nursing care also influences nurses' ratings and perception of the quality of care provided on their units. That difference was reflected in this study. Quality of care scores average 0.39 to 0.68 points on a 4-point scale higher for high-performing NMs. When nurses complete all essential nursing care, they feel better about the overall quality of care, which can be reflected in fewer adverse nursing-sensitive patient events.²⁴

An aspect where differences between high-performing and low-performing NMs was not as anticipated by this research team was related to nurse education and certifications. The percentage of RNs with a BSN degree or higher and the percentage of RNs with specialty nursing certification across acuity setting types did not vary based on NM performance. High-performing NMs in acute care units had 6% fewer nurses with a BSN degree or higher, whereas high-performing NMs in emergency care departments had 7% more nurses with a BSN degree or higher. The percentage of certified nurses per unit also varied across acuity settings. In acute care, emergency care, and pediatric care, between 6% and 19% more nurses reported having a specialty nursing certification for units with high-performing NMs. This finding suggests that nurse credentials are influenced by additional factors. One likely explanation is the national drive to increase the percentage of BSN-prepared and certified nurses in general.²⁵ The 2011 Future of Nursing report advocated for the advancement of nursing education and certification. In response, many organizations responded by modifying their hiring practices, emphasizing a preference for higher levels of education for direct care nurses. Nurse executives standardized hiring preferences through these hospital-wide policies, resulting in less variation across individual nursing units.²⁶

Recommendations for Nurse Leaders

Comprehensive 360°/180° evaluations, patient and employee engagement, financial performance, and nursing perceptions of quality of care should be included in an integrated analytics approach to evaluating the performance of NMs. Recognizing that keeping a low-performing NM in place may lead to patient harm; therefore, prioritizing an action plan for performance improvement is key. Creating a detailed plan of action to improve the engagement and performance of the NM in a time-limited and measurable way is a critical 1st step. If the expected performance outcomes are not achieved, a more difficult decision to move the low-performing leader to another role or out of the organization altogether must be considered. The longer the low-performing leader is left in place, the higher the risk of poor patient outcomes and continued erosion of nursing engagement measures.

It is equally important that senior leaders recognize and invest in highly engaged NMs. High performers can often be overlooked and may feel underappreciated. Implementing a continuous listening strategy to stay close to high performers is a proven approach.²⁷ Having regular mentoring sessions, stay interviews, and leadership development planning based on 360°/180° assessments are examples of proven retention initiatives for high-performing NMs.^28-32

As important as it is for the senior nurse leader to be actively engaged in the development processes for NMs, it is equally important that NMs have high levels of self-awareness and are assessing their own level of engagement. The ability to recognize early signs of fatigue, burnout, and declining engagement and intervening is an important component of effective leadership and self-care.³³ Although it may be difficult to admit that our own efficacy and engagement may be suffering, it is much easier to arrive at this conclusion rather than having a leader deliver that message.

Conclusion

This study revealed observable differences between high-performing NMs and low-performing NMs in measurable performance outcomes. High-performing NMs achieved superior nurse outcomes with implications for the quality of nursing care and patient outcomes. Although NM performance can be influenced by the scope and complexity of the specific role, senior nurse leaders should not overlook poor NM job performance. Exploring possible causes and initiating performance improvement plans are essential to achieving organizational goals at all levels. Although attention must be paid to underperforming NMs, senior nurse leaders must also nurture and prioritize high-performing, highly engaged NMs. The difference in performance may be critical to patient outcomes.