Though the Covid-19 pandemic brought heightened attention to nurses overall, a unique nursing role has been long overlooked and, for the public, largely misunderstood: that of the nurse manager. Like nurses in other roles, nurse managers are increasingly leaving their jobs — and it’s critically important for organizations to find ways to keep them.
On a given unit/department, the nurse manager is the linchpin of a nursing team, responsible for ensuring quality patient care as well as the recruitment and retention of nursing staff. Nurse managers are also on the front line with their colleagues, leading a culturally diverse and multigenerational nursing workforce, and with their staff coordinate all aspects of patient care. They work to maintain a safe environment for staff, patients, and visitors alike. They ensure that staff adhere to policies and procedure. And they work to meet institutional goals while mentoring less experienced nurses. It may be helpful to think of nurse managers as the CEOs of their respective units: They create the culture of trust and sustained excellence and performance of their nursing staff, while also working directly with patients and their families.
From 2020 to 2022, the American Organization for Nursing Leadership (AONL) conducted a four-part longitudinal study exploring the Covid-19 pandemic’s impact on nurse leaders. They found a decline in nurse leader well-being over the course of the pandemic, particularly in nurse managers. Thirty-three percent of nurse managers reported they were not in a state of emotional well-being, and 20% were contemplating leaving their positions. Average turnover rate for front-line nurse managers is around two years, and in the Northeast U.S., the current vacancy rate stands at roughly 15%. Imagine if the CEO of a non-medical organization turned over every two years. There would be immediate attention given to why such turnover existed.
High nurse manager turnover is quite similar to other clinical nursing staff turnover both in cause and in rate. It’s connected to burnout and moral distress driven by unsustainable workloads, lack of work-life balance and role clarity, and ever-increasing scope of responsibility.
However, nurse managers do face their own challenges, including a lack of professional advancement opportunities; being “stuck in the middle” between senior leadership and clinical nurse staff over decisions impacting the work environment; and inadequate support and resources to fulfill their professional responsibilities.
High nurse manager turnover affects nearly every aspect of health system operations and patient care. Replacing them requires recruitment, onboarding, training, enculturation, and hiring temporary replacements at higher rates of pay, but also has trickle-down effects: nurse retention and engagement, patient experience, a culture of safety, quality metrics, and interdisciplinary collaboration. While current data estimate the cost to replace a nurse range from $60,000-$80,000, we do not have sufficient data to estimate the cost of replacing a nurse manager, but it is surely higher. Thus, developing, attracting, retaining, and promoting talented nurses for the middle manager role is paramount.
Some organizations are attempting to fix this problem. The pandemic forced organizations to innovate quickly while still using an evidence-based approach to the development, implementation, and evaluation of new protocols.
One specific example is the adoption of an alternative four-day work week for nurse managers. In this unique program, nurse managers work longer shifts over fewer days supporting a work-life balance. This program launched at the Mount Sinai Health System (where one of us, Toby, works) in New York City in 2022, where problems including burnout, compassion fatigue, and a lack of work-life balance were prompting many nurse managers to resign. In an interim program evaluation not yet published, 92% of nurse managers agreed that the new schedule supported work-life balance, and 100% agreed that the new schedule aligned with the organizational value of “care of self and care of colleagues.” To date, the nurse managers have reported that the program also had positive impacts on staff nurse retention, patient experience, and operational and safety metrics such as discharges before noon, length of stay, and health care-associated adverse events.
Other approaches to retain nurse managers include offering adequate training, tangible opportunities for professional development and career advancement, meaningful recognition, and succession planning. Another way organizational leadership can retain their nurse managers is a mentorship program in which nurse managers are mentored by rotating clinical and nonclinical members of the organization. This can help to provide a supportive professional network of a community of mentors. Creating healthy work environments for nurse managers through organizational support is vital to retention.
All of these programs also need to ensure retention of diverse nurse managers, because having nurse managers from underrepresented backgrounds influences an organization’s ability to deliver equitable care. Systemic racism, social injustices, and inequalities are pervasive in nursing, and activities to sustain organizational change that will support the recruitment and retention of nurse managers from underrepresented and marginalized communities are needed. The American Nurses Association’s National Commission to Address Racism in Nursing calls out nurse managers specifically as the ones to identify and address inappropriate behavior on a unit. Yet there is still a lack of diverse representation among nurse managers.
Institutional nurse manager residency programs (like those already in place that focus on new graduate nurses) may provide the organizational support and interpersonal skills needed to strengthen diverse nurse manager recruitment and retainment. Programs build skills in key areas including: relationship-centered executive leadership (cultivating empathy and vulnerability to engage effectively with patients and staff); systems thinking (identifying and engaging interdisciplinary stakeholders, and examining factors influencing recruitment, retention, and professional development); analytic and research (collecting, analyzing and disseminating data on job satisfaction, turnover, and other key metrics); problem-solving (identifying, prioritizing, and responding to issues); change management (navigating implementation and communication of new human resources policies, practices, and procedures); and financial acumen (understanding the economics of investments in talent development, acquisition, and promotion).
The Covid-19 pandemic marked the increase of not only nurses leaving clinical nurse staffing roles, but also nurse managers leaving their leadership positions. When we value the nurse manager role, we will in turn be investing in front line nurses and the millions of patients and families we serve.
Toby Bressler, Ph.D., R.N., is senior director of nursing for oncology and clinical quality at the Mount Sinai Health System. Lauren Ghazal, Ph.D., is assistant professor at the University of Rochester School of Nursing and a family nurse practitioner.