Emeritus Professor Christine Duffield FACN
Australian College of Nursing President
In most settings health services are structured around nursing wards or departments and managed by an experienced registered nurse (RN), the first-line nurse manager. Variously titled ward sister, charge nurse, head nurse, nurse/nursing unit manager, this role is critical in the organisation and delivery of health care. These front-line managers are the linchpins between nurses and other clinicians, patients and relatives/significant others, and the organisation’s management. Their role is pivotal in creating environments where nurses and other staff can work safely and provide quality patient care.
My PhD (1990) identified the role and functions of first-line nurse managers. As with most doctoral candidates, this was not where I started. I wanted to find out how this management role improved patient outcomes. I believed then, and continue to believe, that the first-line nurse manager is the most significant role in any health care setting; this individual is every organisation’s ‘front-of-house’.
Many years later, we now know that nurse managers at all levels in a health care setting are critical to patient safety and staff retention. Organisations with more nurse managers per 100 hospital beds have been found to experience lower mortality (Regan 2011). Competent first-line nurse managers improve staff performance, patient satisfaction, and nurses’ intention to stay (Gunawan and Aungsuroch (2017). Nurses are more likely to be positive about their workplace and remain employed where there is a highly visible and accessible senior nursing administrator but also, and perhaps more importantly, where they perceive that there is a good manager in charge of the ward or unit (Roche et al. 2016).
Replacement of nurse managers with non-nurse ‘business managers’ has been found to result in an increase in adverse clinical outcomes (nurse sensitive indicators such as decubitus ulcers, sepsis, UTIs, pulmonary failure, and wound infections to name a few) (McCloskey and Diers 2005). The improvement of patient, nurse and system outcomes when nurse managers are involved in decision-making stems from the fact they are clinicians as well as managers. They continue to engage in a range of clinical care activities in their management role, albeit in a different way, although at times called on to utilise their clinical skills at the bedside (Duffield et al. 2019). The belief that clinicians should be appointed as managers of clinical services is not a ‘new’ view. Reason (1990, p. 174) supported the appointment of managers with a clinical background over those with no clinical experience stating ‘[the] more removed individuals are from … front‐line activities…, the greater is their potential danger to the system’. Nurses must continue to be appointed to these roles.
In a seminal piece of work, Diers and Potter (1997) outlined the complexities at play in what was defined as an ‘unmanageable’ nursing unit – named this by non-nurse managers. We now understand that these complexities relate not only to patients (greater variability in case mix, high occupancy and acuity), but also to staff (years employed, years working on the unit, qualifications) and the unit itself (patient churn and transfers) (Duffield et al. 2015; Duffield et al. 2020). Nurse staffing (numbers, skillmix, and skills mix), and its relationship to patient safety is now a well-established science, confirmed in various systematic reviews (Griffiths et al. 2016; Kane et al. 2019; Griffiths et al. 2020).
Patient safety depends on the staffing decisions made by nurse managers, particularly those at the ‘coalface’. Every ward or unit, and indeed those who manage them, is unique, facing its own specific workload and staffing challenges. The first-line nurse manager will design and adapt their staffing responses to suit their individual ward or unit circumstances. Ensuring that organisational imperatives are achieved, requires more senior nurse and non-nurse managers working together. The International Council of Nurses (ICN) in its White Paper (2018) on nurse staffing, has taken the stance that direct care staff and nurse managers must be involved in any and all staffing decisions, and the professional judgment of registered nurses must be respected, not only in setting staffing targets but also when they call for changes to staffing on a shift. This statement was endorsed by ACN in 2018.
All nurses manage from the moment they graduate. They manage themselves. They manage patients and families through the health care system and very early on in their career, they manage others on their team, including other clinicians (Wise et al. 2021). However, we all know that the most capable and competent clinician does not necessarily make the best manager. A different but complementary skillset is required. The transition from clinician to manager is not an easy one and can adversely affect productivity, nurse satisfaction and patient outcomes in the ward or unit (Roche et al. 2015). Unfortunately, all too often nurses are appointed to management positions based on nursing experience and clinical expertise without the necessary education or support to undertake the managerial role (Roche et al. 2015), and at times, against their wishes – they are the last person standing!
The role of first-line nurse managers is critical. Patients’ lives depend on them and their leadership. However, the increased administrative burdens and the fact they often earn less than most of their staff, coupled with a lack of educational opportunities to undertake the role successfully, make these vital positions unattractive.
This year will see the Institute of Leadership at ACN offer its inaugural nursing unit manager program. This course will provide those in, or those aspiring to nurse unit management roles with practical skills required to influence and manage self, others, resources and operations for the benefit of staff, community and the recipients of care.
It has never been more important than now that nurse managers at all levels are empowered with the leadership and management skills, information and authority needed to create care environments that allow nurses to do what they do best (Spence Laschinger et al. 2012). In turn they must be valued, respected and appropriately remunerated.
Diers, D. & Potter, J. (1997) Understanding the unmanageable nursing unit with casemix data: a case study. Journal of Nursing Administration, 27(11), 27-32.
Duffield, C. (1990) Role ambiguity, role expectations and the educational preparation of nursing unit managers in hospitals in New South Wales (Australia), University of New South Wales, Australia
Duffield, C., Roche, M., Dimitrelis, S., Homer, C. and Buchan J. (2015) Instability in patient and nurse characteristics, unit complexity, and patient and system outcomes. Journal of Advanced Nursing. 71(6), 1288 – 1298.
Duffield, C., Roche, M., Debono, D. and Wise, S. (2020) Harnessing ward level administrative data and expert knowledge to improve staffing decisions. A multi-method case study. Journal of Advanced Nursing. 76(1), 287 – 296.
Griffiths P, Ball J, Drennan J, Dall’Ora C, Jones J, Maruotti A, Pope C, Recio Saucedo A, Simon M (2016). Nurse staffing and patient outcomes: Strengths and limitations of the evidence to inform policy and practice. A review and discussion paper based on evidence reviewed for the National Institute for Health and Care Excellence Safe Staffing guideline development. Int J Nurs Stud. 2016 Nov;63:213-225. doi: 10.1016/j.ijnurstu.2016.03.012. Epub 2016 Mar 30. PMID: 27130150.
Griffiths P, Saville C, Ball J, Jones J, Pattison N, Monks T; Safer Nursing Care Study Group (2020). Nursing workload, nurse staffing methodologies and tools: A systematic scoping review and discussion. Int J Nurs Stud. 2020 Mar;103:103487. doi: 10.1016/j.ijnurstu.2019.103487. Epub 2019 Nov 29. PMID: 31884330; PMCID: PMC7086229.
Gunawan, J., & Aungsuroch, Y, (2017) Managerial competence of first-line nurse managers: A concept analysis, International Journal of Nursing Practice, 2017 Feb;23(1). doi: 10.1111/ijn.12502. Epub 2017 Jan 3.
International Council of Nurses (2018) Evidence-based safe nurse staffing: position statement. Available at: https://www.icn.ch
Kane RL, Shamliyan TA, Mueller C, Duval S, Wilt TJ. The association of registered nurse staffing levels and patient outcomes: systematic review and meta-analysis. Med Care. 2007 Dec;45(12):1195-204. doi: 10.1097/MLR.0b013e3181468ca3. PMID: 18007170.Kane et al., (2019)
McCloskey, B. A., & Diers, D. K. (2005). Effects of New Zealand’s health reengineering on nursing and patient outcomes. Medical Care, 43(11), 1140–1146.
Reason, J. (1990) Human Error, Cambridge University Press, Cambridge, https://doi.org/10.1017/CBO9781139062367
Regan, R. (2011) Characteristics of the registered nurse workforce: associations with mortality rates in general hospital-based populations. Unpublished doctoral thesis. University of British Columbia, Canada.
Roche, M., Duffield, C., Dimitrelis, S. and Frew, B. (2015) Leadership skills for nursing unit managers to decrease intention to leave. Nursing: Research and Reviews. 5, 57-64.
Roche, M., Duffield, C., Friedman, S. Twigg, D., Dimitrelis, S. and Rowbotham, S. (2016) Changes to nurses’ practice environment over time. Journal of Nursing Management. 24(5), 666 – 675.
Spence Laschinger HK, Wong CA, Grau AL, Read EA, Pineau Stam LM. The influence of leadership practices and empowerment on Canadian nurse manager outcomes. J Nurs Manag. 2012 Oct;20(7):877-88. doi: 10.1111/j.1365-2834.2011.01307.x. Epub 2011 Sep 20. PMID: 23050621.
Wise, S. Duffield, C., Fry, M. and Roche, M. (2021) Nurses’ role in accomplishing interprofessional coordination. Lessons in ‘almost managing’ an emergency department team. Journal of Nursing Management. 30, 198 – 204. http://doi.org/10.1111/jonm.13464