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

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A Profile of the Structure and Impact of Nursing
Management in Canadian Hospitals Regional
Comparisons
Co-Principal Investigators Heather K. Spence
Laschinger, PhD, RN Professor and Associate
Director Nursing Research School of Nursing,
University of Western Ontario London,
Ontario Carol Wong, MScN, RN Assistant
Professor School of Nursing, University of
Western Ontario London, Ontario July 4,
2006 Funded by The Canadian Health Services
Research Foundation, Nursing Research Fund,
Ontario Ministry of Health and Long Term Care,
Health Canada, London Health Sciences Centre,
Vancouver Coastal Health Authority, Mount Sinai
Hospital, Registered Nurses Association of
Ontario
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Research Team

• Co-Investigators
• Marjorie Armstrong Stassen, University of
  Windsor 
• Jerry White, University of Western Ontario 
• Michael Kerr, University of Western Ontario, and
  Institute of Work Health
• Marcy Saxe-Braithwaite, Providence Continuing
  Care Centre 
• Sue Matthews, Ministry of Health and Long Term
  Care, Ontario
• Leslie Vincent, Mount Sinai Hospital
• Piotr Wilk, University of Western Ontario 
• Danielle DAmour, University of Montreal
• Judith Ritchie, McGill University Health Centre
• 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
• Thomas Ward, Consultant

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Background to Project

• Dramatic changes in leadership roles over past
  decade
• Wider scope of responsibility and span of control
• Managerial positions significantly reduced
• 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)
• Leadership gap" is developing in nursing

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Objectives

• Provide descriptive analysis of nursing
  leadership/ management structures at senior,
  middle, and unit 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 unit managers work

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• Conceptual Framework

Organizational Characteristics General
organizational structure and management
model Union management relationship Extent of
restructuring
Structural Leadership Characteristics Involvement
in Organizational Governance Involvement in
Senior Management Team Decisions Span of Control
Outcomes Empowerment Organizational
Support Decision Latitude Influence on HR/Policy
Decisions Role Satisfaction Job
Satisfaction Quality of Care Intent to Leave Job
Security Patients Ability to Manage Care at
Discharge
Integrative Mechanisms Coordination
Within Units Coordination Among
Units Communication Satisfaction
Personal Characteristics Demographics Self
Leadership Style Perception of SNL Leadership
Style Professional Identity
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Methods

• Data Collection Mail survey
• Sample Acute care settings within Academic
  Health Centres (AHC) and Community
  Hospitals (CH) with gt 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)

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Sample Senior Nurse Leader (SNL) nurse who
holds 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
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Response Rate by Management Level and Hospital
Type
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Average Age by Management Level and Region
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Professional Background by Management Level and
Region
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Highest Level of Nursing Education

• The following slide illustrates the highest level
  of nursing education for each level of
  management.
• Example
• In Western Canada, SNLs highest level of nursing
  education
• BScN 39
• Masters 44
• PhD 17

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Highest Level of Nursing Education by Management
Level and Region
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Highest Level of Nursing Education by Management
Level and Region
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Direct Reports by Level of Management
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Median Number of Direct Reports by Management
Level and Region
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Nursing Leadership Role Configurations

• An overall picture of the SNL role was determined
  by reviewing the organizational charts of all 66
  participating organizations.
• Two SNL role configurations were identified
• In total 84 had line authority for clinical
  programs and reported directly to CEO or senior
  VP/Director.
• In total 16 had staff authority with
  responsibility for professional practice
  personnel and reported directly to CEO or senior
  VP.

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Nursing Leadership Role Configuration by Region
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Role of Professional Practice Leader
Professional Practice Leaders (PPL) staff
position responsible for professional practice of
nursing within organization The number of sites
with a PPL role were identified in each province
and aggregated to the regional level.
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Professional Practice Leaders by Region and
Hospital Type
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Distinct Department of Nursing

• Hospitals with a distinct department of nursing
  were defined by a
• Central nursing departmental approach to the
  clinical operation of nursing
• Departmental structure for each discipline with
  control over human resources and budget

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Distinct Department of Nursing by Region
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Types of Staffing Mix by Region
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Nursing Involvement in Organizational Governance
Senior Team Involvement attend meetings of board
of governors, senior team and medical advisory
committees actively influence policy at these
levels (0no involvement 6high
involvement). SNL Comparable Salary and Title to
other executives with similar responsibilities
(0dissimilar 2similar). Staff Nurse
Participation membership on hospital-wide,
interdisciplinary, professional practice,
advisory committees (0no participation
5high participation).
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Nursing Involvement in Organizational Governance
2004/2001 Comparisons
Range 0 - 6
Range 0 - 5
Range 0 - 2

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SNL Decisional Involvement

• 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

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SNL Decisional Involvement

• For each type of strategic decision, the
  following were assessed
• timing (how early SNL involved in the process)
• 1beginning 5end of process
• scope (breadth of expertise offered)
• 1narrow/single area 5broad/many different
  areas
• number of decision making activities SNL
  engaged in
• raising issues, clarifying problems, generating
  alternatives, evaluating alternatives, choosing
  options
• 1few activities 5several activities

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SNL Involvement in Senior Management Team
Decisions CEO/SNL Comparisons
Range 1 to 5
High score more breadth
Low score early involvement
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SNL Involvement in Senior Management Team
Decisions CEO/SNL Comparisons
Range 1 to 5
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SNL Decisional Involvement

• For each type of SMT decision, the following were
  assessed
• SNLs influence over final decisions
• 1no influence 5great deal of influence
• Quality of senior management decisions in past
  6 months pertaining to
• 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
• 1do not agree 5strongly agree

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SNL Involvement in Senior Management Team
Decisions CEO/SNL Comparisons
Range 1 to 5
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Significant Changes Impacting SNL Role
SNLs were asked to report the most significant
changes that had occurred since they had assumed
the position (event and date). Most (50) had
assumed SNL role in 2000 or later. Summaries of
the responses were content analyzed.
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Significant Changes Impacting SNL Role
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Time Between Significant Changes to SNL Role
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Facilitators and Barriers to the SNL Role
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Decision Latitude, Participation in Decision
Making (Hage Aiken, 1967)
Decision latitude ability to make autonomous
decisions (1 never 5 always) Participati
on in Decision Making hiring/promotion of
professional staff, adoption of new policies/
programs (1 never 5 always)
36
Decision Latitude, Participation in Decision
Makingby Management Level and Region
Range 1 to 5
37
Perceived Organizational Support
(POS) (Eisenberger et al. 1986)
Employees generalized beliefs about extent to
which organization values contributions and cares
about well-being. Examples of items include
This organization strongly considers my goals
and values and This organization takes pride in
my accomplishments at work. 0strongly
disagree 6strongly agree
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Perceived Organizational Support by Management
Level and Region
Range 0 to 6
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Support for Professional Practice (Nursing Work
Index-Revised, Aiken Patrician, 2002)
Autonomy, 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. 1strongly agree 4strongly
disagree
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Support for Professional Practice by Management
Level and Region
Range 1 to 4
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Communication Satisfaction (Puttie, 1990)
Listening, honesty, and understanding between
themselves and their immediate
supervisor 1strongly disagree 7strongly
agree
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Communication Satisfaction by Management Level
and Region
Range 1 to 7
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Coordination Among and Within Units (Shortell et
al., 1994)

• Extent to which mechanisms contribute to
  coordination of staff activities and quality of
  care within and among units
• (1not at all effective 5very effective)
• Written rules, policies, and procedures
• Written plans and schedules
• Managers effort to coordinate activities
• One-to-one communication between staff
• Ad hoc group meetings
• Task forces and standing committees
• Regular patient care rounds

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Coordination Within and Among Unitsby Management
Level and Region
Range 1 to 5
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Extent of Restructuring
Extent of organizational restructuring and work
redesign that occurred within organizations
during past 3 years. Only selected components
are presented here. Responses included 1.
no current activity or planned action, 2. idea
is being explored, 3. plan has been developed,
4. initial processes implemented, 5.
processes being reviewed, 6. full integration.
Responses 2-5 were recoded to under
consideration.
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Changes in Managers Span of Control in Last 3
Years by Region
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Changes in Overall Staff in Last 3 Years by Region
48
Implementing Advanced Practice Nursing Roles in
the Last 3 Years by Region
49
Implementing Best Practice Guidelines in Last 3
Years by Region
50
Change in Quality of Care During Past Year by
Management Level and Region
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Confidence Patient Can Manage Own Care at
Discharge (Aiken Patrician, 2002)
Level of confidence that patients are able to
manage their care when discharged from
hospital Not at all confident Somewhat
confident Confident Very Confident
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Confidence in Patient Management of Own Care at
Discharge by Management Level and Region
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Empowerment

• Organizational structures that enable employees
  to accomplish work in meaningful ways
• Opportunity to learn and grow
• Information re values, goals, current
  activities of organization
• Support in the form of feedback and advice
• Resources necessary to do the job
• Informal power relationships with superiors,
  peers, subordinates
• Formal power visibility, flexibility

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Total Empowerment by Management Level and Region
Range 6 to 30
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SNL Empowerment Subscales by Region
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MM Empowerment Subscales by Region
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FLM Empowerment Subscales by Region
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Leadership Style (Kouzes Posner, 1994)

• Self-rated frequency of engaging in 5 leadership
  practices
• Enabling others to act
• Modeling the way
• Challenging the process within organizations
• Encouraging the heart of others through praise
• Inspiring a shared vision
• Overall leadership style score encompasses all
  5
• FLMs and MMs rated their SNLs leadership
  practices.
• 1almost never 10almost always

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Perceptions of SNL Leadership Styleby Management
Level and Region
Range 1 to 10
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SNL Self-Assessed Leadership Style by Region
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MM Self-Assessed Leadership Style by Region
62
FLM Self-Assessed Leadership Style by Region
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MM Perceptions of SNLs Leadership Style by Region
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FLM Perceptions of SNLs Leadership Style by
Region
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Job Satisfaction, Role Satisfaction and Job
Security
Job Satisfaction General satisfaction with their
job 1not at all satisfied 5completely
satisfied Role Satisfaction That they had
authority to do their job according to
expectations made on assuming the
role. 1strongly satisfied 5strongly
dissatisfied Job Security Likelihood of
losing job during the next 12 months 1very
likely 2fairly likely 3not likely 4not at
all likely
66
Job Satisfaction, Role Satisfaction and Job
Securityby Management Level and Region

Range 1 to 5
Range 1 to 5
Range 1 to 4