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JONA
Volume 47, Number 3, pp 159-164
Copyright B2017 Wolters Kluwer Health, Inc. All rights reserved.
THE JOURNAL OF NURSING ADMINISTRATION
Impact of Role Stressors on the Health
of Nurse Managers
A Western Canadian Context
Sonia A. Udod, PhD, RN
Greta Cummings, PhD, RN, FCAHS, FAAN
W. Dean Care, EdD, RN
Megan Jenkins, MPH, BSc
OBJECTIVE: A qualitative exploratory inquiry was
used to understand nurse managers_(NMs_) percep-
tions of their role stressors, coping strategies, and
self-health related outcomes as a result of frequent
exposure to stressful situations in their role.
BACKGROUND: Strong nursing leadership is re-
quired for desirable staff, patient, and organizational
outcomes. A stressed NM will negatively influence
staff nurse satisfaction and retention, patient out-
comes, and organizational performance. Stress can
affect NMs_mental and physical heath, leading to
job dissatisfaction and turnover.
METHODS: A qualitative exploratory inquiry was
conducted using semistructured interviews with
23 NMs and 1 focus group interview.
RESULTS: Findings suggest that coping strategies
may be inadequate, given the intensity and demands
of the manager role, and could negatively impact
NMs_long-term health.
CONCLUSIONS: Senior nurse leaders can signif-
icantly impact the health and productivity of NMs
by minimizing the adverse effects of role stress and
foster a positive work environment.
Nurse managers (NMs) play a pivotal role in today_s
healthcare environment, with emphasis on reducing
costs and increasing productivity. These factors
increase tension in management decisions, which
can have unanticipated consequences on NMs_stress
and performance. According to the most current data
from the 2003 Canadian Community Health Survey,
67% of head nurses and nurse supervisors report the
highest level of job stress among healthcare providers.
1
The cost of replacing an NM is estimated to be 4 to
5 times higher than what hospitals typically calcu-
late.
2
The cost is exacerbated by aging demographics
and younger nurses who view the NM role as demand-
ing, making it an unattractive option.
3
Evidence sug-
gests that NMs_stress level and performance have
direct effects on nurse satisfaction and turnover,
influence the quality of the work environment, and
can affect their mental and physical health.
4,5
Review of the Literature
The NM role is critical for ensuring a quality work-
place that influences organizational performance, nurse
satisfaction, empowerment, staff turnover, and patient
outcomes.
6-8
A complex workplace has increased
workload and span of control, increased demand for
efficiency, and increased regulatory requirements for
safe, quality patient care.
9,10
Nurse managers report a variety of health-related
outcomes resulting from frequent exposure to stressful
situations, such as adverse psychological outcomes
(feeling overwhelmed, heightened sense of awareness)
and adverse physiological outcomes (physical exhaus-
tion, sleep pattern disturbances).
5,11
Two Canadian
studies examined NM stressors and suggest the need
to better support NMs for the changing roles.
12,13
JONA Vol. 47, No. 3 March 2017 159
Author Affiliations: Assistant Professor (Dr Udod) and Grad-
uate Research Assistant (Ms Jenkins), College of Nursing,
University of Saskatchewan, Saskatoon, Saskatchewan; Professor
(Dr Cummings), Faculty of Nursing, Edmonton Clinic Health
Academy, University of Alberta, Edmonton, Alberta; and Dean
and Professor (Dr Care), School of Health Studies, Associate
Vice President, Teaching & Learning, Brandon University, Brandon,
Manitoba, Canada.
Funding was provided by Saskatchewan Health Research
Foundation through a New Investigator Establishment Grant.
The authors declare no conflicts of interest.
Correspondence: Dr Udod, Health Sciences Bldg, E-Wing
4346, 104 Clinic Place, University of Saskatchewan, Saskatoon,
Saskatchewan, Canada S7N 2Z4 (sonia.udod@usask.ca).
DOI: 10.1097/NNA.0000000000000459
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
These authors concur that healthcare organizations
cannot simply implement stress management train-
ing to cope; they must address the underlying orga-
nizational factors that influence the NM role.
The Mental Health Commission of Canada
14
highlighted the importance of reducing factors that
increase the risk of mental health illnesses in the
workplace. The manager_s inability to successfully
manage work stress has contributed to shorter tenure
in their role and created greater potential for lower
job satisfaction and burnout.
4,15
In a systematic
review, researchers found that the manager_sintent
to leave or stay is multifactorial as the manager con-
tends with financial constraints and a high turnover
of nurses.
16,17
This has resulted in increased role
stress for the NM and reduced organizational lead-
ership capacity.
18,19
Not surprisingly, managers are
highly susceptible to workplace stressors, making
this crucial segment of the nursing workforce vulner-
able to negative health outcomes.
11,20
Theoretical Framework
The conceptual basis of this study is Lazarus and
Folkman_s
21
Stress and Coping Theory involving the
dynamic relationship between a person and the en-
vironment that are interdependent in nature. Stress is
a multidimensional phenomenon determined by a
person_s perceptions and may be assessed as harm,
loss, threat, or challenge. During a stressful encoun-
ter, the person is appraising the situation to deter-
mine what is happening and what can be done. This
appraisal alters a person_s emotions by constructing
a new meaning of the encounter. Stress manifests as a
biopsychosocial response when the individual_s per-
ceptions of the work environment are seen as taxing
his/her resources and endangering well-being. Cop-
ing refers to the way in which an individual thinks
and acts within a specific context and is a continuous
appraisal of the shifting person-environment relation-
ship that has implications for whether the outcome
can be evaluated favorably or unfavorably.
Methods
Research Design and Purpose
The goal of this qualitative exploratory inquiry is to
understand NMs_perceptions of their role stressors,
coping strategies, and self-healthYrelated outcomes
as a result of frequent exposure to stressful situations
in their role. This study was conducted in urban and
rural acute care settings in western Canada. Quali-
tative methods provided opportunities for deeper insight
into the phenomenon.
22
Individual interviews and
focus group interviews are a way to triangulate data
collection by providing an audit trail and a rigorous
understanding of participants_reality rather than using
asinglemethod.
Lazarus and Folkman_s
21
Stress and Coping Theory
guided data collection and analysis. The concepts of
stress, coping, and organizational systems closely align
with the framework and extend Shirey_s
20
suggestion
of using various theoretical and methodological ap-
proaches to improve understanding of stress and coping.
Sample and Setting
Nurse managers were defined as frontline supervisors
of clinical nurses who have 24-hour/7-day-a-week
responsibility for their unit(s). Participants were
recruited through purposeful sampling and completed
demographic questionnaires, individual interviews
(n = 23), and a focus group interview (n = 5). Partic-
ipants came from 8 care facilities within 2 regions
representing both rural sites (39%) and urban sites
(61%). They were mostly women (91%) and ranged
in age from the category 26 to 61+ years, with the
majority (43%) falling into the 41- to 50-year cat-
egory. Nursing experience ranged from 0 years to
20 to 35 years, with the majority (57%) having 20 to
35 years of experience. The number of staff super-
vised varied from 26 to 500 people, with 52% of man-
agers having more than 100 individuals to supervise.
The average number of years as an NM on their
current unit was 5.0 years.
Data Collection Procedures
Once the project received approval from the university
research ethics board and participating healthcare
agencies, contact was made with senior nurse admin-
istrators in each health region. To ensure confidenti-
ality, a facility administrative assistant sent an
introductory e-mail, providing details about the study.
Participants interested in participating in the individ-
ual interviews responded to the research assistant.
Five of the 23 participants who agreed to an indi-
vidual interview volunteered to participate in the
focus group. The focus group interview was facili-
tated by the nurse researcher, and field notes taken by
the research assistant. Participants were asked to
maintain the confidentiality of the session.
Data Analysis Procedures
Transcripts were stored and managed using NVivo
10 qualitative software (QSR International, Burlington,
Massachusetts) to code data segments relevant to emerg-
ing phenomena. Transcripts were coded using the
procedures of thematic analysis based on Braun and
Clarke_s
23
6-phase approach to enhance rigor. The
interview transcripts were read, and participant phrases
and sentences indicating the role stressors and coping
160 JONA Vol. 47, No. 3 March 2017
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
strategies of the managerial role and self-health related
outcomes were noted. Then, initial codes were gener-
ated in a systematic fashion. Operational definitions
were written in a codebook gathered from the interviews
and analyzed in a consistent and rigorous process.
Analytic processes from grounded theory such as
concurrent data generation and analysis and constant
comparison of data were used to identify and analyze
patterns of meaning (themes). Finally, refining the
themes and subthemes into a thematic map produced
a conceptualization of the data patterns and relation-
ships. Table 1 summarizes the themes and subthemes
of the role stressors and coping strategies affecting
NMs_self-healthYrelated outcomes.
Findings
Role Stressors
Subtheme 1: Working With Limited Resources. All
participants described their roles as working with
limited resources (budget and staff) in the day-to-
day operation of managing a patient care unit(s).
BThe budget[was part of the manager_s everyday
language and was a cost-conscious activity driven
by economic efficiency and organizational productiv-
ity. All participants reported that budget and staffing
shortages dictated how many nurses could be sched-
uled and if overtime could be provided. As 1 partic-
ipant noted, BThere is always a challenge for adequate
resources and that we_re providing safe care[and is at
the Bvery forefront in our minds.[
Subtheme 2: Responding to Continuous Change
Within Organizational Work Complexities. All partic-
ipants referred to organizational processes that are
cumbersome and inefficient, while simultaneously
responding to a continual flow of new initiatives that
included the Lean management system, models to
enhance patient flow, and improving the delivery of
care. One participant commented, BIright now we_re
in the Kaizen Lean journeyIthe pressures from that
are very overwhelming.[
Significant energies were invested in redirecting
the organization through new initiatives to improve
quality of care, move patients through the system, and
improve financial outcomes. Participants worked dili-
gently with staff to cultivate practices to realize the
desired cultural change despite their own escalating
workloads. At times, participants had difficulty artic-
ulating the pressures, as explained by 1 participant:
There_s a real disconnecttoward doing Lean that is a
real priority, but it_s [Lean] completely adverse to
how we functionI. You need to be on the gemba
[the unit], but it_simpossible.
Dealing with organizational change became
integrated into manager_s daily work challenging
their ability to prioritize managerial responsibilities
and feel successful in their role.
Subtheme 3: Senior Management_s Disconnection
From Practice. Participants referred to a perceived
lack of understanding and support by middle (direc-
tor) and senior healthcare management regarding the
reality of practice environments and the extent to
which NMs could facilitate change and how staff
believed things should be done. Participants indicated
directors did not always have the experience and edu-
cation to appreciate the complexity of care on the unit
and that Bhow they manage throughout the organi-
zation needs a complete overhaul.[
When the participants were comfortable enough
with their directors to voice another viewpoint, they
described it as Bswimming upstream, always against
the current.[One participant went as far as to say,
BYou jus t f e e l like y o u _rebeatingyourheadagainst
the wall; you feel no one_slistening.[
Coping Strategies
Subtheme 1: Planful Problem Solving. In order to
minimize stress and/or prevent issues from arising,
participants assumed a proactive approach to
solving problems in their tasks and encounters
with staff by being visible on the unit, building
relationships, and supporting staff. One participant
begins the workday by Ba loop around the facility[
to determine what needs immediate managerial at-
tention to ensure smooth care delivery. Another
participant referred to coordinating a physician_s
schedule to ensure smooth delivery of care:
You are trying to arrange things, but it_s dependent
on several different factors. For example, I have to
book a C-section within a 1-week timeframe. Sounds
easy, so which room is slightly booked to capacity
but not overbooked? Out of the 5 days, I narrow it
down to 1 day.
Table 1. Role Stressors and Coping Strategy
Themes
Theme Subtheme
Role stressors Working with limited resources
Responding to continuous change
within organizational work
complexities
Senior management_s disconnection
from practice
Coping strategies Planful problem solving
Reframing situations
Having social support
Health outcomes Psychological and physical effects
and family and personal strain
JONA Vol. 47, No. 3 March 2017 161
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
Another participant stated she collaborates with
staff to prevent issues from arising, as she explained:
I meet staff at 7 o_clockIwe do our huddle, and we
talk about the day, then we_ll troubleshootIif we
have sick calls or whatever the staff are self-directed
to call people in, or if they have trouble, they let me
knowI
Subtheme 2: Reframing Situations. All partici-
pants referred to a psychological process that involved
reflecting, reorienting, and reconciling situations as a
way to decrease anxiety and fear. Participants under-
stood coworkers_pressures and attempted to cope
with the situation in varying ways such as taking the
initiative in Bdoing it my way[and Bletting it roll off
my back[in developing resilience in the role. Partic-
ipants made deliberate choices on how and under
what circumstances to respond to work demands. As
1 participant explained:
I will sometimes get into hot water with not at-
tending as many meetings. I believe my job is there
[on the unit]. I like to see meetings that have value, if
it_s something that I need to move forward, and it_s
going to benefit our facilityISo if it_s not, then my
place is at work [unit].
Subtheme 3: Having Social Support. The ma-
jority of participants addressed the importance of
psychosocial support and nurturing they received
from superiors, colleagues, family, and friends. One
participant stated that her family Blike to camp and
get outIwe certainly get away, and you need to do
that.[All levels of management were a significant
support to participants in various ways as they
provided a sounding board to vent, shared ideas,
and provided guidance to navigate the intricacies of
the role. One participant shared her experience:
The previous manager of emergencyIcoached me
into this job. I have a tremendous amount of
respect for my director. It_s probably one of the
reasons that I stay in this job is because I do have a
profound respect for herI.
Health Outcomes. Participants described a var-
iety of health-related outcomes as a result of frequent
exposure to stressful situations in their role that
included psychological effects, family and personal
strain, and physical effects. From a psychological
perspective, participants frequently reported they
had difficulty doing a job they believed valuable for
staff that included coaching staff and conducting per-
formance appraisals, as they were often called to
resolve crises. As a consequence, a prevalent theme
across interviews suggests that managers experienced
cues that made them feel so acutely stressed out they
could Bnot turn it off at the end of the day[and were
unable to convey in words the emotional exhaustion
they felt. Some reported experiencing depression and
seeing a counselor as they navigated challenging work
environments. Some managers referred to having bad
days and taking it out on their spouse and family.
From a physical perspective, several NMs indi-
cated they knew the value of exercising regularly but
often Bdon_t nearly have the time or the energyIto
exercise,[leading to weight gain and sometimes
weight loss, and often had Bsleepless nights thinking
of all the things that you have open in your brain that
you need to do.[
Discussion
Results support the application of Lazarus and
Folkman_s
21
Stress and Coping Theory as a method
of understanding the relationships among the NMs_
work environment, their stressful encounters, cop-
ing strategies, and perceptions on their health.
Based on the findings in this study, NMs have
severely high levels of role stressors. While there is
evidence of coping strategies, the available psycho-
social resources may be inadequate for the short- and
long-term health outcomes of NMs. The most com-
mon source of role stressors was related to workload
in the context of increasingly stretched resources
situated within a context of an evolving and growing
unrealistic expectations of the NM role. Pressures
related to responding to organizational initiatives,
cumbersome and complex bureaucracies, and senior
administrators_perceived lack of understanding of
patient care demands are consistent with manager
role stressors found by other researchers.
4,5
Because health services are publicly funded and
administered on a provincial or territorial basis in
Canada within guidelines set by the federal govern-
ment, each organization within a health region needs
to deliver care within a set budget. Faced with mount-
ing pressure to address spiraling costs and inefficien-
cies, the Ministry of Health in a western Canadian
province made a multimillion dollar investment in the
Lean management system to enhance quality and safety
of patient care while reducing costs.
24
As with any
large-scale change, NMs were pivotal to this effort.
Proactive, planned problem solving, social sup-
port, and reflecting, reorienting, and reconciling sit-
uations are some of the ways NMs counteredthe role
stressors. Managers who participated in problem-
focused coping strategies such as focused and
deliberate problem solving suggest they were able to
influence and control the work situations.
21
Man-
agers knew what needed to be done and developed a
plan of action to respond to a problem. Other studies
have found that social support is a common way of
162 JONA Vol. 47, No. 3 March 2017
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
coping.
5,13
This could suggest that NMs often use
planned problem solving and social support in staying
ahead in their role.
In this study, negative health outcomes could be
associated with severely high workloads. These
findings could suggest that coping strategies may be
inadequate, given the intensity and demands of the
role. Mental health issues may manifest as depres-
sion, anxiety, or somatic illness. The coping strategies
may temporarily Btake the edge off[and give a sense
of relief from stressors but fail to address the fund-
amental cause of the stressor and may be insufficient
for the manager_s long-term health. Laschinger et al
18
found that although NMs reported high levels of
burnout, they reportedly experienced good mental
and physical health; however, middle managers were
more empowered than NMs. Managers may be
internalizing the stress leading to maladaptive coping
strategies, decreased mental and physical well-being,
and/or leaving the role entirely.
Implications for Nurse Leaders
Senior administrators can impact the health and pro-
ductivity of NMs through focused interventions that
reduce the negative effects of mental and psycho-
logical stress in managers. Table 2 reflects suggested
interventions for stress subthemes. The findings
clearly support the need for leadership development
to decrease NM stress and improve their sense of self-
efficacy.
19
Evidence suggests that learning on the job
without the benefit of formal educational programs
and lacking feedback on performance causes man-
agers_stress and job dissatisfaction.
25
Creating a social
support system and work climate that improves role
expectations and promotes feeling of belonging in a
community of like-minded individuals with shared
concerns provides managers with time and opportu-
nity to build their social support networks.
25
Second, managers need to be involved in rede-
signing their role that could include implementing a
comanager model. This model is a managerial
intervention that employs 2 full-time managers for
1unit.
26
This change has been suggested elsewhere
in the literature that could decrease employee turnover
and make the role more appealing to potential re-
cruits.
5,13,26
Nursemanagersmaybebetterableto
divert more energy to coaching, mentoring, and
strengthening relationships with staff that could lead
to improved staff and patient outcomes and sow the
seeds for succession planning. Because NMs bear a
major responsibility for 24/7 hospital unit care, the
findings from this study should inform decision
making by senior nurse leaders.
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