Identifying needs of the caregiver

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Content Identifying Needs of the Caregiver
by
Kimberly L. Morton
Rossier School of Education
University of Southern California
A dissertation submitted to the faculty
in partial fulfillment of the requirements for the degree of
Doctor of Education
May 2023

© Copyright by Kimberly Linsand Morton 2023
All Rights Reserved

The Committee for Your Full Name certifies the approval of this Dissertation

Dr. Esther Kim
Dr. Frances Kellar
Dr. Rufus T. Spann, Committee Chair

Rossier School of Education
University of Southern California

2023

iv

Abstract
Nursing is a high stress profession where critical thinking skills are needed to ensure the delivery
of efficient patient care. Nurses, as caregivers, work in critical care areas where the expectation
is to set their own personal challenges aside to perform the duty of taking care of patients at the
most vulnerable times of their lives. Self-care and the ability to maintain wellness at work may
be neglected by nurses at times, due to personal commitment in role performance. This study
examines the ability of nursing leadership to discern when unit nurses are compromised. A
mixed method study was conducted to examine the responses from 10 Nurse Administrators and
their responses to their unit nurses when working under crisis. Due to role expectations, unit
nurses themselves may not have the ability to place self-care as a priority, therefore omitting
well-being. The role of nursing leadership is imperative within healthcare organizations to coach,
advise and mentor their direct reports. Nursing leaders who lack assessment skills to recognize
compromised staff play their role in compromising healthcare systems as well as patient care
outcomes.
Keywords: nursing leadership, health care organizations, chief nursing officer, director of
nursing, human resources

v

Dedication
To God-thank you! To both my parents who were God assigned, I could not have achieved this
without your eternal love. I know that you are both smiling down from heaven, and you have
sent daily prayers of encouragement. Mom wanted me to be a Nurse and Dad wanted me to “get
that Doctorate”. This is for you Dad!
To my Daughter, I appreciate your patience. It was not easy watching and waiting for “mom” to
return, you helped me get to the finish line by speaking my future success into its existence.
To my family and friends, thank you for understanding and all your support from the beginning
to the end. Sincere appreciation.
To all the nurses, from student nurses, novice nurses, managers, directors, executives, and chiefs:
do not give up on our profession. We have come too far to turn around. What would the world be
without us? Who can take care of anyone better than us? Nurturing is a gift from God and that
nurse is you! We are the caregivers to others that we must be to our nurses.
For the rest of my life, unto the profession of Nursing, I will serve thee, with compassion, service
and heartfelt empathy, Hand over heart, grace at all times, a nurse willing to serve is a friend of
mine.

vi

Acknowledgments
I am grateful to all of those at the University of Southern California with whom I have had the
pleasure to work during this and other related projects. I appreciate being a part of Cohort 17 and
sharing this doctoral experience with my peers. Each of the members of my Dissertation
Committee: Dr. Kim, Dr. Kellar, and my Chair-- Dr. Spann, have provided me with extensive
personal and professional guidance while simultaneously teaching me a great deal about both
mixed method research and life in general.
This was an independent research study. The researcher is a licensed professional registered nurse.
There is no conflict of interest in the study. No financial support for participant recruitment was
needed for this study.
Correspondence concerning this dissertation should be addressed to Kimberly L. Morton,
University of Southern California, 3551 Trousdale Parkway, Los Angeles, CA 90089. Email:
klmorton@usc.edu.

vii

Table of Contents
Abstract .......................................................................................................................................... iv
Dedication ....................................................................................................................................... v
Acknowledgments.......................................................................................................................... vi
List of Tables .................................................................................................................................. x
List of Figures ................................................................................................................................ xi
List of Abbreviations .................................................................................................................... xii
Chapter One: Introduction .............................................................................................................. 1
Introduction of the Problem of Practice .............................................................................. 1
Context and Background of the Problem ............................................................................ 2
Purpose of the Project and Research Questions .................................................................. 2
Importance of the Study ...................................................................................................... 3
Overview of Theoretical Framework and Methodology .................................................... 4
Definition of Terms............................................................................................................. 7
Organization of the Study ................................................................................................... 8
Chapter Two: Review of the Literature .......................................................................................... 9
Problem Statement .............................................................................................................. 9
Literature Review................................................................................................................ 9
Conceptual Framework: Burke Litwin Model .................................................................. 29
Summary ........................................................................................................................... 34
Chapter Three: Methodology ........................................................................................................ 35
Research Questions ........................................................................................................... 35
Research Design................................................................................................................ 36
viii

Research Setting................................................................................................................ 38
Positionality ...................................................................................................................... 38
Participants ........................................................................................................................ 40
Instrumentation ................................................................................................................. 40
Data Collection Procedures............................................................................................... 43
Validity and Reliability ..................................................................................................... 48
Ethics................................................................................................................................. 49
Underlying Ethics ............................................................................................................. 49
Limitations and Delimitations .......................................................................................... 50
Chapter Four: Results or Findings ................................................................................................ 52
Participants ........................................................................................................................ 52
Results and Findings for Crisis Recognition .................................................................... 55
Discussion Research Question One .................................................................................. 59
Results and Findings for HR Support ............................................................................... 60
Discussion Research Question Two.................................................................................. 71
Results and Findings for Peer Support Specialists ........................................................... 72
Discussion Research Question Three................................................................................ 77
Conclusion ........................................................................................................................ 77
Chapter 5: Recommendations ....................................................................................................... 80
Recommendations for Recognizing Crisis........................................................................ 81
Implications for Practice ................................................................................................... 92
Future Research ................................................................................................................ 93
Conclusion ........................................................................................................................ 94
ix

References ..................................................................................................................................... 97
Appendix A: Survey Demographic Questionnaire ..................................................................... 111
Appendix B: Interview Questionnaire ........................................................................................ 114

x

List of Tables

Table 1: Table Name Here, 40
Table 2: Table Name Here, 44

xi

List of Figures
Figure 1: Transactional Factors 4
Figure 2: Transformational Factors 5
Figure 3: Revised Burke-Litwin Model 6
Figure 4: Burke-Litwin Model 33
Figure 5: Mixed Method Case Study Design 36
Figure 6: Human Resources Reported Occurrences Among Nursing Leaders 62
Figure 7: S.M.A.R.T. Goals to achieve Nurse Leadership 82

xii

List of Abbreviations
AACN American Association College of Nursing

ANA American Nurses Association

CNO Chief Nursing Officer

HR Human Resources

PTO Paid Time Off

RN Registered Nurse
1

Chapter One: Introduction
Introduction of the Problem of Practice
Nursing represents a profession of compassion where the dynamic of the work setting
calls for resilience in fast-paced high-stress environments. The challenge for those who choose
to take on this caregiver role as a professional nurse is the ability to balance competing priorities
between patient needs, organizational goals, and managing self-care (Laschinger et al., 2014).
Formal education prepares one to become a nurse in addition to passing the state licensure exam.
Nurses are deemed competent when they can demonstrate clinical skills according to practice
standards set by governing bodies of the profession such as the American Nurses Association
(Beckham and Riedford, 2017). As these skills are taught to ensure life-saving measures for the
patients, there is a growing concern about exhausted caregivers and the responsibility held with
safeguarding nurses who lose sight of their own health.
This study examines the role of nurse leaders, as managers or above, and their ability to
identify nurses who are working under personal crisis while providing patient care. Nurses serve
as health care advocates while placed at the front line of care. Society, at large, views nursing as
one of the most respected professions but 29.5% of new graduates reported a desire to leave the
profession due to constant stress and helplessness (Oates, 2018). Registered nurses are also
identified as key personnel in patient safety. There are over 3 million nurses employed within the
United States (U.S. Department of Labor Statistics, 2020). The health and well-being of nurses is
vital to the health and well-being of their patients (Oates, 2018). While there have been extensive
studies on nursing burnout, limited research has been documented on preparing nurse leaders to
address the 45% of nursing staff who report to work consistently overwhelmed due to poor
2

work/life balance (Black, 2012). Nurse leaders must address this growing issue within nurse
professional practice as increased stressors lead to poor patient outcomes that include but are not
limited to interrupted patient care, medication errors or patient mortalities (Hall et al., 2016).
Context and Background of the Problem
While much has been written about the nursing shortage and nurse burnout, there is less
research on the management role in supporting staff who find themselves working through
crises. A public health crisis, such as the Covid-19 global pandemic highlighted the perils of
nursing where the urgency in response to patient care safety revealed the pitfalls in maintaining
staff safety (Branden, 2020). Professional bodies of nursing emphasize the importance of placing
the needs of the patient first but, at the expense of the healthcare workers, patient safety is
compromised (Wood, 2018). Nursing leadership finds itself maintaining the balance of patient
care and staff needs by attempting to manage the revolving door of staff nurses. Nurses depart
from health care organizations when their immediate needs are not met by the healthcare facility
(Bautista et al., 2018). Nurses need multiple levels of support to foster their well-being. The
nurse manager, along with human resources (HR), was identified as the clinical leader to
promote the professional nurse position (Mozaffari et al., 2015). The repeated theme of
collaborative relationships between healthcare facilities and nurse managers continues to be
highlighted in academic research (Moisoglou et al., 2020). In the current state of nursing crisis,
the prioritization for nurse well-being must be placed at the forefront of human resources (HR)
instead of last resort, in order for nursing to thrive.
Purpose of the Project and Research Questions
The purpose of this project seeks to analyze data collected from nurse managers that
will support the leadership role in supervising nursing staff who provide patient care in high-
3

stress critical care areas. The analysis will begin by using responses from the interview questions
which assess nurse managers’ knowledge of unit culture, staff personal/professional needs, their
role in human resources and value of the peer support nurse. The questions that will guide this
study are as follows:
1. In what ways are nursing leaders positioned to recognize when nursing staff is in crisis,
needs support or identifies as feeling compromised working in high level stress
environments?
2. To what extent do nurse leaders engage in partnering with HR to determine or enact
relevant employee policies and practices that support nursing staff?
3. How do health care organizations use informal peer support systems to support the nurse
leadership/line staff relationships during periods of high stress/crisis?
Importance of the Study
As leaders, nurse managers are prepared to support clinical ineptness for new graduate
nurses as well as support seasoned nurses with acute patients. With increased staffing shortages
and health care crises, nursing as a profession faces additional pressure that requires compassion
in adequate working conditions (James & Bennett, 2020). The working conditions require a
change in leadership approach. When nurse leaders focus on command and control or target-
driven approaches, it demoralizes staff and leads to poor patient care (Ahmed, 2018). This
research study will probe current views held by nurse managers who are responsible for patient
care in high-stress areas. The data analyzed along with the current literature review will serve as
a guide to close gaps and provide a roadmap used by management as support pathways for their
teams. It is imperative that nurse leaders emphasize the need for value-based self-care (James et
al., 2020). Focusing on self-care values may be a challenge in current working conditions,
4

therefore continued research to support nurse managers will promote nurse wellness and patient
care success.
Overview of Theoretical Framework and Methodology
The Burke-Litwin model of organizational performance and change (1992) serves as the
theoretical framework for evaluating the problem of practice. This model identifies 12 elements
of change in leadership which have bidirectional relationships with one another (Burke and
Litwin, 1992). There are eight transactional factors: structure, management practices,
systems/policies, unit climate, task/skills, motivation, individual needs, skill, and
individual/organizational performance. The transactional variables represent the idea of an
exchange between leadership and team (Burke and Litwin, 1992). Figure 1 illustrates a version
of this model.
Figure 1
Transactional Factors

Note: From A Casual Model of Organizational performance and change, Journal of
Management, 18(3), 523-545. Burke, W. W. & Litwin, G. H. (1992).
5

The remaining four factors are transformational variables which include: mission, strategy,
leadership, and culture. Transformational variables represent areas where change is caused by
environmental forces that will require change in behavior from members within the organization
(Burke and Litwin, 1992). The Burke-Litwin model has both internal and external factors which
demonstrate the impact of leadership on the overall organization. The internal factors highlight
management roles within the organization, whereas the external factors demonstrate the
outcomes of leadership (Burke and Litwin, 1992). Figure 2 illustrates a version of this model.
Figure 2
Transformational Factors

Note: From A Casual Model of Organizational Performance and Change, Journal of
Management, 18(3), 523-545. Burke, W. W. & Litwin, G. H. (1992).

6

The revised version of the Burke-Litwin model offers the perspective of the impact between
internal/ external context on leadership and organizational performance with four themes:
Leadership is at the forefront of strategy, distinguished management level, process & efficiency,
and outcome levels with efficacy measures (Spangenberg &Theron, 2013). The adaptation of
the revised model consists of contextual factors demonstrating how the external environment and
individual performance represent outcomes (Spangenberg & Theron, 2013). In Figure 3 the bi-
directional arrows pointing in all directions represent an open system, where change in one
element will affect all the others.
Figure 3
Revised Burke-Litwin Model

Note: From A critical review of the Burke-Litwin model of leadership, change and performance
management, Management Dynamics, 22(2), 29-28. Spangenberg, H. & Theron, c. (2013).
7

Definition of Terms
The following relevant terms provide clarity on the verbiage within health care when
discussing health care organizations and nursing role differentiation, The researcher has provided
the definitions below as these terms are used throughout the research study, literature review and
data analysis.
Accreditation: the process by which a health care institution, provider or program undergoes
external peer assessment to demonstrate compliance with standards developed by an official
agency which strengthens community confidence in the quality and safety of care and treatment
services (Kuwaiti and Al Muhanna, 2019).
Credentialing: term applied to processes used to designate that an individual program,
institution, or product has met established standards set by governmental or non-governmental
recognized as qualified to carry accreditation approval, recognition, or endorsement (American
Nurses Association,2022).
Crisis: a substantial change in usual health care operations and the level of care it is possible to
deliver, which is made necessary by a pervasive or catastrophic disaster (Berlinger et al., 2020).
Leadership: a nursing health care professional who has the passion to excel in the health care
sector through the application of nursing leadership skills and principles. Nurse with oversight of
organizational structure and lead nursing teams in providing patient care (Hill et al., 2014).
Management: responsibility for oversight of the department including planning, organizing,
supervising, hiring and/or termination, directing daily processes, and instructing nursing staff
through hands-on approach to ensure the efficacy of patient care and treatment planning (Ahmed,
2018).
8

Registered Nurse: a compassionate, dedicated professional who has completed a rigorous
program of extensive training, obtained state licensure, and demonstrated critical thinking to care
for patients’ biological, physical, and behavioral needs. Key responsibilities include but are not
limited to:
• Perform physical exams and health histories before making critical decisions.
• Provide health promotion, counseling, and education.
• Administer medication and other personalized interventions.
• Coordinate care in collaboration with a wide array of healthcare professionals.
(American Nurses Association, 2022).
Organization of the Study
The dissertation follows a traditional five-chapter model. Chapter One highlighted the
significance of the research, its impact on nursing, concepts, and terminology. Chapter Two
provides a review of current literature, including the conceptual framework for the study. The
literature review includes insight into what nurses working under crisis scenarios encounter and
the current practices amongst nursing leadership. Chapter Three outlines the research
methodology, including the selection of participants data collection and analysis of data results.
Chapter Four provides the results and findings (qualitative). Chapter Five details the discussion,
the proposed recommendations based on data and literature, closing perceived gaps in nursing
practice as well as recommendations for implementation and evaluation plan for the solution in
nurse management.

9

Chapter Two: Review of the Literature
Problem Statement
This paper addresses the problem of nursing leadership and their role in identifying
nurses working while compromised from lack of well-being. As a profession, nursing
contributes to the largest portion of health care with over 3 million nurses being employed within
the United States (U.S. Department of Labor Statistics, 2020). While nursing is identified as one
of the most respected healthcare professions, it is also identified as one of the most stressful
healthcare occupations, where there is a nursing crisis on the rise from lack of self-care (Oates,
2018). The evidence highlights that burnout and compassion fatigue were identified as leading
indicators where 63.7% of nurses surveyed reported the need for psychological support (Yildirim
et al., 2020). This problem is important to address because a lack of recognition leads to
increased medication errors, patient safety risks, unsatisfactory patient care, or even worse,
patient fatalities (Hall et al., 2016).
Literature Review
This review covers literature that examines the issues related to crisis support needed for
registered professional nurses. The articles reviewed highlight stressors which impact quality of
work life leading to challenges nurses face such as depression, anxiety, lack of self-care,
caregiver role strain and increased job turnover. Although there has been much research on
nursing burnout, there is a lack of consistency in educating nursing leadership to provide support
for staff well-being as a priority of patient care (Branden, 2020).
Nurse Well-Being
The role of the nursing professional is to focus on successful outcomes for patient care,
where patients hospitalized due to illnesses become well by achieving optimal health. The well-
10

being of nurses is essential to these patient outcomes because the combination of negative
mental, physical, or emotional states impact patient safety (Oates, 2018). The quality of work
life to support nursing well-being is reflected in a work environment where employees report an
increased sense of job satisfaction and limited psychological stressors that affect the ability to
function in their work environment (Jayaraman & Chandran, 2010). It is critical that nurses
receive support from their healthcare organizations to develop resilience (Croke,2021).
According to the cross-sectional study by Kim et al., 2019, factors such as workplace bullying,
compassion fatigue, and secondary trauma from increased stress led to decreased professional
quality of life and increased nursing turning over rates. Workload was also identified as a
contributing factor to nurse stressors where 89% of nurses surveyed reported increased non-
bedside tasks due to shortage of nursing staff (Bautista et al., 2019). Nursing stressors extend
more when they play a key role in the global healthcare crisis, where they are often asked to
remain flexible despite risking their own health to provide care for patients (Wood, 2018). In
healthcare crises such as Ebola, H1N1, and more recently, Covid 19 nurses reported a lack of
work environment coping skills (Branden, 2020). Nurses reported reluctance to ask their
colleagues how they are coping during stressful times because each one had to focus on their
own self-care (Billings et al., 2021). Human factors such as stress and anxiety, that contribute to
a lack of nurse well-being also contribute to adverse patient outcomes (Hall et al., 2016).
Healthcare organizations must reconsider staffing levels which affect nursing, patients, and
system outcomes (Horrigan et al., 2013). According to Deans, 2019 in a well-being survey, 76%
of nurses interviewed reported that they did not have time for a break while working an eight-
hour shift. Managers may not be aware that their staff is suffering from forms of fatigue due to
being preoccupied with their own deadlines (Moore, 2020), Nurse leaders must be visible to their
11

staff to address well-being and openly acknowledge their stress (Croke, 2021). Quality of work
life is measured by the favorableness of the job environment with management’s ability to solve
problems (Jayaraman & Chandran, 2010). The consequences of not looking after the staff’s
well-being places harm to nurses’ physical and mental health.
Work Culture and Organizational Acuity
With the increase in nursing shortages, increased stress directly impacts high-acuity areas
such as emergency rooms, surgical areas, and intensive care units. Stressful workplace
conditions create a climate of toxic work environment where a nurse’s professional quality of life
has been deemed a serious social issue (Kim et al., 2019). Nurses reported the stressors from
staff shortages in these departments also led to caregiver fatigue (Branden, 2020), The increased
nurse-to-patient ratios, increased workload, and mandatory overtime create a multifaced problem
for which front-line nurses do not have any control (Gorman, 2019). These identified stressors
lead to loss of productivity at estimated cost at over $11, 581 per nurse (Laschinger et at., 2014).
Health care organizations have acknowledged that the current working culture for nurses has
changed (Jayaraman & Chandran, 2010). According to the study conducted by Kim, et al. 2019,
nurses with less than 5 years of experience have higher burnout rates compared to senior staff
with greater than 10 years of nursing experience. In the study conducted by Hall et al., 2016,
70% of nursing errors were made by nurses who identified as being “burned out” while at work.
Increased demands and lack of staff satisfaction in the workplace create high-pressure
environments where trends are reflective of low retention rates for new graduates (Gorman,
2019). Aside from increased work demands, nurses experience pressure from their peers that
affect the quality of their work environments (Jayaraman & Chandran, 2010). Nurses who work
in high-acuity areas may also face patient families who are under distress, suffering, scared, or at
12

times become violent (Valdez, 2019). Whether patient families or peers, it has been an ongoing
debate about whether to consider nurses as healthcare workers victims (Marran, 2019). The
narrative attributed to nurses, as frontline workers from their health care organizations, is to
remain positive and see the challenges as an everyday part of the job (Billings et al., 2021).
Nurses are labeled as resilient for their ability to rise to the occasion with increased demands on
their energy but, working under this caveat poses an increased risk to patient care (Branden,
2020). Furthermore, nurses have grown tired of being labeled resilient as it tends to give a frame
of thought for healthcare organizations that increased demands are justified (Branden, 2020).
Supporting evidence from nursing scholars have discovered, within healthy work environments,
a nurses’ well-being is secured when they can provide quality patient care which enhances
society at large. (Bragadottir, 2016). Nurses attempt to cope with personal and professional
crises by continuing to show up for work despite these challenges.
Workplace Toxicity and Crisis
The inability to cope with workplace stressors may bring about a professional crisis in the
form of anxiety, depression, substance dependence, absenteeism, inability to retain nurses, and/or
peer-to-peer episodes of aggression. These identified stressors are also housed under the tenets of
compassion fatigue, relatively associated with burnout. Although very similar, compassion
fatigue occurs most often as the result of being exposed to another individual’s trauma (Sorenson
et al., 2016). Burnout is characterized by El-bar et al. (2013) as the result of powerlessness and
decreased job satisfaction. Nurses have been labeled numb in attempting to balance the area of
compassion when their work culture is strategically focused on performance base measures
(Upton, 2018). Increased demands to save patient lives during unpredictable work pace stressors
create insecurities related to job performance (Epstein et al,.2010). Nurses struggle to filter the
13

growing demands in the workplace and downplay the challenges faced amongst work culture.
Within the United States the result of anxiety, depression, substance use, etc., has led to
increased caregiver shortage, coupled with growing job dissatisfaction (Hall et al., 2016). In the
cross-sectional study by Bautista et al., (2019) it was discovered that a heavy workload was
identified by 31% of nurses surveyed to be the specific stressors that led to job dissatisfaction.
Even if nurses identified as being depressed, they reported feeling capable of handling patient
care needs (Oates, 2018). Nurses choose to be physically present at work to facilitate the needs
of patients over attending to self-care needs.
Nursing staff arriving to work knowing they are not mentally or physically doing well is known
as presenteeism (Black, 2012). Presenteeism impacts healthcare organizations with a decrease in
productivity (Mohammadi et al., 2021). In addition to presenteeism, the conditions of the work
environment contribute to quality outcomes for the patient and nurse (Brewer & Verran, 2013).
Healthy work environments are now being proposed as a social determinant of health for nurses
because it defines the standard of quality where a nurse provides patient care (Bragadottir, 2016).
According to the qualitative study by Mohammadi et al., (2021), it was determined by analysis
that nurse managers reinforce presenteeism due to nursing shortage/lack of nursing staff.
Presenteeism showed greater amongst 71% of staff, ages 21-30, who worked longer hours as
pressured by their nurse managers (Black, 2012). Nurses who expressed being overworked
reported more about the acuity in patient caseloads with less staff than working longer hours for
a shift (Jayaraman & Chandran, 2010). If nurses perceived increased changes within a single
shift, such as admissions, discharges, or transfers becoming excessive it may affect their practice
knowledge (Brewer & Verran, 2013). The survey conducted by Silva et al., (2019) found that
55.6% of nurse respondents reported working overtime in the past six months and averaged 36
14

hours of overtime completed per staff member. In future research studies, academic nurse
researchers plan to use the concept of presenteeism to measure work-life quality (Bragadottir,
2016). Nurses who are present for work physically but are not mentally prepared to provide
patient care are at risk for other means to cope with stress.
Workplace conditions that lead to counterproductive behaviors are defined as toxic or
uncivil (Laschinger et al., 2014). The professional quality of life for nurses continues to be
compromised by these behaviors as they fulfill the role of taking care of patients. Toxic
characteristics of nurses are associated with fatigue which are also linked to negative behaviors.
Workplace incivility such as violence, aggression, and intimidation are deemed deviant, with a
prevalence rate as high as 19% (Laschinger et al., 2014). Nursing researchers have discovered
that of these occurrences, 80% of nurses surveyed found workplace bullying to be the most
emotionally exhaustive (Kim et al., 2019). In the case study presented by Wood (2018),
excessive criticism by nursing colleagues led to participants’ reduced self-confidence as
registered nurses. Poor self-esteem was a repeated theme in the research conducted by Hall et
al., (2016) which led to depressive episodes affiliated with increased medication errors in patient
units. In extreme cases of depression where suicidal ideation, self-harm, or suicidal attempts
were prevalent, nurses abandoned self-compassion to achieve unrealistic outcomes at work
(Wood, 2018). Unlike other professions, nurses work in ill health environments and bear witness
to suffering, creating psychological stressors (Jayaraman & Chandran, 2010). Compared to other
professions, healthcare workers report burnout from work stressors that lead to higher reports of
substance dependence and suicide (Zeller, &Levin, 2013). Nurses who are not equipped with
coping skills for job stressors have repeatedly been proven to self-medicate, forming an attitude
15

of denial/invincibility (Mumba & Kraemer, 2019). The risk factors associated with nursing crisis
extend to substance dependence contributing to personal and professional challenges.
Staff shortages within specialty areas leave nurses in high demand where self-medicating
(with the substance of choice) as a coping skill can go undetected. According to Zicafoose
(2018) with the growing nursing shortage, nurses are being asked to take on more responsibility
in their job role. An increase in patient assignments, requests for unit shortage coverage, and
being asked to cover other units increase work stressors. Mumba & Kramer (2019) reported
there are also additional dynamics of increased physical/emotional stress, where nurses who may
have a family history of impairment, seek out substance dependence as a crutch for poor coping
mechanisms. Nurses employed in intensive care units and emergency rooms were found to have
higher rates of substance dependence triggered by emotional trauma from childhood or poor self-
esteem (Epstein, 2010). With a given history of psychological distress, nurses employed in
specialty areas encounter episodes of repeated trauma when there are increased incidents of
patient death (Mumba & Kraemer, 2019). In the research study conducted by Kunyk (2015),
nurses were uncertain by 53% if they had ever worked alongside an impaired nurse and 62% of
those surveyed, responded that they would not address impairment with a peer colleague for fear
of confrontation. Impaired nurses remain under low suspicion because they have the ability to
frequently change jobs without blemishes on their record (Zicafoose, 2018). Aside from
substance dependence as a coping skill for work stressors, additionally employee-driven turnover
rates impact patient care when organizations are unable to retain nurses in specialty areas.

16

Decreased Retention Rates
Nurses envision having a career where they provide quality patient care. Nursing
employees in critical care areas associated poor quality of work life and desire to leave their
profession because they felt unsupported by management (Sorenson et al., 2016) Nurses assigned
in specialty areas accounted for 22% of turnover rates due to high workloads and conflicts with
nursing peers (Bautista et al., 2019). The negative impact of prolonged vacancies from nurse
turnover is increased workloads (McNeil et al., 2020). Prior to departing an organization,
employees surveyed reported an increase in absenteeism due to the failure of management to
mitigate conflict on their teams (Ferro et al., 2018). According to the study by Kim et al. (2019)
nurses with less than 5 years of experience reported increased absenteeism and higher turnover
rates as their way to resolve workplace bullying/rude behaviors. In the study conducted by
Dyrbye et al. (2019) nurses with an average length of 25 years of work experience reported
lower rates of absenteeism but 15.6 % of participants rated themselves as poor work performers.
Within some organizations, tenured nurses report a lack of rapport with their nurses’ managers.
In the study conducted by Armstrong et al. (2014) senior staff reported feeling devalued for
desiring a sense of community in the workplace and 42% of nurse managers were unaware of the
needs of a nurse with greater than 10 years of experience. Benefits such as organizational
retention rates would be achieved if nurse managers appreciated work history experience without
regarding staff as replaceable bedside caregivers (Chen & Ching-Fu, 2018). Managerial support
influences nurse well-being. Nurses reported feeling valued is essential for job satisfaction
(Oates, 2018). Raising the bar on leadership roles in recognizing the crisis nurses face will help
strengthen manager/staff relationships to enhance patient care.

17

Nurse Leadership Recognition of the Environment
Nurse managers are the identified leaders for their units. Human Resources (HR) identify
the nurse managers as key individuals who are representative of nursing administration for the
healthcare organization. The nursing administrative role comes with the authority to designate
nurse-patient assignments and change the work environment, ensuring the quality of patient care
(Brewer & Verran, 2013). Nurse managers are also directly involved in the presence, absence,
and scheduling of work shifts (Mohammadi et al., 2021). According to the study conducted by
Ulrich et al., (2014), 69.6% of nursing administrators reported that they were aware of healthy
work environment standards but were ranked by their staff as poor providers of resources. Thus,
the importance of the nurse manager is to be aware of unit needs for staff as well as patients.
Nurses may have traumatic experiences that decrease their productivity or challenge their
ability to think rationally, (Marcella-Brienza & Menillo, 2015). The nursing professional quality
of life can be impacted by traumatic events such as workplace bullying, domestic violence,
anxiety, depression, grief, and compassion fatigue (Kim et al., 2019). It is the relationship
between nurses and their managers that fosters psychological well-being. The significant role of
the leader is to balance the workload of the staff for performance levels to be achieved (Chen &
Ching-Fu, 2018). Nurse managers who are deemed competent develop their relationship
managerial skills by being observant of the moods, motives, or behaviors of their team members
(Beckham & Riedford, 2017). Effective communication was also cited as a favorable
characteristic of a good leader because he/she can influence the staff with thoughts and values to
achieve effective goals (Ferro et al., 2018). Nurse leaders who say nothing leave staff with an
inadequate response to handle their crisis (Branden, 2020).
18

Furthermore, managers play an important role in maintaining the balance of the unit by
having the responsibility of addressing team morale (Marcella-Brienza & Menillo, 2015).
Nursing administrators who were found more engaging with their staff were more successful
than those who lacked engagement, resulting in failed governance (Ahmed, 2018). Intuitive
nurse managers recognize the stressors of their team from attempting to cope with the cycle of
being pressured at work and being at home stressing about their return (Dean, 2021). Nurse
managers who exaggerate about crisis on the unit without action appear to trivialize staff issues
imposing mental exhaustion on their team (Branden, 2020). Influential nursing leaders establish
clear goals to secure an environment where patient care is effective (Jayaraman & Chandran,
2010). Managerial influence supported by executive leadership also aided in the organization’s
investment to support healthy workplace culture for its nurses (Wood, 2018). Hence, nursing
staff is empowered when the leadership creates a positive work culture where staff are not afraid
to admit that they are having challenges and are not afraid to seek help (Finlay et al., 2019).
Nurse unit managers struggle, finding themselves challenged by the same issues of work and
family balance, workplace stress, harassment (bullying) and intensified escalations of work
(O’Donnell et al., 2012). All levels of nursing thrive when they are supported by leaders who are
engaged with their teams, showing collaborative effort in goals. Nurse managers may support
their staff for patient clinical care but may be lacking in empathy or support for caregiver needs.
Nursing Leadership Support
The question continues to be raised of how nurse managers can be supportive to staff but
maintain the organizational goals of the healthcare organization. Interventions used to decrease
nurse stressors include management focus on nurse well-being (Oates, 2018). Nursing leaders
cannot afford to be absent or silent. As a part of credibility, nurse managers should not only
19

strive to be visible but also approachable (Quinn, 2017). Remaining visible is a critical part of
staff morale, when team members are looking for leadership guidance (Moore, 2020). A
manager’s support has a positive effect on employees’ attitudes and behavior as evidenced by
increase in trust (Holland et al., 2017). The conversation about professional nursing challenges
needs to be held and spoken about daily for transparency (Branden, 2020). Both workplace
environment and management culture influence employee’s health and well-being (Black, 2012).
In clinical care specialty areas of high stress (emergency department, ICU, surgery, and
behavioral health) nurse managers must be well-versed in coping strategies as their teams look to
them for accelerated leadership and guidance (Moore, 2020). Nurse managers who are observant
of how their department is functioning also have a keen sense that nurses starting in specialty
areas have a higher rate of being overwhelmed which would include the possibility or need for a
staff nurse to be reassigned to a different unit (Cole, 2020). Effective nursing leaders mitigate
anxiety in staff as they utilize their administration position to be present for those nurses who
identify with working in crisis (Branden, 2020). Managers can model empowerment in
leadership by demonstrating self-care initiatives (Black, 2012). Managers who actively support
staff take the time to listen, and ask about employee well-being (James & Bennett, 2020).
Nurse managers must recognize the need for work-life balance which allow the employees to
have some extension of control over their schedules (Jayaraman & Chandran, 2010). It is
detrimental to the nursing staff when the nurse manager does not lead by example. Nurse
managers with poor boundaries, who regularly stay hours beyond their shift, may have the same
expectations for staff (Dean, 2021). The effective nurse manager serves as a collaborator, who
builds trust with their unit as they balance changing work environment priorities/demands
(Porter-O’Grady, 2010). When organizations prioritize staff well-being their nursing teams
20

perform better (Black, 2012). The nurse leader is encouraged to establish long-term, trusting
relationships with the nursing body which shows investment in nurses. When nurses perceive
their relationship with their employer to be social, they show a higher sense of commitment as
opposed to a transactional relationship based on economic exchange for service (Veld, 2014).
For well-being measures to be created, nursing leadership has to create a trusted work culture.
Nurses positively benefit from a demonstrated level of empathy from the nurse managers toward
their staff to create a supportive environment.
Creating a Positive Workspace
Nursing leaders who plan to create a positive workspace are in tune with the needs of
their unit. They succeed in keeping turnover rates lower when they can retain nurses by
recognizing the generational differences between junior and senior staff (Cole, 2020). Clinical
leader competence involves unit collaboration, fostering nurse work quality of life satisfaction,
and demonstrating emotionally competent behavior (Beckham & Riedford, 2017). Nurse
managers have the ability to bring support staff to the unit, when permitted by senior executives,
while maintaining their credibility as leaders (Tang & Hudson, 2019). Healthcare organizations
are beginning to recognize this importance by implementing “back to floor” initiatives, where
senior nursing staff set aside time each week to work alongside younger colleagues (Quinn,
2017). Clinical staff support consultants aid the nurse manager in preserving the balance of
competing priorities while creating a learning environment for staff (Laschinger et al., 2014).
Providing a support coach also proved to be beneficial for nurses motivated to develop emotional
competence (Sadri, 2012). Support staff act as additional resources, typically senior nurse
interns, who are astute to generational differences amongst nursing staff and are utilized for
professional support (Cole, 2020). The alignment of the support staff alongside the unit manager
21

provides collegiality in relationship management skills (Beckham & Riedford, 2017). Nurse
managers are able to demonstrate business leadership skills when they openly extend flexibility
to the senior staff and acknowledge senior staff for being knowledgeable (Armstrong-Stassen et
al., 2014). Clinical support staff who have mastered leadership skills, empower other members
of the team positioning them to take ownership of their unit (Galuska, 2014). Structural
empowerment decreases work incivility and reduces burnout (Laschinger et al., 2014). Senior
nurse mentors also provide support to staff outside their clinical roles, which decreased attrition
rates in some healthcare organizations by 7% (Cole, 2020). The foundation of nursing leadership
for effective management begins in the baccalaureate degree programs (Galuska, 2014). When
nurse managers are provided leadership support and education, they are equipped with the skills
to promote self-care for their team. Nursing schools have begun to add self-care to their
curriculum in response to nurse crisis trends.
Education of Nursing and Self-Care
Nursing students encounter clinical training stressors in anticipation of becoming
registered practicing nurses. Both nursing students and professional nurses promote teaching
self-care to patients when personal self-care is neglected (Ashcraft & Gatto, 2015). There is a
lack of consistency in the concept of the term self-care in nursing education literature (Slemon et
al., 2021). The American Association College of Nursing (AACN, 2018) defines an
undergraduate nurse as competent in self-care in order to be prepared to take care of others.
Nurses who are perceived as taking care of themselves are viewed as role models by their
patients (Ashcroft & Gatto, 2015). In response to increased stressors noted in nursing students,
nursing schools have developed curriculua to aid in building resilience for coping with future
stressors within the nursing profession. Self-care educational interventions found nursing
22

curriculum included 1-hour classroom assignments paired with self-care models, assignments on
identification of stressors, and courses in holistic nursing which included journal writing
assignments (Slemons et al., 2021). Inclusion of health care promotion for nursing students
throughout the curricula promote the value of selfcare as a professional nurse prior to job
burnout. Faculties who teach leadership courses are encouraged to promote positive
relationships among staff to maintain respectful/civil work environments (Laschinger et al.,
2014). Coping strategies acquired in nursing school decrease the rate of changing roles from the
functioning bedside nurse to the nurse as the patient (Wood, 2018). Consequently, a nurse’s lack
of self-compassion can also be traced from practices learned in nursing school. Amongst student
nurses, it is noted that detail to self-care takes a downward spiral as responsibilities to care for
others increase (Ashcraft & Gatto, 2015). Even as a part of the curricula, nursing students are
taught to identify their self-care strategies with limited formal input from faculty (Blum, 2014).
Nursing instructors model manager and staff nurse relationships in the clinical training
environments. Although the professional body of nursing mandates placing the needs of the
patient first, it is ambiguous in setting the standard for nursing self-care (Wood, 2018). Nursing
school graduates who have not identified best practices in self-care prior to graduation will face
challenges finding support for self-care initiatives in the workplace, if not promoted by the
healthcare institution.
Nursing Self Care
There are some nurses in the current workforce who were not taught self-care in nursing
school. The concept of self-care became notable in 1971 by nursing theorist Dorothea Orem and
made a part of the nursing baccalaureate program curriculum in 2008 (Ashcraft & Gatto (2015).
According to research conducted by Cole (2020), Generation X nurses make up 40% of the
23

nursing workforce, cited as wanting to work smarter not harder regarding work life balance.
Nursing academic scholars insist that it is the nurse’s responsibility in finding their road to self-
care but fail to recognize the systems that contribute to stress and burnout (Slemon et al., 2021).
In the study conducted by Martin (2015), nurses were offered to eliminate 12-hour shifts at their
institution as support for fatigue preservation, After the 30-day pilot completion nurses reported
working a 5-day/40-hour work week did not improve their self-care practices (Martin, 2015),
The culture of an organization and empowerment of its nursing staff are important to consider
when discovering ways to improve staff health (Wood, 2018). Nursing self-care begins with
setting boundaries within the workplace (Oates, 2018). Partnering with positive leadership
includes an allowance of self-inventory where nurses report if they are fit for practice (Wood,
2018). Nurses who demonstrated trust in their leadership team were transparent in reporting
feeling overwhelmed in crisis. Per James and Bennett (2020) it is easier for nurses to protect
their mental health, through transparency, than to recover from a crisis. Work-life balance is a
form of self-care where nurses are given control over their work schedules by their employers
(Jayaraman & Chandran, 2010). Nurses are advised to embrace self-care strategies that work for
their own unique individual needs (Oates, 2018). Attending to basic needs include taking
breaks/lunches, taking paid time off (PTO), being aware of increased anxiety, deprivation of
sleep, attending to hygiene, taking walks off the unit if needed, and paying attention to physical
health (James & Bennett, 2020). These self-care activities aid in stress reduction but are not
commonly promoted while working on the unit.
Stress reduction programs that promote self-care include mindfulness training for emotional
management (Zeller & Levin, 2013). Resilient nurses use emotional intelligence for decision-
making in emotionally charged, critical care areas (Mealer et al., 2012). Nurses who are
24

engaged in mindfulness training are better to recognize thoughts, emotions, and physical
sensations that arise under states of heightened stress (Zeller & Levin, 2013). Nurses may also
benefit from clinical supervision to receive emotional support to cope with work stressors (Oates,
2018). Clinical supervision is not a requirement of nursing post-graduation and would not be
received unless a nurse knows to ask for this level of support. Nurses who received clinical
supervision developed a rapport with management leads that increased trust in nurse
management and helped with retaining staff (Cole, 2020). Nursing staff who prioritize self-care
measures ensure the delivery of efficient patient care (Black, 2012). In the study completed by
Oates (2018), it was found that clinical supervision positively affected nurse well-being in that it
distanced nurses from challenging situations and connected them to nursing peers. Practicing
self-care support aids nurses in reducing stressors, preventing burnout, and enhancing resilience
(Slemon et al., 2021). Nurses reported that their family members were supportive to them in
their self-care efforts, but they expected more support from society, their colleagues, and their
organization (Mozaffari et al., 2015). Healthcare leaders share the responsibility to support their
team’s self-care efforts by reminding them of the importance of taking care of themselves in
order to take care of their patients (Wood, 2018). Effective nurse leaders who demonstrate
compassion listen to the needs of their nursing team (Quinn, 2017). It is impactful how a
manager’s leadership style on a unit influences work culture. The leadership style of the manager
influence standards of the unit and outcomes of staff to patient engagement.
Transformational Leadership
Nursing leadership is a vital element in the professional nurses’ quality of work life. An
involved nurse leader is an advocate for quality care, a great communicator, a collaborative voice
on the unit, a mentor, a role model and a visionary (Jayaraman & Chandran, 2010). Nurse
25

managers as ethical leaders are individuals who are given the task of making decisions that
impact the lives of those within an organization (Grande, 2015). In health care, the most
advised leadership style to adopt is emotionally transformational leadership (Ahmed, 2018).
Transformational leadership as a motivational style promotes visible engagement and motivates
nursing teams to provide high-quality care to patients (Black, 2012). Transformational leaders
motivate followers to have a common goal, where processes of change are seen on the individual
and the organizational level (Jambawo, 2018). There is a dominance felt by the transformational
leader which leads to obedience of the follower as they have an emotional connection or
affection towards the leader (Northouse, 2019). Achievement of emotionally competent
empathy for nurse managers requires them to have insight into where they can examine personal
obstacles in performance (Beckham & Riedford, 2017). It is important to note that in resonant
leadership it is also distinguished by its foundation on emotional intelligence, but this leadership
style remains unexplored with empowering work environments for nursing outcomes
(Laschinger et al., 2014). However, a transformational leader helps to guide those they lead to
see how they can become great when they develop their potential, The intuitive appeal of
transformational leadership is popular because it is viewed as someone who is advocating on
behalf of others promoting change (Northouse, 2019). Utilizing transformational leadership
skills, nurse managers balance competing priorities that demand their attention (Jayaraman &
Chandran, 2010). If one considers themselves a transformational leader in nursing practice it is
no longer enough to establish rapport in the clinical practice environment, but new leaders must
now possess healthcare business skills (Laschinger et al., 2014). As an effective leader, the
manager’s vision is aligned with the organization and supported by human resources to support
employee needs. The nurse manager seeking to secure knowledge on organizational practices
26

strengthens their relationship with the HR team in order to provide continued support to its
nursing staff.
Human Resource Strategies
Human resource executives provide support to the nurse management team in
recruitment, retention, and maintaining employee well-being. Healthcare organizations whose
primary commitment is to provide exemplary care for patients are also expected to have the same
goals regarding the well-being of their staff (Black, 2012). Healthcare organizational success
begins with forming a cohesive team between nursing leadership and their HR departments
(McNeil et al., 2020). Nursing researchers have identified the 2 most common areas where
leadership has traditionally leaned on the human resources department for support: management
of behaviors requiring disciplinary intervention and staff retention efforts to alleviate nursing
shortages (O’Donnell et al., 2012). Unit nurses find themselves in a social exchange relationship
at work which is proximal to the nurse manager but often time, distal to the organization
(Holland et al., 2017). A unit nurse who is dependent solely on the nurse manager for
information may put themselves at risk if the nurse manager is unaware of organizational
policies. As the research by Dean (2019) highlights, nurse managers out of touch with human
resource departments risk running inhumane shifts for their lack of basic knowledge of nursing
rights regarding staff breaks or lunches. The HR team serves as a gateway providing resources
for staff while supporting the management in the promotion of organizational goals. The HR
team along with nurse executive leadership holds nurse managers accountable for the
development of employee commitment to organizational goals (Alfes et al., 2013).
However, quality of work life (QWL) is becoming more of a prevalent HR issue with
increased demand for effective policies to govern policies on work-life balance in healthcare
27

organizations (Jayaraman & Chandran, 2010). In the promotion of healthy coping skills, nursing
scholars suggest that HR partner with nursing leadership introduce mindfulness training as a
worksite wellness program (Zeller & Levin, 2013). The HR team would therefore enhance
leadership support with the implementation of stress policies that include guidance on stress
management, offer stress management training, and improve communication and consultation
mechanisms (Moore, 2020). The more nurse managers are empowered to develop an
understanding of the challenges their staff face, they develop effective innovations due to
training from the organizations’ HR experts (West et al., 2017). Healthcare organizations who
value the quality of work life for nurses ensure that their HR team promotes work environments
that result in the excellence of healthcare delivery (Jayaraman & Chandran, 2010). HR
maintains the records for turnover rates and vacancies related to staffing which has been linked
in multiple studies directly to patient outcomes (Brewer & Verran, 2013). The quality of nursing
care is essential for accreditation of the health care organization reflecting nursing excellence
and patient care excellence. In recognition of quality, the governing bodies of nursing
acknowledge such relationships with full accreditation, reportable by local government.
Nursing Impact and Hospital Accreditation
Hospitals seek to have their leadership team obtain recognition for providing excellent
care by achieving accreditation and/or credentialing standards. Within the United States, the
Joint Commission on the Accreditation of Health Care Organizations sites that each hospital
should have a governing body responsible for the safety, quality of care, treatment, and services
of all patients (Kuwaiti and Muhanna, 2019). The accreditation standards incorporated safety
goals to protect patients. One of the standard preventative nursing measures is known as the
“Five Rights” which establishes that the right medication, is given at the right dose, administered
28

via the correct route, at the right time, to the right patient (Wang et al., 2015). Quality standard
indicators such as evidence-based practices are a mandatory for hospitals seeking accreditation
(Kuwaiti and Muhanna, 2019). Measuring an organization’s standard of care involves evaluating
their policies on quality indicators and performance outcomes which are both tracked to identify
any deficiencies in care structure (Morris, 2012). There are self-reported parameters by
healthcare organizations that have impacted hospital accreditation. Hussein et al. (2021) identify
job stressors, staff shortages, job satisfaction, nursing leadership behavior and lack of nursing
leadership commitment as challenges hospitals face for accreditation. Healthcare organizations
will not successfully obtain accreditation status if their staff is not competent in observing
nursing practices defined by standard quality indicators (Kuwaiti and Muhanna, 2019). Nursing
academic scholars have noted the positive effect of perceived patient safety culture due to an
organization’s accreditation status (Hussein et al., 2021). It is also noted if a hospital shows the
ability to achieve successful accreditation status there is a positive impact on its nursing culture
(Kuwaiti and Muhanna, 2019). In the study conducted by Hussein et al., 2021, there is a
trending positive relationship between accreditation, clinical outcomes, and decreased patient
mortality rates. Hospitals maintain their accreditation status by ensuring they have a quality
nursing team that excels in all performance measures. Hospitals may attract more exemplary
nursing staff if their organizations are deemed a magnet for success.
Healthcare organizations are recognized by their measure of excellence in nursing which
identifies them as promoting quality patient outcomes, known as “Magnet Status” (Williams et
al., 2013). The Magnet Recognition Program was developed by the American Nurses
Credentialing Center (ANCC) as a standard for best practice (Tai and Bame, 2017). The
principles behind Magnet Status recognition programs are identified by organizations with
29

benchmarks to measure quality patient outcomes, promote higher education amongst its nursing
staff, and have high retention rates. (Gordon, 2017). These characteristics outline the tenets of a
magnet organization because the hospital attracts talented nursing staff whom they retain, thus
alleviating gaps in care with staff shortages. A hospital Magnet program has 5 components:
Transformational leadership, Exemplary professional practice, Structure, Knowledge, and
Quality results (Williams et al., 2013). The Magnet Recognition concept is considered an
innovative strategy where effective healthcare leaders within those organizations better manage
hospital resources, thus improving quality of care (Tai and Bane, 2017). Both hospital
accreditation and Magnet status reinforce quality in nursing and patient care outcomes (Gordon,
2017). The theoretical concept from the Burke-Litwin Model of Organizational Performance and
Change (Burke & Litwin, 1992).) support how effective nursing leadership drives organizational
change performance. Knowledgeable nurse managers who impact organizational culture, are
proficient in managing nursing teams whose performance is reflected in external factors such as
patient outcomes and hospital standards.
Conceptual Framework: Burke Litwin Model
The conceptual framework used for “identifying needs of the caregiver” research is
supported by the organizational performance and change model developed by Burke and Litwin
(1992). The Burke-Litwin model is an organizational development model which utilizes both
theories of implementation and change to improve an organization’s performance (Burke and
Litwin, 1992). The model identifies an open system framework where 12 elements of change
have bidirectional relationships with one another (Burke & Litwin, 1992). The 12 variables are
divided into two categories: Transformational and Transactional (Burke & Litwin, 1992). The
eight transactional factors range from management practices, unit climate, individual needs,
30

individual skills to motivations (Burke & Litwin, 1992). The four transformational variables
include: strategy, leadership, and culture. Management is highlighted as a key internal
contextual factor (Spangenberg &Theron, 2013), While managers are noted at the core of the
Burke-Litwin model, it is their influence that impacts external factors such as organizational
outcomes.
The external factors which impact leadership within healthcare organizations are the
regulatory accreditation bodies that govern patient safety. If patients are not safe, the hospital
does not gain notoriety or worse, lose accreditation. Poor outcomes associated with losing
accreditation are also associated with increased risk to patient safety, including mortality
(Hussein et al., 2021). Hospitals that a lack effective leadership lose accreditation due to
inspections on quality which reveal lack of compliance in following nursing standards on patient
care (Kuwaiti & Muhanna, 2019). Medication errors and staffing shortages are key indicators
exposed upon review by accrediting bodies, explaining/detailing patient safety risks of healthcare
organizations.
The mission and strategy of the organization is identified in the mission statement (Burke
and Litwin, 1992). A hospital’s mission is to keep patients safe. The strategy is to be a
responsible care partner, upholding the oath of all healthcare standards and being fiscally
accountable to stakeholders (Wang et al., 2015).
Leadership reflects executive values and serves as behavioral role models to the
organizational employees (Burke & Litwin, 1992). Nursing leadership within a healthcare
organization is held responsible for demonstrating leadership skills such as empathy, listening,
delivering quality patient care, and empowering work structures that foster job satisfaction
(Laschinger et al., 2014)
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Culture is defined as the way things are done within an organization. Overt and covert
rules guide an organization’s culture (Burke & Litwin, 1992) It is the meaning system by which
the employees operate. A healthcare organization with an enlightened culture demonstrates good
nursing practice as the norm and employee engagement is a regular part of nursing behavior
(Black, 2012).
Structure is the arrangement of employees into different areas and levels of responsibility
(Burke and Litwin, 1992) Structure is important for the vision/mission of an organization where
decision-making authority is distinguished. Nurse leaders such as Chief Nursing Officers
(CNOs) collaborate with HR specialists to create long-term recruitment strategies for nurse
managers, as administrators, who work together to promote interdepartmental cohesiveness,
carry out the mission of the organization, and respond to a changing workforce for nurses
(McNeil et al., 2020). The nursing leadership structure from Chief Nursing Officer to frontline
nursing staff involves autonomy to make decisions that support best practices.
Management Practices are the behaviors used by management teams to use people and
resources to carry out the strategy of the organization (Burke & Litwin, 1992). Nursing leaders
must demonstrate their ability to focus on patient health conditions as well as business
management acumen that may range from regulatory inspection to facility repairs (Evans, 2019).
Systems are standardized practices that demonstrate how an organization functions by
using performance appraisals, reward systems, human resources, and information systems to
facilitate work (Burke & Litwin, 1992). Healthcare organizations succeed at retaining nurses
when they decrease job role strains, acknowledge nursing achievements, invest in nursing by
emphasizing trust between HR and providing resources to support the relationship (Veld, 2014).
32

Climate is the experience or feelings by members within a working unit that in turn affect
their relationships with each other and other departments (Burke & Litwin, 1992). Health care
organizations that invest in the development of a healthy workplace culture will put their staff
first, empowering them to deliver quality care (Wood, 2018).
Task requirements and individual skills are behaviors needed to complete one’s assigned
job in which an employee feels directly responsible for his/her accomplishment. In the study
conducted by Martin (2015), she discovered that nurses who worked consecutive 12-hour shifts
suffered from chronic fatigue, which also led the Joint Commission to issue a sentinel event
alert, due to evidence demonstrating the inability to complete nursing tasks without quality
concerns such as medication pass errors, needle sticks, patient, and staff injuries.
Individual needs are psychological elements that support individual actions that enrich
the workforce by their activities on their job (Burke & Litwin, 1992). Nurses value boundaries
between their home and work life which attribute to self-well-being, thus increasing productivity
at work (Oates, 2018).
Motivation is a demonstration of behavior that moves one towards a goal by taking on
needed/persistent action (Burke & Litwin, 1992). Nurse managers enhance a climate of well-
being by expressing support for continued leadership training and reducing staff stress in
shortages which increases retention rates (Veld, 2014).
Individual and organizational performance is the result of achievement in quality,
customer satisfaction profit, and productivity (Burke & Litwin, 1992). Hospital organizations
that have earned Magnet Recognition Program status report higher nursing satisfaction scores
due to their work environments (Gordon, 2017). Magnet status attributes showcase the inclusion
33

of shared government where nurses participate in decision-making as a provider, excel in
foundation quality care measures, demonstrate staffing adequacy, and nurse manager ability to
support their nursing team (Williams et al., 2013). Figure 4 uses the Burke-Litwin Model to
outline the internal and external factors of leadership change and performance as represented by
nursing leadership.
Figure 4
Factors of Leadership Change within Nursing Leadership

Note: Developed by K.Morton, 2022.
34

Summary
This literature review synthesizes the research for identifying the needs of nurses as
caregivers. The review provides insight into the challenges faced by nurses who are academically
prepared to take care of patients but who are professionally compromised without leadership
support. The research correlates the effect of missed management opportunities within the work
climate that contribute to compromised nurses who lack leadership guidance, are uninformed of
organizational HR tools, and suffer in silos of bullying, addiction, burnout, or depression. The
increased stressors on registered nurses, as a crisis, directly impact patient health outcomes. As
healthcare organizations delay the prioritization of leadership training, they create a working
environment for nurses that is unsustainable. Lack of nurse leadership training place healthcare
institutions themselves at risk of jeopardizing patient safety standards and patient quality
measures and threatens the community at large if governmental accreditation is lost. The
literature review aligns with the Burke-Litwin model of organizational performance and change
(1992) which serves as an overarching framework, illustrating the theories that highlight
leadership as a contributing factor for an effective workplace. Nurse leaders who are provided
with effective leadership skills minimize nurses working in crises.

35

Chapter Three: Methodology
The purpose of this study was to evaluate nursing leadership knowledge, discernment,
awareness, and empathy of their nursing staff who may be in crisis as they attempt to care for
patients while neglecting their self-care. Chapter Two reviewed previous research that examined
the tenets that led to working in crisis, which impacted patient outcomes. The literature review
also probed the strengthening of nursing leadership if aligned with human resources for quality
measures that lead to the success of hospital organizations. The conceptual framework illustrated
in Figure 1 encompasses these key factors which stem from the Burke-Litwin model of
leadership, change, and performance (1992).
Research Questions
The questions that will guide this research project are as follows:
1. In what ways are nursing leaders positioned to recognize when nursing staff is in crisis,
needs support or identifies as feeling compromised working in high-level stress
environments?
2. To what extent do nurse leaders engage in partnering with HR to determine or enact
relevant employee policies and practices that support nursing staff?
3. How do healthcare organizations use informal peer support systems to support the nurse
leadership/line staff relationships during periods of high stress/crisis?

This chapter provides a detailed methodology for the research project. The review begins
with the description of the participating stakeholders in the study and the selection of
participants. This chapter also highlights the survey sampling criteria, strategy, and
rationale. The researcher outlines the proposed data collection, instrumentation, and
36

procedures for data analysis. The chapter then concludes with the validity and reliability of
the study, ethical considerations, and study limitations.
Research Design
The design chosen for this study includes a qualitative mixed-method case study design
(Creswell & Creswell, 2018). Within the mixed case study design, there is a development of
cases from both qualitative and quantitative results gathered from integrated data (Creswell &
Creswell, 2018). Using an inductive approach, both qualitative and quantitative data were used to
form multiple cases, where comparisons can be made amongst cases selected (Creswell &
Creswell, 2018). The case study participants consisted of 10 nurse leaders from 10 different
hospitals in the greater Chicago area. Each nurse leader was invited to complete a quantitative
survey and a qualitative interview. Participants were asked to complete the quantitative survey
prior to the qualitative interview. Post interviews, the researcher gathered qualitative and
quantitative data to conduct the analysis and formulate the resultant case comparisons. This case
study design allowed the researcher to analyze the data for patterns or trends amongst selected
cases as noted in Figure 5 below.

37

Figure 5
Mixed Methods Case Study Design
Mixed Method Case Study Design

Note: From Research design: Qualitative, quantitative and mixed methods approaches (page,
231). Creswell, J. W. & Creswell, J. D. (2018). Thousand Oaks, CA: Sage Publications

Nursing leaders have a minimum of 3-5 years of nursing experience to become an
administrator (Zeller & Levin, 2013). The nursing school experience and pre-administrator work
experience with nursing colleagues would provide exposure to the topic being studied. The case
study design used as a strategy of inquiry will allow the researcher to gather both quantitative
data and qualitative data at the same time (Creswell & Creswell, 2018). The interviews were
designed specifically to assess the nurse leader’s experience with nurses working in crisis,
awareness of unit culture, level of empathy toward staff, manager’s ability to act as a resource,
manager’s knowledge of HR policies/benefits and level of comfort as a manager addressing
38

these issues with a subordinate. This format allowed the researcher to obtain pertinent
information for research and include narrative elements by capturing each participant’s story
(Meriam & Tisdell, 2016).
Research Setting
The researcher initiated the study by introducing the purpose of the study. After the
purpose of the study was explained, the researcher described the relevance of the research
concerning nursing leadership. Nurse leaders were asked to first respond to a qualitative survey
5-7 business days before the day of interviews with the researcher. The survey was sent to each
participant via email of preference, utilizing the Qualtrics survey link. The qualitative survey was
estimated to take no longer than 8-10 minutes to complete. Post survey, nurse leaders
participated in a privately conducted interview via Zoom link or face-to-face with the researcher.
The researcher asked each participant to plan for a 40-to-45-minute interview session. For
purposes of confidentiality, interviews took place in private areas where the interviewer and
researcher were the only individuals present. The data was recorded with a voice recorder after
receiving permission from the interview participant. Nursing leadership interviews were
conducted via Zoom conference call, The researcher’s goal was to make interviews personal,
respectful, and non-judgmental. Upon completion of the Zoom call interview, a further
explanation was given to the participant on how the results of the study would advance nursing
leadership in supporting nursing staff prior to the loss of nurses’ well-being.
Positionality
The paradigm of inquiry for this research study is interpretive or qualitative. From the
qualitative perspective, a researcher’s goal is to understand the experience of the participants and
influential factors (Merriam & Tisdell, 2016). Organizational dynamics of structural placement
39

for staff, human resource knowledge, organizational goals and quality outcomes in patient care
were objectives learned by the researcher in initial nursing preceptorship. Given the positive
experiences early on in their nursing career, the researcher placed a high value on the importance
of being empathic toward subordinate nursing staff. Merriam and Tisdell (2016) noted that an
experience cannot be objective because it includes the way the experience is interpreted by the
individual. As stated in the literature review, successful nursing units have team leaders with
exuberant people skills. Leadership has the fundamental role of creating conditions that
guarantee the nursing workers’ professional growth, monitoring their satisfaction with the work,
and strengthening their commitment to quality care for the patients in their unit (Ferro et al.,
2018).
As a nurse with over 20 years of experience, the researcher has held multiple leadership
roles, including Chief Nursing Officer (CNO). From bedside nursing to nursing leadership
positions, managerial responses were noted over the years, by the researcher, to crises nursing
staff would encounter within health care organizations. Nurse leadership meetings were held at
the executive level due to lack of knowledge on foundational management skills. Repeated
nursing crisis management concerns included addiction, burnout, domestic violence, bullying,
and life/work balance. The interest in supporting the nurse as the caregiver grew as a research
topic due to agreement within the nursing profession that nursing’s current state of personal well-
being is in jeopardy. However, there is a lack of standardized planning or research on how to
educate nurse managers on supporting nurses working in crisis.
As the researcher is in a nursing leadership role there was an awareness that the
participants may have identified the interview process as casual amongst professional peers,
anticipating agreement on nurse leadership styles. Additionally, the researcher identifies as an
40

African American female, a person of color, and credentialed via educationalism. Participants
were offered the opportunity to review the researcher’s background for any questions or
concerns. In assistance to follow up on the current study, the researcher offered participants an
opportunity to review their responses prior to the final study analysis. The researcher also offered
to present research study outcomes to participants in tribute to the time invested in the research
study.
Participants
The stakeholder group for this research study was selected by purposeful sampling.
There were 10 participants in this study who are full-time licensed registered nurses, holding a
minimum of a baccalaureate of science degree in nursing (BSN), functioning in the role of a
nurse administrator at the level of manager or above with a minimum of 5 years of nursing
experience which includes at minimum one year experience within one critical care area (ICU,
ED, Behavioral Health, and Surgery areas) and has served as a nurse manager for a minimum of
two years. Recruitment was completed by extending an invitation to participate in this study via
professional nurse organizations and nurse leadership referrals. A purposeful sampling of nurse
leaders with greater than 5 years of experience and critical care area experience increased
credibility/validity, reflecting the most accurate data for high-stress clinical areas.
Instrumentation
The research design incorporated qualitative research methods using mixed-method case
study design. In a qualitative research approach, the researcher relies on the data and attempts to
establish the meaning of the phenomenon from the view of the participants (Creswell &
Creswell, 2018). As mentioned before, participants were initially invited to complete a survey
prior to participating in the interview. The survey consisted of demographic questions for
41

baseline data collection incorporating the use of a Likert scale for ranking knowledge,
awareness, and HR competency. The interview protocol used for this research project was a
semi-structured interview, with open-ended questions that requested specific data from the
respondents (Merriam & Tisdell, 2016). A voice recorder was used with the permission of the
participants. I chose this approach for the nursing leaders being interviewed to feel comfortable
about the questions. Upon answering questions, the nurse manager replied freely and prompted
for more information, making the interview feel more conversational. Questions utilized in both
data collection tools focused on participants sharing their opinions, knowledge, cultural
sensitivity and awareness, and their background. The interview questions were relatable to the
research questions because both focused on leadership awareness and their ability to recognize if
their staff was in jeopardy/crisis (Table 1).
Table 1
Survey Instrument
Demographic Questions
Please indicate your role:
a) Nurse Manager
b) Nurse Director/Director of Nursing
c) Chief Nursing Officer
d) Other (enter here) _____

How many years of nursing
leadership experience do you have?
a) 5 years
b) 6-9 years
c) 10 years or more

Questions CF Element Strongly
Agree
Agree Disagree Strongly
Disagree
I Don’t Know
I appreciate the work ethic of my
nursing staff
RQ2: HR
Partnerships and
Practices

My Director of Nursing /VP makes
final decisions for my unit
RQ2: HR
Partnerships
&
Practices

42

I use HR as a resource for staff
issues/concerns non-related to
patient care
RQ2: HR
Partnerships
&
Practices

My nursing staff is drained of physical
and emotional energy
RQ1:
Awareness
& Recognition

My nursing team would inform me if
they were having negative thoughts
about their job
RQ1:
Awareness
& Recognition

My nursing team gets enough sleep
prior to the start of their shift before
they arrive to work
RQ1:
Awareness
& Recognition

My peer support team
specialist/clinical specialist/clinical
educator provides my unit with a
schedule of availability for support
RQ3: Peer
Supports

My nursing team would report any of
their medication errors or patient
adverse outcomes to me prior to the
end of their shift
RQ1:
Awareness
& Recognition

I feel my nursing team prioritizes
taking their paid time off (PTO) days
prior to the
Thanksgiving/Christmas/New Year
holiday season
RQ1:
Awareness
& Recognition

I feel my nursing team would inform
me if they were getting bullied by
their peers on the unit
RQ1:
Awareness
& Recognition

I feel my nursing team would inform
me if they knew one of their peers
had a substance dependence
problem
RQ1:
Awareness
& Recognition

I have taken part in policy or writing
with HR for my unit or the
organization
RQ2: HR
Partnerships
&
Practices

I feel my nursing team trusts me
professionally
RQ1:
Awareness
& Recognition

I completed a formal training or
preceptorship for my management
role
RQ2: HR
Partnerships
&
Practices

I feel confident in my knowledge
about of HR policies of the
organization
RQ2: HR
Partnerships
&
Practices

I feel my nursing team sees me as a
resource outside of clinical or patient
care concerns
RQ1:
Awareness
& Recognition

43

The peer support specialist/clinical
specialist or clinical educator assists
in making decisions for my unit
RQ3: Peer
Supports

I provide my team with information
on how to balance work/life stressors
RQ2: HR
Partnerships
&
Practices

I have an open-door policy for my
team to speak with me whenever
they have a question or concern
RQ1:
Awareness
& Recognition

Rank
the 3 items listed below,
in order of priority, in
areas where you would
like to grow your
leadership practice/skill:
General leadership
development; HR
Partnerships; Peer to
Peer Support
RQ2: HR
Partnerships
&
Practices

Rank the 3 items listed below in
order of perceived value regarding
what’s most important in the role of
a nurse leader:
General Manager Training, Manager
HR Training, or Increased knowledge
on utilization of Peer Support Roles
RQ2: HR
Partnerships
&
Practices

Average age of line staff personnel
on the unit is between:
20-30
31-40
41-50
51 & above
RQ3: Peer
Supports
RQ1:
Awareness
& Recognition

Use 3 words to define the culture of
your unit:
a)
b)
c)
RQ1:
Awareness
& Recognition

Data Collection Procedures
As part of the initial step in data collection for each participant, a quantitative survey was
sent to participants via email. Participants were asked to complete this survey prior to our
scheduled interview. The survey items focused on questions relating to nurse leaders’
experiences along with their knowledge of HR practices and peer support. The researcher
interviewed each participant face-to-face or via Zoom conference call. Each interview was
44

scheduled for 40-45 minutes. Questions for participants were open-ended with the intent to gain
personal views/opinions from the participants (Creswell & Creswell, 2018). The interviews were
not conducted face-to-face but by participant preference, held via Zoom conference call. The
data was also recorded with a voice recorder after receiving permission from the interview
participant. Post interview, the participant was informed that the recorder would be locked in a
safe with keys held only by the researcher. Notes from the interview were also kept by the
researcher in a journal to accompany the audio recorder for the accuracy of the interview
experience. The notes from the interview were locked in a file cabinet for safekeeping. The
participants’ names were omitted and provided with a number for coding and identity. As
outlined in Table 2, interview questions were prepared in advance for note-taking purposes. The
benefit of utilizing the interviewing process is to provide an opportunity for the participants to
directly share their experiences (Creswell & Creswell, 2018).
Table 2.
Interview Instrument
Interview Questions

Potential Probes

RQ
Addressed
Key
Concept
Addressed
Question
Type
1. What motivated you to
become a nurse manager?
Was the transition from
line staff to leader
challenging?

1

Leadership
Experience

Background

2. How would you describe
your leadership style?

Can you tell me more?
When did you know this?

1

Leadership
Style
Opinion

3. Describe the most recent
time when RN staff reported
an inability to complete a

What was your response?
How did you feel about
that?

1

Recognizing
staff in
jeopardy

Opinion

45

work task due to personal
stressors.

4. Can you describe the
personal (non-clinical)
stressors or incidents which
have the highest occurrence
amongst nurses in your
department and the steps you
took to support them?

Were you informed by the
nurse personally?

2

Leadership
awareness of
culture of
unit

Knowledge

5. To your knowledge, what
are the organizational goals?
How do they inform your
leadership practice within
your unit?
To what extent would you
say that your unit is
aligned with the
organizational goals?

1

Leadership
awareness of
culture of
unit

Knowledge

6. Describe the staff response
to peer support staff/clinical
educator or clinical specialist
on the unit?
How do you support their
efforts?

3

Peer support.

Knowledge

7. Can you identify &
describe staff challenges for
yourself as a nurse manager
with your line staff that are
unrelated to patient care and
how you supported them?

Can you provide an
example?

2

Leadership
awareness of
culture of
unit

Knowledge

46

8. Describe the last time you
had to engage the HR team to
support your unit.
What was the
outcome and was the
entire unit impacted by the
decision?

2

HR
Partnerships

Behavior

9. To what extent is the
clinical peer support team
supportive in providing
support and resources to your
unit?
How would you introduce
the support RN to your
team?

3

Leadership
Style

Knowledge

10. How would you describe
your rapport with the HR
team?

How would you say that
the HR team currently
works that might help or
hinder your goals?

2

Leadership
awareness of
role with HR
partner

Behavior

11. Define the process for
escalating RN staff concerns
that interfere with job
performance?

Is this the standard
process?

2

Leadership
awareness of
role with HR
partner

Knowledge

12. Can you provide
examples of any reported
manager calls for any nurse
emergencies non-patient care
related?

How did you feel about
that?

1

Recognizing
staff in
jeopardy

Sensory

13. What is your perception
of the organizational

Can you explain further?

2

Leadership
awareness of
Opinion

47

monitoring tools that are in
place at your facility to assist
RN’s in identifying signs and
symptoms of increased stress?

role with HR
partner

14. If your staff have
challenges that affect their
work, are you aware if they
are seeking direction from
you as the Manager/Director
vs. HR for first intervention?

How do you know?

2

Leadership
Style

Opinion

15. Have you ever worked
with a clinical support team
member on a unit?

If yes, can you describe
your experience?

3

Leadership
awareness/
Recognizing
staff in
jeopardy.

Knowledge

16. Can you describe any
organizational policy
changes/recommendations
from an accreditation body
that impacted your unit?

How did you enforce the
changes to ensure patient
safety?

2

Leadership
awareness of
role with HR
partner

Knowledge

17. Describe how you would
use clinical support team
member to support your
nursing staff?
How many hours per
week would you allow
them to come to the unit?

3

Recognizing
staff in
jeopardy

Knowledge

48

18. Please describe your vison
for work/life balance?

Can you elaborate?

1

Leadership
Style

Opinion

Validity and Reliability
Validity refers to the integrity and application of research methods, while credibility is
established as the findings accurately reflect the data (Noble & Smith, 2015). To ensure the
validity of the research, the study encompassed a sample size of 10 participants with the same
questionnaire sequences to maintain format consistency. The researcher established credibility
with the participant by providing the purpose of the research, professional career history, current
credentials, and academic status to develop rapport prior to being interviewed. The researcher
explained all responses to the questionnaire and explained how responses would be coded for
identification to maintain confidentiality. Clarification of terms was provided for reliability.
Reliability is defined as consistency, where the research study is conducted in the same way and
yields consistent results with the data collected (Merriam & Tisdell, 2016). The researcher
provided a consistent manner upon introducing the purpose of the study. To further ensure
reliability, the researcher asked the same questions in the same order to every research
participant. Post interview, the researcher offered each participant to have a copy of their
transcripts for clarification of interpreted survey answers. To maximize credibility and
trustworthiness in the study, the specific strategies used included triangulation (multiple uses of
resources of data), member checking (going back to the interview candidate and seeking
49

clarification from data obtained), and reflexivity (openness & self-reflection on biases about the
research study) (Merriam & Tisdell, 2016).
Ethics
Researchers must act ethically as they interact with participants. The researcher
complied with the University of Southern California’s Code of Ethics. Informed consent was
obtained in advance by giving written consent forms and participants were informed that they
were under no obligation to participate in the study. The researcher explained that participation
was voluntary. If any aspects of the research were thought to negatively impact their well-being,
all 10 Nurse leaders were given the choice to stop participation at any point in the study. There
was no compensation given for research participation. All participation for this study was
voluntary. The researcher explained positionality and explained that the purpose of this study
was to support student success. Furthermore, participants were reassured that their identity
would remain anonymous, and the information gathered would be treated as confidential. The
study proposal successfully passed the University of Southern California IRB process for
approval.
Underlying Ethics
This research study serves the interest of nurse leaders seeking to support their nursing
staff who have identified nursing working in crisis as an epidemic. Both nurse leaders and staff
nurses who suffer from a lack of well-being will benefit from this study. Nurse leaders gained an
understanding of how to strengthen management support techniques in efforts to retain clinical
staff. Nurses who have contemplated giving up on their careers will also learn avenues of
support for transparency with nurse managers prior to job jeopardy. Hospital organizations may
perceive harm in their reputations with their nursing staff if HR numbers reflect increased rates
50

of turnover, burnout, or poor patient outcomes. The researcher’s objective was to seek increased
safety outcomes for nurses and the patients under their care. The researcher has designed the
questions and framed their scope. The results were disseminated to interested participants and
presented to the organizations where they work upon participant request. Citing ethics as a
founding principle in nursing, Kunyk & Austin (2012) concluded that the body of nursing as a
profession, has a responsibility to be “congruent with ethical standards” and support all those
under nursing care.
Limitations and Delimitations
There are identified potential limitations to the study. The researcher obtained data from
participants who may have not articulated truthful details about their experience. The researcher
conducted the interviews in a private setting outside of the hospital without direct observation of
the participants’ leadership styles. There may also be biased responses from the candidate due to
the researcher’s presence or knowledge of the given study (Creswell & Creswell, 2018). Due to
nursing being a female-dominated profession, a higher number of participants were female.
The research project has several delimitations. The researcher has chosen nurses with
college degrees (minimum baccalaureate, BSN) who are in leadership roles. There are nurse
managers with greater than 10-20 years of experience without college degrees (associate degree
level RNs) who are nurse managers. Nurses who manage areas such as ICU, ED, Behavioral
Health, and surgical specialties were chosen due to acuity levels in these clinical areas.
Manager’s level or above were chosen for the designated nursing leadership role. Each
shift has a clinically competent charge nurse on the unit who leads the team for the allotted time
but does not make decisions for hiring, promotion, annual performance review, disciplinary
51

actions, or termination of the staff. The study does not include other stakeholder groups such as
medical assistants or certified nursing assistants.
The methodology of research was designed to ensure that the data received for this study
included the correct participants, utilizing a consistent survey tool and interview protocol to
answer the identified questions of inquiry. The researcher provided current positionality which
included prior nursing experience with the selected research topic on managing nursing in crisis.
The reliability of the study was strengthened by nurse managers and above, as participants, who
provide oversight to clinical teams within acute care settings. In Chapter 4, data collected from
these participants will be analyzed further to determine if it is consistent with current literature.

52

Chapter Four: Results or Findings
The purpose of this study was to analyze data collected from nurse leadership regarding
knowledge, awareness, and empathy to support the supervision of nursing staff who provide
patient care in high-stress critical care areas. The researcher used a mixed-methods case study
design with a development of cases from both qualitative and quantitative results gathered from
integrated data (Creswell & Creswell, 2018). The researcher began the analysis by using both the
qualitative and quantitative responses from the interview questions which formed multiple cases
that assessed nurse managers’ ability to recognize crisis. The researcher then analyzed the
collected data for knowledge of unit culture, staff personal needs, professional needs, their role
in human resources, and the value of the peer support nurse. The results and findings, along with
a summary, are sequentially categorized under the key factors which stem from the Burke-Litwin
(1992) model of leadership, change, and performance. The questions that guided this study were
as follows:
1. In what ways are nursing leaders positioned to recognize when nursing staff are in crisis,
need support, or identify as feeling compromised working in high level stress
environments?
2. To what extent do nurse leaders engage in partnering with HR to determine or enact
relevant employee policies and practices that support nursing staff?
3. How do healthcare organizations use informal peer support systems to support the nurse
leadership/line staff relationships during periods of high stress/crisis?
Participants
Participants included 10 nursing administrators who completed both a quantitative survey
as well as a qualitative interview. Each participant represented nursing administration from 10
53

different hospital facilities. The researcher began data collection by sending the nurse
administrators an email with instructions to complete a quantitative survey and informing them
that the qualitative interview would be scheduled within 5 to 7 business days. There were no
participant withdrawals from the survey or the Zoom interview. The researcher closed the online
survey after achieving a 100% response rate in the third week of data collection, while
qualitative data collection concluded upon the last administrative interview. In total, data
collection lasted 4 weeks from the initial survey to the final interview with all 10 participants.
Nursing Leadership Identified
The participants in this study included nurses from various leadership roles, such as nurse
managers, nursing directors, a vice president of nursing, and chief nursing officers. None of the
nurse leaders who participated in this research study were employed at the same organization.
All participants met the minimum requirement of having at least 5 years of leadership
experience. Four participants held a bachelor’s degree (BSN) in nursing. The other participants
included three nurse leaders who held master’s degrees and three participants who held doctoral
degrees.
According to the qualitative findings within this study, the motivation to become a nurse
leader resulted in two categories: (a) administrators reported they chose to become a nurse leader
due to observed poor leadership skills or (b) they were chosen directly to become a manager by
leadership in their organization. Three of the nursing participants reported having poor nurse
leadership when they were staff nurses, which influenced their decision to pursue managerial
roles. In line with the conceptual framework of the Burke-Litwin model, leadership directly
impacts the culture of the organization and its performance (Burke & Litwin, 1992). The
respondents within this study who were selected for nurse manager roles expressed the honor of
54

being selected but shared their uncertainty in confidence to lead their unit without formal
training. To function effectively, Nursing teams need identified leaders who fulfill the leadership
role with purpose (James & Bennett, 2020). The nurse leaders in this study expressed the
sentiment that if their former nurse managers could become leaders within the organization, then
with the pursuit of higher education, they, too, could apply for leadership roles. After completing
degrees or certifications for their specialty, they applied to nurse management positions.
Participant 6 explained her rationale for applying for the nurse manager position:
I had a manager that made poor choices. After she left the organization, I applied for her
job. My motivation was to make the team better, we did not deserve poor leadership. I
knew this transition would not be hard for me because I would be supported by my peers.
I always worked as the quiet leader.
Seven of the research participants reported that they were motivated to become part of
nurse management because they were chosen by nursing administrators. As a collective, they
shared they never interviewed for any nurse leader position directly but were chosen due to their
employment history at the hospital, commitment to the unit as an employee, or years of service
in their career as a nurse. Five out of the seven leaders reported that their transition to the
manager role was difficult because there were no expectations outlined. Nurse managers and
administrators are responsible for unit workflow efficiency (Branden, 2020). None of the
participants reported receiving any formal managerial training unless they specifically asked for
mentoring by the administrator who selected them for the position. Participant 4 shared,
I was never interested in leadership; management was gifted to me. I was sought out and
told I was going to be the manager. I worked at the hospital for 10 years. The transition
was very difficult from peer to manager on the same unit, but my boss supported me.
55

All participants reported that once they accepted leadership roles, they never went back to
staff nurse positions. They learned the responsibilities of the manager role via on-the-job training
from other nurse leaders and by working closely with the director of nursing. Their leadership
team placed value upon them in terms of their personal knowledge of and rapport with staff.
Developing a personal rapport with staff as a new manager was identified as a leading
contributor to gaining staff trust when directing unit nurses in patient care.
Results and Findings for Crisis Recognition
Research Question #1: In what ways are nursing leaders positioned to recognize when
nursing staff is in crisis, needs support, or identifies as feeling compromised working in high-
level stress environments?
Leadership Strategy for Recognizing Crisis
From the set of interviews and participant responses, nurse leaders espoused having a
good rapport with their nursing staff and that they had an “open door” policy whereby nursing
staff could come to them at any time with crisis issues as they arise. According to the Burke-
Litwin model (1992), the culture of an organization is described as the informal way things are
conducted within an institution. Nurse leader participants outlined in their interviews that the
open-door policy was their way to establish individual relationships with their staff. Nursing
leaders are aware that the efficiency of the unit/patient care is dependent upon the staff’s well-
being (Branden, 2020). The participants used the phrase “open-door policy” to describe their
leadership style. As nursing leaders, they impressed upon the researcher that by establishing a
relationship with line staff, they were better positioned to identify team members who had poor
work/life balance or were working in a crisis. Furthermore, the open-door policy allowed nurse
administrators to establish an organizational culture of trust, where line staff felt supported,
56

specifically by nursing. Participant 7 described the need for having an open-door policy as a unit
manager:
Having an open-door policy shows that you are a servant leader, you are empathetic, and
that you are collaborative. You listen to the staff whenever they call you even if it’s in the
middle of the night. You can coach them through and be stern, if needed, at the same
time.
Each leader verbally expressed their empathy for their team. Compassionate leaders
possess the ability to maintain effective relationships, listen to colleagues, and make suggestions
for improvement (Major, 2019). A concurrent description of the nurse/manager relationship was
akin to a family dynamic where the participants described themselves as the parental figure, such
as the mother or father of the unit. Having an open-door policy for staff to come to them with
any concerns and establishing trust as the unit leader fostered awareness. Each nurse
administrator also reported having a commitment to their team outside of scheduled working
hours. Nurse managers who establish an agreed set of expectations with their team develop a
strong and stable culture as a consistency trait (Casida et al., 2012). Per their choice, all 10
administrators reported they were accessible to their staff 24 hours a day, 7 days a week, if
needed, by request of their nursing staff. It was noted that even at the director or chief nursing
officer (CNO) level, an administrator could be reached by their cellular phone. Participant 6
reported showing her support to line staff by describing the rapport of trust and the benefit of
being available after scheduled work hours with an emergency room RN:
I noticed one of the nurses in the department, who typically dressed very nicely, was
looking quite different one day. Her scrubs were torn, she was wearing a head scarf and I
reminded her this was against hospital policy. I asked her if she was okay and if she
57

needed to speak with me privately. While on the unit she responded she was okay but
called me in the middle of the night. As I answered my phone, I could hear her sobbing
and crying to tell me she was thankful that I stopped and spoke to her earlier that day.
She explained how she was currently in a marital crisis, depressed and embarrassed her
marriage was ending. She explained the need to work for financial reasons but due to
personal stressors would probably need to take some time off work.
Unlike other hospital departments, nursing is managed 24 hours a day, with oversight
from the assigned manager and after-hours relief by supervisory staff. The nurse administrators
are scheduled to work the day shift, considered business hours, working amongst other key
hospital administrators such as chief officers or the human resource (HR) team. The hospital
structure of the nursing department allows nurses to provide 24-hour patient care. Within the
conceptual framework of the Burke-Litwin model (1992), the structure of the organization is a
key factor for decision-making authority, communication, and relationships for implementation
of an organization’s mission. All 10 nurse administrator participants attributed their commitment
to the organization outside of scheduled working hours to receiving better insight into the
personal life of their team members. Participants reported that although the hospital was staffed
with relief supervisors, they would receive calls from the supervisory staff to address crises.
Nursing leaders all agreed that they always answered calls for crisis occurrences on the unit
outside of business hours pertaining to both staff and patient concerns.
Organizational Culture
Eighty percent of participants expressed that they felt familiar enough with their team to
recognize when they were drained of physical and emotional energy. In agreement, 70% of the
nurse leaders identified stressors on the unit as the primary reason for after-hour administration
58

calls. These stressors included staffing shortages due to lack of attendance or absence due to
family emergencies. Additionally, the administrators themselves reported a lack of boundary
issues with finalizing an end to their workday, which led to poor sleeping patterns. Burke-Litwin
(1992) explained that management practices are a set of behaviors carried out by organizational
leaders to support strategy. Nursing leaders agreed that they experienced physical exhaustion
from embracing the strategy of being accessible 24 hours a day, 7 days a week for their hospital
colleagues. Research results for this study indicated that eight out of the 10 participants also
agreed that their team did not receive enough sleep before coming to work for their shift.
Nursing fatigue is recognized as a source of adverse patient outcomes and negatively
impacts nurse safety (Martin, 2015). The participants in this study never described the nurses
who worked on their unit specifically as facing burnout; however, based on the survey responses,
80% of leaders took it upon themselves to support staff by providing their personal resources for
work/life balance. Further, because unit managers or administrators took calls outside of working
hours, 60% of the respondents identified concerns for morale due to team bickering, bullying on
the unit, and the inability of nursing staff to work as a cohesive team. As critical care director
Participant 3 reported,
There are no formal monitoring tools in place by the organization, the nurse managers
have to manage their own staff, evaluate each situation, and do something because if
not…it will lead to high turnovers, the hospital needs to do something for us like give
incentives.
Emerging themes from the words used to describe the unit from the survey were terms
such as committed, teamwork, collaborative, and busy. Over 70% of the language used to
describe the unit overall was positive. The reaming 30% of terms used were specific to behaviors
59

described as toxic or angry. Burke-Litwin (1992) identified that the climate of an organization is
representative of collective impressions, expectations, and feelings that employees have which
affect their relationships with their leader. Nursing leaders attributed negative behaviors to
specific individuals on the team who commonly were reprimanded by the manager. When asked
directly about bullying, 90% of nurse leaders stated they believed bullying incidences among
staff would be reported directly to them as the leader due to their close relationships with staff.
The culture of the organization, learning from staff, and empowerment of staff are important
elements for leadership to consider when improving their unit (Wood, 2018). Per the leadership
participants, the open-door policy provided them with pertinent information for keeping the unit
managed and recognizing crises.
Discussion Research Question One
Nurse leaders reported little to no motivation to become nurse managers by their own
initiative. Further, 30% of nurse managers who felt motivated to pursue managerial roles sought
leadership positions in an effort to be supportive to their nursing peers. They reported examples
of poor leadership which motivated them to become a leader. Many of the participants were
never interviewed for their position. Seventy percent of participants admitted they never had any
formal training in how to manage nurses. It was impressed upon the researcher that there was an
unspoken badge of honor to being selected, gifted, or chosen to run a unit. Only one participant
reported that they asked for formal manager training. The other 90%, including those who
officially applied for the manager role, were instructed on management principles by the director
of nursing.
The nursing leaders who participated in this study who had no formal training in
leadership all agreed that it was important to establish relationships with their staff, which
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allowed their teams to have 24-hour access to them outside of the hospital chain of command
structures. In an effort to make their staff feel supported and to show empathy at times of crisis,
the nurse leaders experienced lapses in scheduled time off. The position of the nurse
administrator to recognize their staff in crisis is from a lens of unbalanced structure, therefore
placing them in a silo with minimum guidance from the HR team. When asked about HR
rapport, the leadership responses stemmed heavily from the nursing director versus the manager
themselves having a relationship with HR.
Results and Findings for HR Support
Research Question #2: To what extent do nurse leaders engage in participating with HR
to determine or enact relevant employee policies and practices that support nursing staff?
Nurse Leadership and HR Partnership
Nurse leaders have a vital role in meeting patient care demands. In order to facilitate and
meet the demands of patient care, an effective collaboration between nursing leadership and HR
must be present for an institution’s success (McNeil et al., 2020). Answers reflected in the online
survey revealed that 80% of the nurse leaders used HR as a resource for staff concerns; however,
upon further investigation, the responses from the qualitative survey portion of the research
differed from the responses given during the Zoom interview. The nurse managers explained that
there was a specific process whereby HR was used via the intervention of the director of nursing
or chief nursing officer. Per the Burke-Litwin model (1992), an organization’s culture has a
stronger influence on the organization’s systems. As the participants responded to the qualitative
interview, they explained the culture of nursing as existing as a separate entity from HR. Nurse
administrators reported in 90% of their interview responses that any staffing concern raised,
including crisis, was initially escalated by policy through a chain of command within the nursing
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division. This process was defined by a consistent theme for the administrator to be available for
staff and have an open-door policy for nursing concerns to be addressed only by nursing
leadership. Per these administrators, HR supported these first-step actions by hospital policy.
Upon further discovery, it was revealed that HR was not aware of how many decisions were
made under the discernment of the manager to the director of nursing. As Participant 9
explained,
It is our hospital policy that all nursing concerns must go through nursing first, if there is
any issue the nurse managers and nurse leadership team must handle them first before
going to HR. My office is located right next to the HR office, If I see any nurse walk past
my office, I will get up from my desk to redirect them back to their department or have
them come to speak with me about their concerns.
The established rapport with HR was described in the same way by each participant. The
leadership interactions with HR were described as “cordial, rarely existing outside of hiring
staff.” Nurse administrators based their HR relationships on scenarios described by either the
selection or termination of nursing staff. Recruitment was referred to as a “very slow process” by
all participants. In 100% of cases where administrators recognized behaviors, such as repeated
staff absences initially unreported to HR, nursing leadership made final decisions regarding
termination. Where nurses faced job jeopardy, the relationship with HR was described as good
because the nurse leadership team collectively decided prior to speaking with HR to terminate
that staff member. In cases where nursing staff faced termination, HR was also described as
being very supportive. The nurse manager Participant 6 reported the following:
Staff know how to meet with the nursing leaders first, then we bring it (the crisis) to the
VP of nursing. The nurse manager records the unit concerns and write-up all
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conversations as the front line. I guess they could go to HR, but I tell them to think about
it first because the VP decides if HR needs to be involved. We as nurse leaders have their
best interest. We involve HR if the decision is to terminate.
Due to working with the directors of nursing, the leadership team reported that 80% of
them were aware of the policies of their unit but were not confident in their knowledge of HR
policies themselves regarding staff resources for crises. When surveyed, 60% of participants
ranked manager HR training as the most important role for a nurse in leadership. The remaining
40% of participants ranked general manager training as a priority. Both groups of participants
acknowledged the need for manager training primarily with HR and secondarily regarding
guidelines for general manager training.
HR and Management Practices
The Human Resources department is key for organizing systems and managing human
talent (Burke & Litwin, 1992). Participants in this study explained the processes under nurse
leadership guidance for managing human talent that was not always reported to HR. Within 10
different hospitals, a total of 42 reported HR incidents had occurred over the past 12 months.
These occurrences were grouped into five individual categories: (a) work/life balance stressors,
(b) grief/depression, (c) substance dependence, (d) bullying, and (e) attendance/staffing (see
Figure 6). Stressors reported to management in the work/life balance category represented the
highest individual occurrence at 39%, with one case being escalated directly to HR. The
escalated case was reported to the director of nursing (DON) first followed by HR, as
management had hired a nurse without a valid nursing license. Nursing leaders reported that in
cases where nurses expressed repeated stressors from work/life balance, they were given
scheduled time off to address their personal circumstances or attend to their crisis independently.
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If the culture of a nursing unit does not provide consistency, it will lack shared values and
coordination (Casida et al., 2012).
Figure 6
Human Resources Reported Occurrences Among Nursing Leaders

Note: Developed by K.Morton, 2022.
As a consistent practice, nurse leaders admitted that HR was not contacted directly as a
resource for nursing staff. Nurse administrator Participant 8 explained, “We call in our nurses to
work a lot of overtime, if they are stressed, they can talk to me, and I’ll look at the schedule to
see if they can get some time off.” None of the administrators reported that they sought HR
assistance for coping skill resources, incentives, or to collaborate with the CNO/DON for
strategies to deliver information to the team. To support the staff, the managers listened,
provided empathy, and, if possible, scheduled time off for a 40-hour work week which did not
entail overtime.
39%
21%
19%
14%
7%
HR Reported Occurences
Work Life Balance
Bullying
Depression/Grief
Attendance
Substance Dependence
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Depression, grief, and bullying combined represented 40% of occurrences reported to
management, with all bereavement cases being escalated to HR. In cases of bereavement,
employees were referred to the Employee Assistance Program (EAP) or were given time off by
the manager. Bullying occurrences were primarily handled by the nurse managers. Workplace
incivility, such as bullying, is referred to as low-intensity deviant behavior that may appear
harmless to leadership but poses a threat to healthy work environments (Laschinger et al., 2014).
One single case of bullying was reported within the research study to HR by the nurse manager
because the situation had escalated to a physical altercation, and the nurse identified as the
aggressor was terminated.
The episodic cases of bullying remained in the unit between line staff and management.
None of the bullying cases were reported as being escalated to the director of nursing (DON).
The nurse leaders spoke of their administrative position from a parental dynamic in these
scenarios. They reported during the interview that the nursing staff as a team is taken care of like
a group of children. The nursing leader addressed bullying incidents during 1:1 meetings with
the team member accused. In a separate meeting, the victim was reassured by leadership that the
problem would dissipate because it was addressed by the leader personally, as the authority
figure. Participant 8 explained,
My team has its few that are always yelling and bickering at each other, that’s how they
are…I observe it until I am tired of all of them. Once I had to pull us together for a quick
meeting during the shift, because it had gotten so bad, we took an unconventional route
and prayed for our team.
Out of the 42 reportable items, seven occurrences were successfully escalated to HR. These
occurrences included an RN licensure issue; a pay rate adjustment for a salary increase; a staff
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physical altercation; an incident of stealing time from the time clock, which lead to termination;
and three pharmacy issues.
All three controlled substance/narcotic RN cases were reported due to findings from the
pharmacy department. In these instances, the pharmacy director reported events related to
controlled substances first to the DON or CNO. Pharmacy medication red flags were reported
due to repeated offenses of increasing numbers of narcotic signoffs, patterns of narcotic counts
being incorrect, or patterns of “wasted” narcotics when specific staff worked the unit. In each
case, the DON or CNO approached the unit manager. Each leader agreed that they may have
suspected something was noticeable with the RN’s behavior but never addressed the individual
staff member. In all three pharmacy-controlled substance/narcotic cases, the RNs were
terminated. In one case, the RN license was reported to the state licensure board of nursing. The
state in which the RN license was reported to the board also offered recovery programs for
nurses who suffered from addiction. The other two nurses were terminated without being
reported to the state board of nursing and were not given resources for addiction support
services. Participant 7 described her interaction with an impaired nurse as follows:
I witnessed this nurse have personality changes, being jittery, biting her nails all the time
and then the CNO & Pharmacy Director informed me that she was pulling narcotics. I felt
like I let her down because I saw it and I never came to her about what I observed. Even
though she was terminated she said to me in the HR meeting that she was glad it came to
this, and I came to her so she can get the help she needed.
The three nursing leaders who reported the controlled substance/narcotic cases verbalized they
did not feel equipped to address addiction conversations with their staff. It was expressed that if
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there were addiction concerns, either the pharmacy would report them to the CNO or the unit
staff, such as a charge nurse, would report narcotic miscounts.
When asked about their leadership styles in managing these high-stress area teams, 50%
of the administrators reported they did not have a defined style. Burke-Litwin (1992) outlined the
importance of human motives when exercising the behavior of affection and power to motivate
employees. All nurse leaders within this study reported that they were successful in influencing
their teams by showing commitment and dedication. A nurse administrator’s leadership style can
produce either an effective or ineffective outcome for an organization (Casida et al., 2012). As
nurse leaders who did not seek first-line resources with HR, they referred many times to keeping
an open-door policy to learn the needs of their nursing staff as well as to support them when
stressed. Participant 9 replied,
I lead the team to support them more in a family style, I like to coach them, that’s why I
have an open-door policy. I am not big on disciplinary action. They can call or text me
anytime. I receive a lot of calls after 2 AM.
Further, 40% of respondents said that their leadership style was transformational. Although the
descriptive term used to define their leadership style was “transformational,” none of the ideals
explained were attributes of transformational leadership. Transformational leadership in nurse
administration is the ability to instill inspirational motivating behavior that impacts the culture of
the nursing unit (Casida et al., 2012). Contrary to transformational leadership styles, there
remained a lack of influence on staff, which changed the culture and behaviors within the
department. Most of the examples reported during the interviews included a give-and-take
exchange of rewards for staff service, which, in those cases, leaned more toward a transactional
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leadership style. The nurse administrators went on to explain a few if/then scenarios as the
following:
• If the nurses reported crisis issues that lead to stress, then those nurses were given the day
off.
• If there were bullying and bickering on the unit, then the leadership would order pizza for
the team meeting.
• If there were unit attendance issues, then overtime was offered for other nurses who were
seeking financial assistance.
The remaining 10% of participants reported they had a servant leadership style. Those
leader/staff interactions were described as staff expressing concerns for the unit and the nurse
leader taking proactive measures to accommodate the team. Examples of this approach include
the nurse leader taking on patient admissions or discharges or assisting with placing doctor’s
orders. Nurse leaders also admitted at times to addressing patient/family concerns personally
versus delegating to the charge nurse. These behaviors were also reflective of the initial 40% of
participants who stated they could not define their leadership style. The self-identified servant
leader Participant 5 shared,
I make sure I listen to my team and go on the unit to help them with what they need, you
know? …just like a family style. If it is something missing, I can get it, speak with the
patients, and call the doctors to help out.
Participants in this research study expressed they had strong relationships with their team in that
90% of them agreed that if nurses were having negative thoughts about their job overall, the staff
nurses would report it to them first and give them the opportunity, as the leader, to facilitate the
changes needed to make the unit better. Although 60% of the participants agreed that the director
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of nursing made all the decisions for their department, it was their direct relationship with the
team which was impactful. Therefore, a strong connection was made between leadership and
relationships. HR, collectively, was not viewed as a supportive entity to nurse management
because they were not clinicians and did not understand nursing issues.
HR Stress Monitoring
According to Burke-Litwin (1992), the task of managing employee skills is a requirement
for completing work accomplishments. Nurse administrators who participated in this study
acknowledged stressors of work/life balance for their team that interrupted unit nurses’ ability to
provide patient care. Participants employed as nurses were asked during their interview about
attempts made by HR and/or leadership to provide monitoring tools to keep the pulse on nursing
stress levels. Organizational practices identified to support nurse work stresses were limited.
Based on the survey responses, 30% of participants worked at a hospital where HR attempted to
provide support for monitoring stress. One nurse leader reported that her organization’s HR
introduced a software app through the HR portal where the nurses could gather tips for handling
stress. She admitted that she never tried the app and her staff never reported usage of this tool.
After the introductory HR campaign of the support software, no reports were given to
management regarding the app’s success.
The remaining two out of the three cases where support tools were introduced as an
option to address work/life balance were presented by HR as a follow-up to crisis events that
occurred within the hospital. For these HR in-services, licensed clinician crisis workers came to
the unit to present safety and coping skills to manage stress. One organization held a seminar
discussing violence in the workplace. The other organization held an in-service which promoted
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RNs to self-recognize stress and take notable actions to seek help from colleagues when stressors
affected their work.
The HR team developed a stress code for nurses where they would carry a specific-
colored stress ball and hand it to a co-worker if they felt overwhelmed to the point where they
needed to leave the unit for a 5–10-minute time out. Coworkers were instructed to immediately
assume responsibility for that nurse’s patients and inform the manager. Per the nursing
administrator, her team did not use this nurse code because they expressed the process was
impractical and would not work for a behavioral health unit. The nurse leader did not report a
lack of adherence by staff to HR. She explained that the HR plan would never work and
instructed her team to continue to report to her if they were having a crisis on the unit.
Participant 8 explained,
Our HR attempted to have a code neon alert for the nursing staff. The plan was if the
nurses were stressed, they would give their peers a multicolored stress ball as the signal
that they needed to leave the unit for a time out. The other staff member would then take
the ball, come to my office, report the incident to me as the manager, and take
responsibility for his/her patients until they recovered. The nurses did not use this code. It
just did not work! I told my staff to talk to me…that’s what I’m here for.
Due to critical incident occurrences, both in-services were deemed mandatory for staff
attendance. If nurses did not attend the mandatory presentation, HR informed the staff they
would get a write-up, which would be documented in their employee record. Both nurse
administrators reported that they ensured all their staff attended the mandatory in-services and
that no team member would receive a write up.
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In accordance with the survey, 70% of nurse leaders reported their organization did not
have any monitoring tools in place to monitor staff burnout. Nursing leadership must be able to
recognize signs of stress in their staff, acknowledge their value on the unit, and be mindful of the
barriers to job performance (McComisky, 2017). Nurse administrators within this study were
confident that they could refer the nurses to HR for the employee assistance program (EAP) if
they were to notice a need for HR intervention.
From the survey, 80% of participants reported that they partook in the writing of unit
policies with the CNO. When probed about policy writing, the answers were reflective of the
CNO needing additional information regarding sentinel events that occurred on their unit. The
nurse leaders answered with confidence (n = 60%) that they were knowledgeable about HR
policies for staff support and how it impacted the delivery of patient care. All leaders were well
versed in policies regarding paid time off (PTO), which they frequently regulated as a response
to crisis support. Regarding knowledge of PTO within their hospitals and organizations, 80% of
the participants agreed that nurses taking their PTO were important and, as leaders, they assisted
staff to prioritize PTO prior to the holiday season.
Administrators that were employed at facilities that did not offer official stress
monitoring tools for nurses reported providing work/life balance techniques in staff meetings or
during 1:1 conversations. One ICU nursing administrator instructed her team to make a shared
stress-coping journal of errors for the unit. If a staff nurse came to the administrator, she would
refer them to read their peers’ journals to provide additional support. Additionally, she also
created an anti-stress poster board for her staff and placed them in the staff break room. Any staff
crisis issue brought to her for the week would be placed on the poster board for the unit to read.
When asked if this idea was supported by HR, she acknowledged that both HR and the CNO
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were informed of the unit practice. No HR feedback or guidance was given to support her
initiative. She explained further,
My staff had so much stress from work and life that would lead to small patient errors. In
order to teach them how stress is not good for patient care, I created a journal club. The
journal of errors would be kept in my office, and I would encourage them to write their
mistakes and stressful situations that lead to the mistake in the journal. I also created an
anti-stress poster board which I put in the staff breakroom so other staff could learn but
not make the same mistakes. I would put tips on the board for handling stress. HR knew
what I did but they did not say anything about my idea.
Discussion Research Question Two
In reviewing the data collected from both the survey and interview, there was an
underlying theme of non-trust between HR and nursing leadership. Nursing administrators
repeated the pattern of the strict rule that nurses must seek out nursing administrators first for any
issue. If crisis issues needed to be handled, the immediate manager and the DON would decide
whether to seek HR for guidance. Hence, most decisions were made by the CNO/DON with the
rationale that nursing, not HR, had the best interest of the nursing staff.
Nursing administrators admitted they needed training on policies, HR resources, and
overall management training. The immediate resolution to assist staff was to keep an open-door
policy, even if it meant nurse managers were a silo unto themselves in attempting to handle
nursing crises. Based on participants’ survey answers, there was a lack of buy-in across the board
regarding the role of HR and its function to support all the employees of the hospital, including
nurses. HR did not appear to have a strong voice in nursing regulation except in the cases where
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nurses needed to be hired or fired. There were circumstances where possible coaching and
mentoring may have saved nurses in crisis prior to termination.
If nursing administrators receive further education on leadership styles, they may learn
how to strengthen their relationships with their team before they also experience nursing burnout.
As servant leaders, transactional leaders, or aspiring transformational leaders, there is a boundary
issue that is not beneficial for middle management positions. There is also a dynamic of power
and chaos where line staff does not have adequate support to provide patient care.
All the nursing leaders reported the desire for their staff not to work overtime but rather
to enjoy their days off. As for the nurse leaders themselves, they acknowledged that nursing is
monitored on-site after they leave the hospital, but they take calls 24 hours a day. Nurse leaders
admitted that their behavior resulted in not having a private life outside of their hospital role.
They loved their position as an administrator but could not identify their role under the guise of
work/life balance and expressed concerns that this may be the standard for nursing leadership.
Results and Findings for Peer Support Specialists
Research Question # 3: How do healthcare organizations use informal peer support
systems to support the nurse leadership/line staff relationships during periods of high
stress/crisis?
Staff Mentoring and Peer Support Presence
Participants in this study conveyed their views on peer support systems in periods of
high-stress crises. Burke-Litwin (1992) highlighted that the dependent variable of structure has a
direct impact on the organization’s climate. Administrators within this study identified clinical
specialists and/or nurse educators as key personnel in the hospital who took the responsibility of
providing structure to RN new hires. All nursing participants agreed that having a support-level
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team member, either as a clinical specialist or a nurse educator, for line staff would help decrease
staff turnover rates. Clinical support staff serve as mentors and aid with internal barriers of the
organization, self-doubt, and obstacles faced by work stressors (Vance, 2022). Nurse leaders
reported that 70% of the organizations they represented offered the role of clinical
specialist/nurse educator, whereas the remaining 30% did not offer this leadership position to
support staff. The seven organizations represented that offered nurse educators or support
personnel had to split their time between multiple high-stress clinical units. Critical care unit
educators were directed to split their time between the emergency room staff and the surgical
team. Other sharing units included behavioral health, surgery, and the mother/baby unit. There
were no individually assigned support staff per unit. During the hospital survey, nurse educators
were assigned to meet with staff monthly due to the administrative response for an accreditation
body citation.
In the hospitals represented that did not have a clinical specialist, the managers would
need to provide their staff with continued education and mentoring during staff meetings.
Participant 7 shared the views of the CNO in her department:
She told me that ICU nurses know they take roles in high-stress areas. That’s why they
are hired, they do not need a clinical specialist. As the manager, it is my responsibility to
support them. If I felt, they needed a clinical specialist then maybe those particular
nurses were not smart enough to work in ICU. I was also informed that if a clinical
specialist was considered for hire, they would have to be split between ICU and the
Emergency Department. I informed the CNO that I would support my team and not
choose to have a specialist that would be split between two departments.
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An emerging theme arose during the collection of data for this study regarding clinical support
staff. In organizations that hired clinical specialists, they covered education for multiple
departments, if not the entire facility. Clinical specialists were noted as a valuable commodity
and, in all cases, were used to onboard new hires during orientation. All nurse leaders reported
that if their facility had a clinical specialist, he/she directly reported to the CNO. If there became
a need to support nurses in crisis, the nurse educator was called upon, like HR, for a sentinel
event within the organization. Clinical specialists were not called upon to provide daily work/life
balance support once the nurses were acclimated to the unit. Nursing, as a profession, is not
meeting its ethical obligation to mentor nursing staff, leaving a gap between those that need a
mentor and those receiving mentoring (Vance, 2022). As an administrator, peer support
specialists assist with orientation and organizational goals or fill in for the unit manager if they
are absent. According to 50% of the participants, the clinical specialist contributed to making
decisions for their unit. As reported by Participant 10, who is a CNO,
Our clinical specialist is used heavily during nursing orientation and the first 30 days the
nurses are on the unit. I cannot have them go to the units regularly for staff support. The
nurse managers would only want to use them to help with staffing and taking patient
assignments rather than training.
Nurse leaders agreed that having a nurse educator as a support person would be a budgetary
issue. If a hiring director or manager wanted to obtain a full-time support staff nurse educator,
the full-time position would be taken away from the staffing grid to hire a nurse. Understanding
position control, nursing leaders voiced they would not allow their units to be short by one
nursing staff unless the educator agreed to assist on the unit by providing patient care when they
were short-staffed.
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Peer Support Impact
The Burke-Litwin model (1992) acknowledges that the most important subsystem for an
organization is the establishment of policy and procedures. Nurse leaders within this study
reported that it was the clinical support specialist who provided the structure to nursing staff in
navigating the changes in hospital policy updates. A key role of clinical specialists or nurse
educators is to provide updates to all levels of nursing regarding any hospital policy changes.
Leaders reported that their organizations recognized that the clinical specialist had the capacity
to provide this service, often regarded as support, in learning the organizational goals and
outcomes. Nursing managers admitted that if the DON did not make the organizational goals
clear, the nurse educators were effective in explaining how policy changes impacted the unit and
what pertinent information management was allowed to share with staff.
Managers reported they needed the support of the clinical educators the most during post-
hospital accreditation surveys when policy changes impacted their unit directly. Nurse educators
helped the management team explain the policies to their staff and obtained mandatory
signatures of agreement in cases where hospital citations were given for discrepancies. The
policy changes explained by the clinical specialists most frequently and which impacted the unit
were acknowledged as patient safety by 80%, while the remaining 20% were attributed to
patient/staff ratios for staffing. Although two administrators did not define patient safety as a
reason for unit policy changes, they agreed that staffing ratios also impacted patient safety. Nurse
educators/clinical specialists were responsible for keeping records of all employee signatures as
acknowledgment for understanding hospital policy changes.

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Individual Talent/Needs
Administrators who experienced having support staff personnel when they were line staff
prior to becoming a nursing leader appreciated the nurse support staff role. The administrators
who did not have experience of working with support staff did not place a high value on having
the position because they identified themselves as the educational resource for their team. All
participants agreed that the clinical specialist was a welcome addition to support staff; however,
the participants were divided amongst the allotted time the support person would be present on
their unit. Time frames for staff interactions with the clinical specialist were revealed through the
survey, as 50% of the participants wanted nurse educators to be present for fewer than 20 hours
per month, while the other half of administrators expressed that the clinical specialist should be a
full-time position dedicated only to their assigned unit. One nursing director expressed the desire
for one full-time clinical specialist that could be used at 40 hours per week. They expressed a
desire for the rotating job role, which would allow for weekly representation at each shift and
would reflect attendance on days, evenings, and nights. The ER director went on to explain, “I
would have someone fully dedicated, only to support the emergency room. ER nurses make bad
floor nurses; they need skills training for intricate details and someone to remind the senior staff
to obtain their certifications.”
Based on the survey, participants who had full-time employed clinical specialists shared
that none of the persons hired for that role worked all three shifts. The clinical specialist role, as
defined by HR, was considered administrative, with presence only during the day shift except in
the case of sentinel events. Nurse administrators agreed on the need for clinical support staff but
disagreed on how much time should be spent with the nursing staff.
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Amongst the other 50% of leaders surveyed, it was expressed that limited interaction is
needed between staff and the clinical educator. According to Cole (2020), nursing support staff,
aside from the unit manager, should be instituted at every hospital for unit nurses to have
additional support when seeking advice or help. However, the opinion was expressed that the
clinical specialist was used as an informant by the CNO or DON for closer department
monitoring of the unit leader.
Discussion Research Question Three
There is a division amongst nursing leadership regarding the value of having clinical
support for nursing staff. The nursing leaders expressed the need for themselves, as hospital
administrators, to have policies and hospital deficiencies explained to staff. Participants also
expressed a limited desire for the leaders to utilize the clinical specialist role as a resource for
staff in crisis. Participants expressed on-call fatigue but viewed the clinical educator as an
outsider involving staff rapport. Although the clinical specialist/nurse educator is also a nurse,
they are considered outsiders to the staff and intrusive to the staff/manager relationship. The
clinical specialist serves in an ancillary role, supporting the needs of the CNO versus serving as a
resource for crisis support with the nursing staff.
Conclusion
Under the umbrella of external conceptual factors in the Burke-Litwin (1992) model,
leadership provides direction to the organization and coordinates mission/strategy initiatives to
drive the organization forward (Spangenberg & Theron, 2013). The data from this research study
revealed that this group of nurse administrators is not formally trained to identify staff working
in crisis within their leadership roles. Specialized training occurs with nursing leadership as a
result of a sentinel event with staff or unfavorable patient care outcomes. All participants were
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nursing administrators for a minimum of 5 years. Six nursing leaders served in their
administrator role between 5 to nine 9 and the remaining four leaders held over 10 years of
leadership experience. In all 10 interviews, given the years of nurse leadership experience, no
participant expressed the desire to change the leadership model to better recognize a crisis. An
organization’s effectiveness is dependent upon the relationship between the organization’s
external environment and the organization’s internal structure (Burke & Litwin, 1992).
Exemplifying this scenario within a hospital setting demonstrates that nurse leaders who lack the
ability to recognize nurse crises at work, internally, would increase the risk for poor patient
health outcomes and bring jeopardy to the community at large, externally.
The nurse leaders within this study shared that with the support of the hospital CNO, they
addressed each nursing crisis individually with empathy. Collectively, the participants expressed
accepting a nurse administrative role as well as the primary responsibility to manage nursing
crises alone. The CNOs who participated in this study reported that as executive leaders, they
learned how to handle staff crises from the most tenured or credentialed nurses that worked
within the hospital. CNO participants also shared that they sought advice from HR after those
initial nurse-to-nurse consultations. HR representatives were utilized for additional support after
nursing discussions to obtain policy and procedure directives when finalizing nursing decisions.
The nurse leaders in this study identified that HR is equipped with the knowledge of hospital
regulatory guidelines, but the nurturing of nurses is the job of those who are professionally
designated as caregivers.
Clinical specialists were also perceived as support staff to nursing leaders. They provided
the skills needed to onboard nurses during hospital orientations, but they were not used or trained
for crisis intervention. Clinical specialists provide specialized training for hospital regulatory
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compliance. As an administrator, the clinical specialist serves the greater needs of the
organization, leaving mentoring within the unit manager role. The opportunities for nursing
leadership to extend the olive branch to both HR and the clinical specialist in support of nursing
crisis recognition are needed to address burnout concerns.
Next, in Chapter Five, the researcher provides recommendations for recognizing crisis.
Suggested interventions are presented based on themes found where nursing leadership could be
strengthened by overcoming their disposition with HR and restructuring the clinical specialist
role for mentorship.

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Chapter 5: Recommendations
Nursing represents a profession of compassion where the dynamic of the work setting
calls for resilience in fast-paced, high-stress environments. Nursing leadership finds itself with
the challenge of balancing the needs of the patient, organization, and nurses on the front line.
The purpose of this study was to evaluate nurse administrators in their ability to discern when the
unit nursing staff is compromised or in crisis. Solving this problem of practice supports
achieving equitable outcomes for addressing the needs of nurses in crisis by identifying self-care
as a priority to effectively deliver safe patient care. This study was guided using the development
of a conceptual framework to examine the contextual factors, such as the influence of leadership
and lack of recognition of staff crises by nursing leaders. These identified factors were examined
due to their presumed effects on unit nursing staff as the key stakeholders. Chapter Four
presented the results and findings from the quantitative survey and the qualitative semi-
structured interviews to answer the study’s three research questions. The conceptual framework
used for this study was the Burke-Litwin model of organizational performance and change
(1992). This chapter includes evidence-based recommendations to strengthen the ability of
nursing leaders to discern crises amongst unit staff.
More importantly, nurse administrators lose insight into crisis occurrences if there is
ambiguity in structuring leadership roles. Lack of relationships with HR, the questioning of staff
peer support/educators, and the limited ability to discern crisis contribute to poor outcomes in
patient care. Burke and Litwin noted that the cause-effect relationship between an organization’s
internal and external environment is linked to organizational effectiveness (Spangenberg &
Theron, 2013). The findings in this study embrace the opportunities within nurse management to
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address traditional structures, where a climate of unit crisis is considered a normative role for the
profession.
The Burke-Litwin (1992) model of organizational change attributes climate
improvement to having effective processes combined with a culture of transformation. The
contextual research for this study supports the significance of leadership changes within nurse
management. The results of these findings include educational goals for crisis recognition, Nurse
Manager HR alliances, and Nursing leadership competency for organizational success.
As nurse leaders play a vital role in establishing the work culture, they have the
responsibility to advocate for unit nurses who work while in crisis. To ensure these employees
have access to what they need, nurse managers must possess leadership proficiency to recognize
the early diagnosis of unit incivility or crisis existence (Laschinger et al., 2014). According to all
the administrative participants in this study, early recognition of crisis received limited priority
among healthcare organizations represented in this study. Per their responses, hospital leaders
placed emphasis on the nurse manager to maintain an open-door policy where crisis resolution
required swift urgency and the expectation of both parties to return to work.
Recommendations for Recognizing Crisis
Recommendation 1: Incentivize Nursing Leadership
Nurse leadership roles range from management to executive officers such as the Chief
Nursing Officer or Director of Nursing. According to the survey results of this research study,
70% of the participants had little to no interest in ever pursuing nursing administration roles
within their careers. Due to their demonstration of high-trust/high-caring characteristics, the
participants admitted to being chosen to fill the position of leadership. If nursing leaders did not
have an initial drive to be in their leadership roles, the researcher questions if being chosen to
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lead versus having the initial motivation to lead staff nurses skewed management practices.
Nursing leadership roles would be more attractive if incentivized with management education
(Tang & Hudson, 2019). According to the conceptual framework by Burke-Litwin (1992), bi-
directional relationships between the transactional factors of leadership and transformational
factors of leadership contribute to an open system where each variable is dependent upon one
another to be successful. Using these factors from the Burke-Litwin model, the nurse leadership
role is integral to upholding the standards for management practices and system policies to attain
successful patient outcomes.
Healthcare organizations could begin incentivizing the leadership role by providing
educational reimbursement for leadership training. Health facilities would see a return on their
investment by providing training courses for nurse leadership through a partnership with external
stakeholders who provide formal leadership education (Chandron, 2010). In nursing school,
nurses are taught how to care for patients, but there is no formal training on how to manage their
peers. As stated by Pittman et al. (2012), strategies healthcare organizations use to incentivize
the nurse administrator roles are career ladders supported by advancement in education Per the
Burke-Litwin model (1992) the positive transactional exchange between the organization
managing individual talent and the employee leads to motivation. Nurses are open to
encouragement from their employers on how to improve their careers. Employers who
demonstrate a supportive attitude ensure that career advancement options are visible and at the
institution’s expense (Kallio & Hult, 2022). Once nurses are encouraged to become a part of
leadership, their organization would provide formal training to develop competency skills.
Successful competency, evaluation, and feedback serve as initial guides to manage their team
(Figure 7).

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Figure 7
S.M.A.R.T. Goals to achieve Nurse Leadership

S.M.A.R.T. GOALS
S
Nurse leadership training will include 4 learning modules that will be completed
in 6-8 weeks
M
Nurse leaders will have milestone markers for each competency track completed
with a passing score of 95& or above
A
Support Staff Specialist will assign nurse mentors for supervision and assist nurse
managers to plan team-building activities
R
Nurse Managers who complete leadership training will receive a certificate of
completion and be certified by the hospital organization for crisis training.
T
Nurse Leadership training will be completed annually within the first quarter of
the year.

Note: Developed by K.Morton, 2022.
The next process of improvement to incentivize nursing is to establish levels of
competency with reward recognition for notable career milestones. Competency training for
nurse leadership is meaningful for career development and a key factor in workforce retention
(Kallio et al., 2022). Organizations must establish a competence basis for leaders. Nursing
administrators would need to continuously enhance their skills to demonstrate competency
advancements in comparison to established baselines for accountability (Chandran, 2010).
Career mapping utilizes competency training by placing leaders at the correct level of
management. As the research results of this study show, dedication to a hospital or exuding
compassion does not equate to leadership competency. Having soft skills such as emotional
intelligence is critical within an organization, but leadership competency drives the success of an
organization (Beckham & Riedford, 2017).
In the current state of nursing shortages, nurses seek to have structure for career
development. There is an urgency to develop career mapping where both work/life balance and
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the image of martyrdom do not present as a deterrent to attracting leadership (Kallio et al., 2022).
Hence creating criteria for management competency to enhance career development contributes
to a structural change in the culture of the work environment. Nursing administration sits at the
helm of the hospital organizational structure. The Burk- Litwin model defines the leadership role
as pivotal in providing overall direction to an organization (Spangenberg & Theron, 2013).
Nursing leaders would thrive as a viable resource in the cases where their own stressors
were decreased. Job satisfaction for the nurse leader creates a work environment that decreases
staff crises such as burnout and subsequent turnover (Laschinger et al., 2014). Healthcare
organizations that prioritize structuring the leadership role will drive the motivation of nurses to
be confident to leave the patient’s bedside for a professional contribution as an administrator.
Specific training for staff crisis is just as important as patient crisis training.
Recommendation 2: Provide Nurse Administrators with Crisis Training
According to the findings of this study, all 10 nursing administrators reported they were
made aware of peer problems such as bullying, personal emergencies involving the sudden death
of a family member, substance dependency issues, and work/life balance crisis. Nursing
management described a leadership response to a crisis by making themselves available 24 hours
a day. Within the Burke-Litwin model (1992), process efficiency is a direct variable for the
organizational climate. Nursing leadership establishing availability 24 hours a day is not an
efficient process, nor does it support a climate of job satisfaction. The 10 healthcare
organizations represented in this study did not have tools for any level of nurse administration
managers to formally address the crisis with organizational resources. Organizations leave
nursing leadership to chance, having crisis resolutions determined by trial and error (Balough-
Robinson, 2012). Nurse administrators in this study openly admitted to receiving emergent crisis
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phone calls or requested appointments within their office from staff to speak about urgent
matters. In these given scenarios, the nurse leader used his/her discernment for addressing the
crisis or escalated the issue to the CNO. The future of nursing requires a need to work towards a
reconstructed model of leadership which includes elements that focus on improving system
performance and staff engagement (Ahmed, 2018).
In order to provide efficiency in their roles, the recommendation given is to provide
nursing leadership with crisis protocol training to better serve unit staff. Modules of crisis
training would be considered mandatory for the leadership role. Healthcare organizations that
introduce crisis training to their staff prioritize wellness initiatives and emphasize the value of
safety promotion (James & Bennett, 2020). Given this recommendation, the CNO or Director of
Nursing needs to determine the time frames best suited for manager training. Health care
facilities who provided nurse managers with 1-hour modules on the identification of stressors for
their team promoted the value of recognizing job burnout (Laschinger et al., 2014). According to
the nurse leaders, in current practice, the directive given to nurse management is to deliberate
with intentions of keeping the chain of command intact and informing nursing leaders first of
any crisis thus, all management, keeping the open-door policy. All nursing leadership
participants spoke about keeping an open-door policy to be abreast about the pulse of the nursing
staff crisis. Nursing staff regard Nurse managers as more successful when keeping an open-door
policy to create a positive work culture, where staff is not afraid to share personal or professional
stressors (Finlay et al., 2019). However, nurse administrators, in this study, identified themselves
as lacking work/life balance and accepting poor quality of life as a part of the expected
responsibilities as a leader. For the results of this study, the open-door policy extended itself
without HR resources. Examples included after-hour calls, where house supervisors could not
86

assist nursing staff with emergencies and would instruct the team to contact the managers on
their cell phones.
The next proposed recommendation for the implementation of crisis training is to include
assessment training for addressing staff concerns. It is imperative for nursing leadership to
process indicators of crisis swiftly and accurately (Samuel et at., 2015). Nurse leaders benefit
from the provision of a decision tree to handle staff occurrences with transparency supported by
HR for decision-making options. Decision-making models are used in crisis events to identify
the problem, solutions, and leaders responsible for formulating the plan (James & Bennett,
2020). The implementation of a decision-making model contributes to the nurse managers’
confidence in making system decisions based on approved protocols rather than person-
dependent decisions with the CNO. In the same manner that new clinical skills are taught,
effective communication, hospital policies, and conflict resolutions are steps needed in creating a
culture of nursing leadership (Balogh-Robinson, 2012).
Within the Burke-Litwin (1992) conceptual framework, managing staff talent provides
anchoring support for human capital. The final proposed recommendation for crisis training is
teaching nurse leaders how to identify their leadership styles and make the best use of those
leadership strengths upon guiding staff. The approach used within the training module would
distinguish leadership styles and characteristics. Effective leaders understand how their preferred
leadership style influences their decision-making skills (Ahmed, 2018). Nurse leaders who know
the characteristics of their leadership style also know how best to communicate with their team.
In transformational leadership, empowering others and transforming the value base are key
characteristics and in servant leadership, collaborative/trust-based characteristics are key (James
& Bennett, 2020). Nurse leaders having a strategy for crisis decision-making would strengthen
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professional judgment. As nurse leaders are the frontline for staff, they also need support in
mentoring their teams. Nurse mentors would ensure decisions made by leaders for staff crises
were effective with ongoing staff supervision.
Recommendation 3: Restructure Clinical Support Staff Role
Participants in the study who reported having clinical support/nurse educators at their
healthcare organizations described the Clinical Support Specialist role as administrative, having
limited interaction with the staff nurses. The utilization of clinical specialists in the health care
organizations represented in this study was for the benefit of onboarding the new hire RNs. In
the Burke-Litwin model (1992), managing the organizational climate is a transactional factor.
Purposefully assigning staff to a mentor assists the nurse manager in establishing culture, as
outlined in the conceptual framework. Assigning a clinician with life experience to supervise
each nurse in the facility serves as a benefit to the organization (Oates, 2018). An open
transaction benefit from the model is exampled by the unit staff having an assigned mentor and
the organization positioned as partnering for core strategy. The supervision sessions with
mentors would serve as a first-level resource for RNs with colleagues that provide coaching but
are not seen as the administrative team. The recommendation given is to restructure the Clinical
Support Specialist’s role as the administrator, to assign mentors for nursing staff and become a
direct report to HR as opposed to the CNO.
In best practice, assigning clinical staff mentoring or coaches to the unit manager aids in
providing emotional competence and professional support (Cole, 2020). The Clinical Support
Staff would be responsible for assigning each nurse employed at the hospital facility to a mentor
for assistance with the challenges of the profession and work/life balance stressors. The role of
the mentor is to promote coping skills and provide a positive rapport with the management team
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(Oates, 2218). Within this study, there was a lack of supervision for nurses as new hires or
seasoned RNs within the hospitals represented. Having a mentor in the workplace creates a
culture of inclusivity (Vance, 2022). The internal contextual factors of the Burke-Litwin model
(1992) identify work culture as being managed by leadership. As an administrator, the Clinical
Support Staff Specialist would have the authority to manage assigned mentors for scheduled
nurse 1:1 meetings or real-time presence on the unit. The Clinical Support Specialist has the
training and skill set to use their knowledge to develop nursing talent (Vance, 2022). In cases
where potential crisis would be on the rise, mentors would report these episodes to the official
Clinical Support Specialist who would serve as the next level of escalation.
It is also recommended that the Clinical Support Specialist become a direct report of the
HR Director to ensure the nursing leadership alliance is in accordance with policy, talent
acquisition, and crisis status monitoring. The hierarchical change structure of an organization
affects the behaviors exhibited between leadership and subordinates (Burke & Litwin, 1992).
The inclusion of the Support Staff Specialist’s role within the HR department runs parallel to the
conceptual framework, exemplifying the re-alignment of the management structure to foster staff
talent. Nurses seek feedback, support, and guidance in their daily clinical setting. Nurse
Specialists as executive administrators, have a vital role in teaching and mentoring Nurse
Managers to become competent leaders (Casida et al., 2012). Creating a workplace culture of
mentoring provides staff with the opportunity to address workplace crises from a trusted source.
Initially, managers may be skeptical or view the nursing support team members as intrusive until
they see a turnaround in unit culture (Cole, 2020). The positioning of HR status for the Nurse
Specialist keeps the open-door policy directive guided by staff nurses. Providing a culture within
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an organization where learning is encouraged, and individuals are empowered improves the
health of staff (Wood, 2018).
Recommendation 4: Establish HR Education as Mandatory for Nurse Leaders
As a result of the findings of this study, over 50% of the nursing leaders reported that they
did not have adequate knowledge of their hospital human resource policies. All 10 administrators
expressed their established rapport with HR as a secondary relationship regarding organizational
policies as it pertains to Human Resources. In this study, the primary HR resource support came
from the Director of Nursing. At the highest administrative level of nursing, the Chief Nursing
Officer or Director of Nursing determined what level of HR involvement was needed for nursing
matters. In these scenarios, nursing became a siloed entity, making life-changing decisions for
staff, based on person-dependent experiences. If an organizational leader’s belief about success
does not align with company strategy, the organization will face challenges (Burke & Litwin,
1992). Nurse Manager participants reported that there were formal HR policies, but the division
of nursing operated under the guise of nurse executive leadership direction. Healthcare
organizational success begins with forming a cohesive team between nursing leadership and their
HR departments (McNeil et al., 2020). The recommendation given to establish HR education is
for each management level of nursing to complete mandatory competency training to learn HR
policies within their organizations. As a manager or above, the structure for leadership is
weakened when dependent upon interpretation by a single individual. Bi-weekly meetings are
strongly suggested for HR and nursing leadership to maintain accountability (McNeil et al.,
2020).
The next recommendation is to have the Clinical Staff Specialist as the liaison for the
meeting with managers and the HR team. Healthcare organizations thrive when they have the
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HR team train nurse management on staff challenges, resources, and well-being benefits (West et
al., 2017). After nurse leadership completes the HR policy training, each manager would
empower nursing staff members by providing crisis case studies for discussion/review with team
members. Nurse leaders who presented the opportunity for their teams to work in a group session
exposed unit staff members to develop leadership skills, which provided motivation to their peers
(Cziraki et al., 2017). HR educational activities guided by leadership would promote the
competency of the unit manager. It is recommended that nursing professional development
would involve activities to promote competence that close career knowledge gaps (Ahmed,
2018). Within the Burke-Litwin (1992) conceptual framework continued leadership training
impacts organizational and individual performance. If nurses must keep their clinical knowledge
current to maintain licensure for effective patient care, the standard for management should
include HR competency to retain nursing talent.
The final proposed recommendation for improving HR/nurse leadership relationships is to
implement annual mandatory HR competency exams. Healthcare organizations improve patient
outcomes when nursing leaders are well-versed in HR training concepts such as effective
communication, employee consultation, employee benefits, stress management training,
Employee Assistance Program (EAP) training, and organizational stress policy implementation
(Moore, 2020). As nurse leaders deconstruct former power dynamics, knowledgeable
management teams will arise ensuring pathways for successful patient outcomes. Having HR
knowledge to support staff in crisis is further enhanced with the ability to facilitate team
building.
Recommendation 5: Incorporate Team Building
Study results also revealed that 80% of organizations represented within this research
lacked monitoring tools to track nurse stressors. With gathered knowledge of HR, the
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recommendation is for nurse administrators to incorporate team building to strengthen unit
culture and promote self-care. Unhealthy work environments in nursing can be considered a
social determinant of health (Bragadottir, 2016). Two nurse leaders spoke of team comradery
only occurring, once a year, during their annual Nurse’s Week celebrations. Feedback given
from nursing line staff to these administrators reflected the sense of minimal value or insight into
the critical needs of their own unit. It takes commitment from a manager to frequently gather
their teams, note changes in behavior or validate a level of distress (Vogel and Flint, 2021). It is
noted in the Burke-Litwin (1992) conceptual framework that addressing an individual’s needs
impacts the climate of the unit. Nurse managers maintain the work/life balance of their unit by
engaging staff, sharing governance decisions, and addressing morale on a regular basis (Ahmed,
2018). In the results of this study, there was one organization that attempted to support nurses by
having a nursing emergency code. The nurses did not trust the coding process to support a
colleague in crisis because the model was not created from a documented HR policy or
successful team-building example. Incorporating team building with nurses in health care
organizations is to foster team spirit, where nurses are accepted, valued, and appreciated (Cole,
2020). Nurse management’s flexibility in being creative is key for team building.
The last recommendations given for team building include scheduling care team initiatives
such as creating meditation rooms or scheduling 10-minute massage break services to foster
climate support in crisis. Additionally, well-being activities could be offered during shift breaks
or walk-and-talk outdoor meetings could support team-building initiatives (Oates, 2018). Nurse
administrators would have to ensure ways that supported all nurses had access to these activities.
Development of lifestyle changes on a unit with colleagues as a shared work experience can
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create transformational bonds (Vance, 2022). With nurturing, nursing team culture is then
reestablished, evolving into a cohesive unit for safe patient care.
Implications for Practice
Limitations and Delimitations
Limitations of this study are noted to provide transparency in the findings. The study
attempted to use a mixed methodology of qualitative and quantitative analysis. Limitations were
cited in the beginning for the quantitative findings for the sample size of nursing leader
participants. The qualitative limitations were identified in technical arrangements for
interviewing candidates.
The quantitative sample size was limited to 10 nurse leader participants. To capture a
more representative sample of nursing leaders, the study could have included(with time allotted)
greater than 50 participants with more recruiting specifications. Participants would have
provided more context for the study if divided by age, gender, or ethnic background. Many of the
participants involved in this study (90%), were women. However, women make up a larger
sample size at 83.2% of the nursing profession across the United States. (U.S. Bureau of Labor
Statistics, 2022).
The qualitative limitations of the study were observed in the arrangements for the interviews.
Initially, unforeseen when outreaching participants, there were a significant number of technical
challenges for the nursing administrators with utilizing Zoom as a tool for interview. Nursing
leaders who participated in this study were largely unfamiliar with using Zoom as a platform for
their everyday work environment. The familiarity of face-to-face options was preferred but due
to convenience, all participants agreed that using the Zoom platform was a better option. Pre-
interview sessions were started to provide instructions and teaching on how to download
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software and set up interview options. Once instructed on setup and reassured about privacy in
technology all the interviews were completed without any issue.
Delimitations of the study are the elements of the research that were controlled by the
researcher. The researcher chose to focus on nursing leadership as the driver of influence for
bringing effective change to nurses in crisis. In all levels of nursing administration from
manager to Chief Nursing Officer research supported how to strengthen these positions to impact
floor nursing. The position of the researcher as both nursing administrator and investigator led to
a deeper understanding of the shared experiences given by the participants. The evidence-based
recommendations provide resources for senior-level hospital administrators to make changes in
the organizational structure of the division of nursing. Position control and budgetary guidelines
would not restrict options for healthcare facilities seeking to implement changes despite
organizational size differences.
Future Research
The findings of this research study lend themselves to the examination of nursing
leadership roles. Future research on organizational structure and guidelines for role
differentiation amongst nurse leaders would probe investigations for self-identified career-
determined success in the nursing profession. The foundation for developing leaders would be
essential for handling staff crises. Developmental theories would examine characteristics that
build leadership outside of the patient care role experience. Once leadership characteristics are
identified HR could then create programs with the staff specialist to certify nurse management
levels. Currently, nursing leadership roles are not determined by education. Although years of
experience have been traditionally equated to leadership knowledge, it does not ensure
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competence. Nurse representation as a permanent staple in HR would provide beginnings to
organizational restructuring within hospitals to address staff work/life balance needs.
Crisis management for work/life balance will continue to improve with research on
hospital organizations providing physically safe spaces where nurses can receive on-the-job care
in an emergent state. As certified employee researchers could investigate the outcomes of nurses
receiving real-time care from peers within their organization that support a rotation of
mentoring-to-healing programs which run 365 days a year.
Continued research is needed to showcase that nursing support provides better health
outcomes for patients and hospital accreditation status. Nursing wellness levels are not
advertised publicly to protect the identity and scrutiny of the hospital organization. Although
accreditation reporting is public knowledge, the general public does not look for reporting scores
upon seeking emergent care. With nursing being the backbone of hospital service providers,
research is needed to assess whether overall publicly announcing nursing staff wellness as a
metric with accreditation agencies will guide hospital HR guidelines in staff support. Patient
outcomes are critical for the success of hospitals. Equally important, nursing wellness outcomes
add to the goal of patient care delivery. Further research is needed on implementation mandates
by government or state nursing boards to ensure wellness benefit policies are active in every
institution where nursing is practiced.
Conclusion
The state of nursing is impacted by crises such as insufficient work/life balance skills,
bullying, burnout, insufficient direction from nurse leadership, and lack of support from hospital
organizations as employers. The social determinants of health include supportive work
environments for nurses where the staff is ensured a quality work environment as patients are
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ensured quality of care (Bragadottir, 2016). Healthcare administrators would not disagree that
the goals of patient care are deemed successful upon receiving health restoration, whereas the
same administrators allow ambiguity to deter the standards for nursing wellness. In this research
study nursing leaders found themselves without the structure, as outlined within the conceptual
framework, to support management practices that would provide resources for nurses employed
in high-level stress environments. Healthcare organizations supply 24-hour nursing care via a
profession where attention to the needs of those in the role of caregiver affect the services
delivered to the patient.
As head of influence, nursing leadership owns the responsibility of clinical and
professional competence. When nurse managers are in an unhealthy mental state, they may
experience a state of distress, unable to provide empathy to staff (Beckham and Reidford, 2017).
The participants within this study described a chain-of-command reporting structure that placed
nursing in a silo for escalating staff crises. The decisions for front-line staff were often made by
the executive nursing leader within the organization with minimal input from the human
resources department. Reported crises were addressed out of empathy as opposed to policies
outlined by the standard operating procedures within the hospital for the management of
professional registered nurses. The internal contextual factor of the conceptual framework cites
managing talent with HR partnership as the tenant of structure for the organizational culture.
The conceptual framework included interdependent relationships which identified factors
internally like organizational and individual performance. Peer support/clinical specialist roles
were identified as key to bringing structure to nursing staff because of their power to model
organizational culture by providing mentorship (Vance, 2022). As recommended, clinical
specialists serving as mentors to the staff from the position of an HR liaison would serve as the
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leaders driving external factors such as increased staff retention and decreased negative patient
healthcare outcomes. Successful patient outcomes, as an external factor, is dependent upon
maintaining healthy work environments for nurses, which translates into quality healthcare
systems at large (Bragadottir, 2016).
In the hospitals identified for this study, limitations were placed on the roles assigned to
the nursing educator. Underutilized, nurse clinical specialists, were introduced for nurse
orientation onboarding checklist or adverse hospital events where staff training was mandatory
for accreditation bodies. Successful nurse coaching relationships are guided by instant real-time
mentoring, career advice, work strategy, relief for personal life stressors, encouragement,
redirection, and praise (Vance, 2022). These various levels of guidance enhance employee
motivation.
The future of nursing depends upon clearly defined quality measures of work/life
balance. Healthcare organizations rethinking their internal structures to maximize leadership
roles must occur to create an atmosphere of mindfulness. With leadership organizational tools in
place, the manager, as the caregiver to unit staff, can provide a scaffolded action plan to support
nurses, provide empathy, maintain patient safety, and lead transformational change in healthcare.

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2?accountid=14749
Brewer, B. B., & Verran, J. A. (2013). Measuring Nursing Unit Environments with Four
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Burke, W. W., & Litwin, G. H. (1992). A Causal Model of Organizational Performance and
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model-organizational-performance-change/docview/215258879/se-2?accountid=14749
Casida, Jesus M, PhD,R.N., A.P.N.-C., Crane, Patrick C,M.S.N., R.N., Walker, Tara L,M.S.N.,
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leadership-culture-high-performing/docview/1315303309/se-2?accountid=14749
Chen, S., & Ching-Fu, C. (2018). Antecedents and consequences of nurses’ burnout: Leadership
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Finlay, F., Baverstock, A., & MacCallam, J. (2019). Psychological Support for Rapid Response
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journals/nurse-fatigue-shift-length-pilot-study/docview/1674728475/se-2?accountid=14749
McNeil, G. Hudson, J., Orto, V, Waters, F, Pearce, S., Cates, P., Velez, L, Austin, W. & Walters,
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work-environment-patients-quality-care/docview/2410490909/se-2
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Pittman, P., PhD., Herrera, C. S., Horton, K., R.N., Thompson, Pamela A, RN, F.A.A.N., C.E.O.,
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111

Appendix A: Survey Demographic Questionnaire
Demographic Questions
Please indicate your role:
e) Nurse Manager
f) Nurse Director/Director of Nursing
g) Chief Nursing Officer
h) Other (enter here) _____

How many years of nursing
leadership experience do you have?
d) 5 years
e) 6-9 years
f) 10 years or more

Questions CF Element Strongly
Agree
Agree Disagree Strongly
Disagree
I Don’t Know
I appreciate the work ethic of my
nursing staff
RQ2: HR
Partnerships and
Practices

My Director of Nursing /VP makes
final decisions for my unit
RQ2: HR
Partnerships
&
Practices

I use HR as a resource for staff
issues/concerns non-related to
patient care
RQ2: HR
Partnerships
&
Practices

My nursing staff is drained of
physical and emotional energy
RQ1:
Awareness
&
Recognition

My nursing team would inform me if
they were having negative thoughts
about their job
RQ1:
Awareness
&
Recognition

My nursing team gets enough sleep
prior to the start of their shift before
they arrive to work
RQ1:
Awareness
&
Recognition

My peer support team
specialist/clinical specialist/clinical
educator provides my unit a
schedule of availability for support
RQ3: Peer
Supports

My nursing team would report any of
their medication errors or patient
adverse outcomes to me prior to the
end of their shift
RQ1:
Awareness
&
Recognition

I feel my nursing team prioritizes
taking their paid time off (PTO) days
prior to the
Thanksgiving/Christmas/New Year
holiday season
RQ1:
Awareness
&
Recognition

112

I feel my nursing team would inform
me if they were getting bullied by
their peers on the unit
RQ1:
Awareness
&
Recognition

I feel my nursing team would inform
me if they knew one of their peers
had a substance dependence
problem
RQ1:
Awareness
&
Recognition

I have taken part in policy or writing
with HR for my unit or the
organization
RQ2: HR
Partnerships
&
Practices

I feel my nursing team trust me
professionally
RQ1:
Awareness
&
Recognition

I completed a formal training or
preceptorship for my management
role
RQ2: HR
Partnerships
&
Practices

I feel confident in my knowledge
about HR policies of the organization
RQ2: HR
Partnerships
&
Practices

I feel my nursing team sees me as a
resource outside of clinical or patient
care concerns
RQ1:
Awareness
&
Recognition

The peer support specialist/clinical
specialist or clinical educator assist in
making decisions for my unit
RQ3: Peer
Supports

I provide my team with information
on how to balance work/life
stressors
RQ2: HR
Partnerships
&
Practices

I have an open-door policy for my
team to speak with me whenever
they have a question or concern
RQ1:
Awareness
&
Recognition

Rank the 3 items listed below,
in order of priority, in
areas where you would
like to grow your
leadership practice/skill:
General leadership
development; HR
Partnerships; Peer to
Peer Support
RQ2: HR
Partnerships
&
Practices

Rank the 3 items listed below in
order of perceived value regarding
what’s most important in the role a
nurse leader:
RQ2: HR
Partnerships
&
Practices

113

General Manager Training, Manager
HR Training or Increased knowledge
on utilization of Peer Support Roles
Average age of line staff personnel
on the unit is between:
20-30
31-40
41-50
51 & above
RQ3: Peer
Supports
RQ1:
Awareness
&
Recognition

Use 3 words to define the culture of
your unit:
d)
e)
f)
RQ1:
Awareness
&
Recognition

114

Appendix B: Interview Questionnaire
Interview Questions

Potential Probes

RQ
Addressed
Key
Concept
Addressed
Question
Type
1. What motivated you to
become a nurse manager?
Was the transition from
line staff to leader
challenging?

1

Leadership
Experience

Background

2. How would you describe
your leadership style?

Can you tell me more?
When did you know this?

1

Leadership
Style
Opinion

3. Describe the most recent
time when RN staff reported
an inability to complete a
work task due to personal
stressors.

What was your response?
How did you feel about
that?

1

Recognizing
staff in
jeopardy

Opinion

4. Can you describe the
personal (non-clinical)
stressors or incidents which
have the highest occurrence
amongst nurses in your
department and the steps you
took to support them?

Were you informed by the
nurse personally?

2

Leadership
awareness of
culture of
unit

Knowledge

5. To your knowledge, what
are the organizational goal?
How do they inform your
To what extent would you
say that your unit is
aligned with the
organizational goals?

1

Leadership
awareness of
culture of
unit

Knowledge

115

leadership practice within
your unit?
6. Describe the staff response
to peer support staff/clinical
educator or clinical specialist
on the unit?
How do you support their
efforts?

3

Peer support.

Knowledge

7. Can you identify &
describe staff challenges for
yourself as a nurse manager
with your line staff that are
unrelated to patient care and
how you supported them?

Can you provide an
example?

2

Leadership
awareness of
culture of
unit

Knowledge

8. Describe the last time you
had to engage the HR team to
support your unit.
What was the
outcome and was the
entire unit impacted by the
decision?

2

HR
Partnerships

Behavior

9. To what extent is the
clinical peer support team
supportive in providing
support and resources to your
unit?
How would you introduce
the support RN to your
team?

3

Leadership
Style

Knowledge

10. How would you describe
your rapport with the HR
team?

How would you say that
the HR team currently
works that might help or
hinder your goals?

2

Leadership
awareness of
role with HR
partner

Behavior

116

11. Define the process for
escalating RN staff concerns
that interfere with job
performance?

Is this the standard
process?

2

Leadership
awareness of
role with HR
partner

Knowledge

12. Can you provide
examples of any reported
manager calls for any nurse
emergencies non-patient care
related?

How did you feel about
that?

1

Recognizing
staff in
jeopardy

Sensory

13. What is your perception
of the organizational
monitoring tools that are in
place at your facility to assist
RN’s identify signs and
symptoms of increased stress?

Can you explain further?

2

Leadership
awareness of
role with HR
partner

Opinion

14. If your staff have
challenges that affect their
work, are you aware if they
are seeking direction from
you as the Manager/Director
vs. HR for first intervention?

How do you know?

2

Leadership
Style

Opinion

15. Have you ever worked
with a clinical support team
member on a unit?

If yes, can you describe
your experience?

3

Leadership
awareness/
Recognizing
staff in
jeopardy.

Knowledge

117

16. Can you describe any
organizational policy
changes/recommendations
from an accreditation body
that impacted your unit?

How did you enforce the
changes to ensure patient
safety?

2

Leadership
awareness of
role with HR
partner

Knowledge

17. Describe how you would
use clinical support team
member to support your
nursing staff?
How many hours per
week would you allow
them to come to the unit?

3

Recognizing
staff in
jeopardy

Knowledge

18. Please describe your vison
for work/life balance?

Can you elaborate?

1

Leadership
Style

Opinion

Asset Metadata

Creator Morton, Kimberly Linsand (author)

Core Title Identifying needs of the caregiver

Contributor Electronically uploaded by the author (provenance)

School Rossier School of Education

Degree Doctor of Education

Degree Program Educational Leadership (On Line)

Degree Conferral Date 2023-05

Publication Date 05/04/2023

Defense Date 03/28/2023

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag chief nursing officer,director of nursing,health care organizations,human resources,nursing leadership,OAI-PMH Harvest

Format theses (aat)

Language English

Advisor Spann, Rufus Tony (committee chair), Kellar, Frances (committee member), Kim, Esther (committee member)

Creator Email klmorton@usc.edu,kmorton0601@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC113099740

Unique identifier UC113099740

Identifier etd-MortonKimb-11770.pdf (filename)

Legacy Identifier etd-MortonKimb-11770

Document Type Dissertation

Format theses (aat)

Rights Morton, Kimberly Linsand

Internet Media Type application/pdf

Type texts

Source 20230505-usctheses-batch-1037 (batch), University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the author, as the original true and official version of the work, but does not grant the reader permission to use the work if the desired use is covered by copyright. It is the author, as rights holder, who must provide use permission if such use is covered by copyright.

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA

Repository Email uscdl@usc.edu

Abstract (if available)

Abstract Nursing is a high-stress profession where critical thinking skills are needed to ensure the delivery of efficient patient care. Nurses, as caregivers, work in critical care areas where the expectation is to set their own personal challenges aside to perform the duty of taking care of patients at the most vulnerable times of their lives. Self-care and the ability to maintain wellness at work may be neglected by nurses at times, due to personal commitment in role performance. This study examines the ability of nursing leadership to discern when unit nurses are compromised. A mixed method study was conducted to examine the responses from 10 Nurse Administrators and their responses to their unit nurses when working under crisis. Due to role expectations, unit nurses themselves may not have the ability to place self-care as a priority, therefore omitting well-being. The role of nursing leadership is imperative within healthcare organizations to coach, advise and mentor their direct reports. Nursing leaders who lack assessment skills to recognize compromised staff play their role in compromising healthcare systems as well as patient care outcomes.