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Middle management’s struggle to sustain change: perspectives of the middle management team in nursing

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Middle management’s struggle to sustain change: perspectives of the middle management team in nursing

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Middle Management’s Struggle to Sustain Change: Perspectives of the Middle
Management Team in Nursing

Amy Elisabeth Altomare

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

December 2022

© Copyright by Amy Elisabeth Altomare 2022
All Rights Reserved

The Committee for Amy Elisabeth Altomare certifies the approval of this Dissertation

Esther Kim
Colleen O’Leary
Rufus Tony Spann, Committee Chair

Rossier School of Education
University of Southern California
2022

iv
Abstract
This qualitative study sought to identify a healthcare middle managers’ role in change and the
healthcare organization’s ability to develop leadership and change competencies for their success
in achieving sustainable outcomes. A dual conceptual framework guided the study, including the
knowledge-motivation-organization gap analysis combined with social cognitive theory to
understand both the organization and individual perspectives. The focus of this study was to
identify the needs of the middle manager role so the organization can meet them where they are
and provide opportunities for development. Semistructured interviews and secondary data were
leveraged to gain understanding into the role and responsibilities of the healthcare middle
managers, barriers they encounter, and elements needed for success in role and sustaining
change. Several findings emerged that indicate healthcare middle managers’ competing
priorities, struggles with resolving barriers, and need of directed support and assistance for their
success. Recommendations are presented to establish organizational structure for the healthcare
middle manager to develop skills and competencies to support change implementation and the
sustainment of outcomes.
Keywords: healthcare middle manager, change, quality improvement, change
management, leadership development, knowledge, motivation, environment, KMO, gap analysis,
social cognitive theory.

v
Dedication
To those who have cared for me and lifted me up along this journey—I could not have
accomplished this without your love and support. Your confidence in me during this process
helped me grow and flourish, keeping me focused when I was not sure I would succeed.

vi
Acknowledgements
Thank you to my parents who have always encouraged me to be a perpetual student, your
love and support have helped me through this doctorate. Thank you to those that always had faith
in me completing this dissertation – the ones who ensured I persisted and never gave up. Thank
you for supporting me through the late nights, the nerves, and the countless revisions. Thank you
to cohort 17, I'm so glad to have met you and you have all taught me so much. Special thank you
to the two people I met in this program who refused to let me get discouraged and were always
there to provide confidence boosts when I needed it the most. Thank you to my dissertation
committee who guided me through the process—your feedback and support were instrumental in
my success. Thank you to the wonderful leaders in my life who encouraged me to pursue both
the doctorate and this study, thank you for giving me opportunities to grow and shine. Special
thank you to all the managers and directors who participated in this study – your willingness to
be candid with me as a researcher made this study and the recommendations possible.

vii
Table of Contents
Abstract .......................................................................................................................................... iv
Dedication ....................................................................................................................................... v
Acknowledgements ........................................................................................................................ vi
List of Tables .................................................................................................................................. x
List of Figures ............................................................................................................................... xii
Chapter One: Introduction to the Study .......................................................................................... 1
Context and Background of the Problem ............................................................................ 4
Purpose of the Project and Research Questions .................................................................. 8
Importance of the Study ...................................................................................................... 9
Overview of Theoretical Framework and Methodology .................................................. 11
Definitions of Terms ......................................................................................................... 12
Organization of the Dissertation ....................................................................................... 15
Chapter Two: Literature Review .................................................................................................. 16
The Middle Manager Role in Healthcare and Nursing ..................................................... 17
Perceptions of Leadership: Middle Manager Role and Organizational Hierarchy ........... 23
Challenges of the Middle Manager Role .......................................................................... 31
Organizational Struggle to Sustain Change ...................................................................... 42
Needs of Middle Managers ............................................................................................... 48
Dual Theoretical Frameworks: KMO and Social Cognitive Theory ................................ 57
Conceptual Framework: Intertwining KMO and Social Cognitive Theory...................... 63
Summary ........................................................................................................................... 70
Chapter Three: Methodology ........................................................................................................ 71
Research Questions ........................................................................................................... 71
Overview of Research Design .......................................................................................... 72

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Research Setting................................................................................................................ 73
Researcher Positionality.................................................................................................... 74
Data Sources ..................................................................................................................... 78
Validity and Reliability ..................................................................................................... 92
Ethics................................................................................................................................. 94
Summary ........................................................................................................................... 96
Chapter Four: Results and Findings .............................................................................................. 98
Study Participants ............................................................................................................. 99
Roles and Responsibilities .............................................................................................. 102
Results and Findings for RQ1: A Nurse Middle Manager’s Ability to Facilitate
Change ............................................................................................................................ 109
Results and Findings for RQ2: Needed Skills/Competencies for the Nurse Middle
Manager .......................................................................................................................... 134
Results and Findings for RQ3: Needed Support and Resources for Nurse Middle
Managers ......................................................................................................................... 161
Summary ......................................................................................................................... 178
Chapter Five: Recommendations ................................................................................................ 181
Discussion of Findings .................................................................................................... 181
Recommendations for Practice Aligned With KMO and Social Cognitive
Frameworks..................................................................................................................... 185
Integrated Change Theory to Support Implementation .................................................. 214
Limitations and Delimitations ......................................................................................... 218
Recommendations for Future Research .......................................................................... 219
Conclusion ...................................................................................................................... 220
References ................................................................................................................................... 221
Appendix A: Protocols ................................................................................................................ 244
Respondent Type ............................................................................................................ 244

ix
Consent to Participate in Study ....................................................................................... 245
Introduction to the Interview .......................................................................................... 245
Conclusion to the Interview ............................................................................................ 249

x
List of Tables
Table 1 Comparison of RN and Medical and Health Services Manager Role 51
Table 2 Data Collection Methods for Study Research Questions 73
Table 3 Purposeful Selection Criteria 80
Table 4 Participant Purposeful Selection Criteria Summary 100
Table 5 Study Participant Personas 101
Table 6 RQ1 Findings With Conceptual Framework Elements and Gap Identified 110
Table 7 Identified Barriers to Implementing Change and Current Resolution Strategy 117
Table 8 Review of Learning Management System Course Topics 130
Table 9 Review of Learning Management System Types of Course Offerings 131
Table 10 Review of Learning Management System Courses Targeting Managers 132
Table 11 RQ2 Findings With Conceptual Framework Elements and Gap Identified 135
Table 12 Feelings of Role Preparedness 136
Table 13 Pre-HARP Learning Needs Assessment, April–May 2021 154
Table 14 Post-HARP Learning Needs Assessment, June–July 2022 155
Table 15 Perception on Ability to Apply Training in Role 158
Table 16 RQ3 Findings With Conceptual Framework Elements and Gap Identified 162
Table 17 Needed Support and Resources the Nurse Middle Management Team Sought 163
Table 18 Recommendations to Support KMO and Social Cognitive Frameworks to
Improve Problem of Practice 186
Table 19 Recommendation 1: Alignment to Conceptual Framework 192
Table 20 Recommendation 1: Comprehensive Onboarding Programs for Middle
Managers Logic Model for Evaluation 194
Table 21 Recommendation 2: Change Infrastructure Alignment to Conceptual
Framework 204

xi
Table 22 Recommendation 2: Change Infrastructure for Middle Managers Logic Model
for Evaluation 205
Table 23 Recommendation 3: Creation of a Project Support Center Alignment With
Conceptual Framework 212
Table 24 Recommendation 3: Creation of a Project Support Center Logic Model for
Evaluation 213

xii
List of Figures
Figure 1 Study Organization Stakeholder Groups 6
Figure 2 Study Organization Middle Manager Definition Illustrated 14
Figure 3 Key Activities of the Middle Manager Role in Healthcare 19
Figure 4 Nursing Department Structure 25
Figure 5 Visual Representation of the KMO Theoretical Framework 59
Figure 6 Visual Representation of Social Cognitive Theory 61
Figure 7 Conceptual Framework Using Gap Analysis of KMO and Social Cognitive
Theory 65
Figure 8 Key Activities of the Middle Manager Role As Identified by Interview
Participants 103
Figure 9 Self-Identified Role on Overall Management Team 109
Figure 10 Distribution of Responses to an RN’s Role in Quality Improvement 111
Figure 11 Distribution of Responses to Importance of Quality Improvement in Hospital’s
Ability to Achieve Patient Outcomes 114
Figure 12 Understanding Lessons Learned From Successful and Less Successful Past
Implementations 123
Figure 13 Self-Described Role Success 139
Figure 14 Distribution of Self-Assessment of Level of Confidence in Quality
Improvement Projects 150
Figure 15 Comparison of Weighted Averages Between Pre- and Post-Self-Assessment of
AONL Competencies 156
Figure 16 Participant View of Needed Elements to Feel Supported 170
Figure 17 Thematic Analysis for Advice to a New Manager 172
Figure 18 Synthesis of Findings Through the Perspective of the Conceptual Framework
to Identify Gaps 179
Figure 19 Middle Manager Change Skills to Develop and Persist in Using 200
Figure 20 Design Thinking Illustrated 215

xiii
Figure 21 Design for Equity Change Model Illustrated 217

xiv
List of Abbreviations
AACN American Association of Colleges of Nursing
CLABSI Central line associated bloodstream infection
CNO Chief nursing officer
EBP Evidence-based practice
FTE Full-time equivalent
HAPI Hospital acquired pressure injuries
HARP Hierarchy of accountability, responsibility and professionalism
HCCC Heart of Care Cancer Center
IOM Institute of Medicine
KMO Knowledge motivation organization
LEO Leading an Empowered Organization
NCI National Cancer Institute
NDNQI National Database of Nursing Quality Indicators
RN Registered nurse/registered nursing
U.S. BLS U.S. Bureau of Labor Statistics
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Chapter One: Introduction to the Study
As the need for healthcare grows, the necessity for qualified registered nurses (RNs) to
provide quality patient care also increases as concern rises over nurse shortages and the rise in
individuals leaving organizations and the profession (National Academy of Medicine, 2021; U.S.
Bureau of Labor Statistics [BLS], 2021e; Zhang et al., 2018). RNs are involved with direct
patient care in a variety of healthcare settings; they educate, care for, and support both patients
and their families (U.S. Bureau of Labor Statistics [BLS], 2021e). A supply and demand model
for RNs developed by the U.S. Department of Health and Human Services anticipated there will
be seven states with a projected deficit in RNs (i.e., demand exceeding supply) by 2030. The
most significant shortage is anticipated in California, with a need for 44,500 full-time equivalent
(FTE) RNs, resulting in an 11.5% difference between supply and demand (Juraschek et al., 2019;
U.S. Department of Health and Human Services, 2017). Using data from
PricewaterhouseCoopers’ Health Research Institute, Fennimore and Wolf (2011) found it is
important to build commitment for employees to stay with an organization because nurse
turnover rates range from 8.4% (i.e., established nurses) to 27.1% (i.e., first-year nurses).
Additionally, there are anticipated retirements of “roughly 1 million baby boomer RNs”
(Auerbach et al., 2015, p. 853), leading to concerns over shortages, with organizations not
anticipating growth fast enough to replace retired nurses. Furthermore, 86% of surveyed baby
boomer RNs planned to retire in the next 5 years and 39% planned to retire in a year. About 10%
of surveyed RNs not looking to retire stated they would “leave direct patient care in the next
year” (AMN Healthcare, 2019, p. 8; Auerbach et al., 2015). To account for the influx of nurse
retirements, the National Academy of Medicine (2021) estimated a 35.5% growth from 3.35
million nurses in 2018 to 4.54 million nurses in 2020, depending on state or region. The growing
2

demand for nurses emphasizes the need for organizations to examine the role of middle
managers to successfully facilitate their responsibilities while anticipating future needs for
middle managers.
Based on the literature review conducted for this study, the middle manager role is
viewed as an integral part of healthcare organizations to maintain daily operations, ensure safe
and quality patient care, serve as a resource to frontline staff, and be a strategic partner with the
organization by facilitating, implementing, and sustaining change to achieve results and
outcomes. Healthcare organizations depend on the middle manager role to facilitate day-to-day
operations, connect frontline staff and the organization, support change strategies, and navigate
the complexities in organizations (Belasen & Belasen, 2016; Dainty & Sinclair, 2017). In 2011,
the Institute of Medicine (IOM, 2011) released a Future of Nursing report detailing the integral
role nurses play in being leaders and partners in the future of healthcare and emerging change.
The report served as a call to action to healthcare organizations to be proactive in leadership
development given many organizations have not created the structure necessary to support
current and future leaders (Fennimore & Wolf, 2011; Hallock, 2019). Due to changing needs and
approaching retirements, nursing organizations in the United States could experience a shortage
of leaders to fill current and future leadership positions, with turnover costing organizations
between $82,000 to $88,000 per RN, as of 2010 (Fennimore & Wolf, 2011; Sanchez-Hucles &
Davis, 2010). The healthcare middle manager’s job satisfaction is influenced by organizational
structure and support, empowerment of the role, ability to enact change, specific characteristics
of the role and responsibilities, and opportunities for development (Lee & Cummings, 2008).
Understanding the middle manager role in healthcare allows organizations to understand
leadership needs and connections to achieving sustainable, lasting change.
3

Healthcare organizations have struggled to maintain and sustain change to achieve results
and outcomes. Jamrog et al. (2006) found 82% of global/multinational companies, encompassing
many different industries, experienced an increased rate of change, and 69% reported disruptive
changes in the organization. Organizations face a failure rate of sustainable change estimated
between 50% for evidence-based practice (EBP) changes and up to 90% for complex
innovations, demonstrating a problem (Alexander & Hearld, 2011; Jacobs et al., 2015). Changes
happen as new evidence, technology, and practice changes evolve in healthcare; however, a lack
of sustained outcomes will remain if barriers to structure, implementation, and engagement
continue (Damschroder et al., 2009). The lack of knowledge and skills to sustain change presents
barriers to healthcare middle managers in supporting frontline staff and their organizations
during times of change while achieving goals and outcomes.
There has been an increase in patient care staff leaving healthcare organizations and the
profession from 2020 to present due to the COVID-19 global pandemic, social and racial
injustice, and increased professional and personal loss (National Academy of Medicine, 2021).
Galanis et al. (2021) studied nurse burnout associated with the pandemic and found 34.1% of
nurses suffered from emotional exhaustion, 12.6% experienced depersonalization, and 15.3% felt
a lack of personal accomplishment with certain sociodemographic factors contributing to nurse
burnout, including: “gender, age, educational level, and degree” (p. 3291). As an indicator of job
turnover, AMN Healthcare (2019) found 44% of surveyed nurses reported feelings of wanting to
resign and 27% reported they were unlikely to stay in their current job beyond 1 year. Factors
influencing turnover included: (a) flexibility and work–life balance, and (b) compensation and
benefits. Furthermore, 66% of nurses in the survey worried their job was affecting their health. It
is important to understand the feelings experienced by both frontline direct care staff and middle
4

managers in healthcare to help inform how subsequent recommendations will be received during
these unprecedented times in healthcare.
Context and Background of the Problem
Heart of Care Cancer Center (HCCC) is a pseudonym used to protect the confidentiality
of the research site. HCCC is a National Cancer Institute (NCI) designated comprehensive cancer
center that believes in bench-to-bedside research to deliver exquisite care and quality outcomes
to patients under their care. HCCC is a private, not-for-profit, clinical research hospital with
outpatient clinics located on a central campus and throughout Southern California that provides
comprehensive cancer care to their patients and support to families. Additionally, it was ranked
as a best hospital in cancer care by US News & World Report. The organization focuses on
making a difference in people’s lives by working toward the elimination of cancer and diabetes
through exceptional care, innovation, transformation, and education. HCCC values center on
compassion, service with a sense of urgency, integrity, intellectual curiosity, excellence, and
collaboration; these values often bring employees to the organization. The organization prides
itself in its commitment to diversity, equity, and inclusion, striving to be a community of
employees, consisting of researchers, clinical care staff, physicians, support services, business
and professional services, and volunteers. Everyone’s different expertise and uniqueness come
together to work toward a cure, save lives, and support patients and families on their care journey
while being a leader in delivering healthcare and supporting the community. The people of
HCCC are the core of what the organization strives to be and accomplish for its patients.
Description of Stakeholder Groups
The nursing department of HCCC represents one third of the employee base with
approximately 3,000 patient care staff, of which 1,600 are RNs. The nursing department is
5

comprised of frontline RNs, patient care service staff, researchers, charge nurses, house
supervisors, nurse managers, senior nurse managers/directors, executive directors, and the chief
nursing officer (CNO). The focus of the nursing department at HCCC is safe and quality patient
care that brings cutting-edge treatments and research directly to the patient, supporting the
patient receiving treatment and their families.
The middle manager role at HCCC consists of nurse managers and senior nurse
managers/directors. This role is responsible for facilitating day-to-day operations to ensure
staffing is sufficient with frontline nurses providing safe and quality care to patients. The middle
manager role reports directly to the executive director level staff, who are focused on removing
barriers and supporting nursing and organizational strategic plans. The CNO is responsible for
supporting nursing, being a key liaison for the board of directors, facilitating collaboration with
physicians, and meeting goals that further organizational outcomes and goals. The middle
manager role is an integral element of the nursing hierarchy in the study organization and
provides connections between frontline daily operations and organizational strategy. Figure 1
demonstrates the stakeholder groups in the nursing department hierarchy of the study
organization.

6

Figure 1
Study Organization Stakeholder Groups

The study organization is comprised of frontline staff of patient care assistants, RNs,
charge nurses, and house supervisors. The middle management team in nursing is comprised of
nurse managers and senior nurse managers/directors who serve as a connection, as referenced in
the literature and study interview, between frontline staff and the senior leadership of executive
directors. Finally, the CNO is a representative for nursing on the executive leadership team. In
7

this dissertation study, I explain the stakeholder groups throughout the literature review and
qualitative interviews.
Demographics of the Stakeholder Group
It is important to understand the demographics of individuals who hold the middle
manager role found in the nursing hierarchy of a healthcare organization. The U.S. BLS (2021d)
classified a medical and health services manager as needing an RN license and a bachelor’s
degree at a minimum, with some organizations looking for a master’s degree. In 2021, the
medical and health services manager classification, aligned with middle managers, had 480,700
jobs nationwide with 50,630 employed in California and 16,770 in the Los Angeles–Long
Beach–Anaheim metropolitan area (U.S. BLS, 2021b). Of those 480,700 middle managers, 30%
were employed in hospitals, 12% in physician offices, 9% in care facilities, 8% in government
organizations, and 7% in outpatient care settings (U.S. BLS, 2021d).
The middle manager is a key role, and the demand for it continues to grow; however,
there are less opportunities available in higher-level roles in the nursing hierarchy in healthcare
organizations. For example, the U.S. BLS (2021d) estimated a job growth of medical and health
services managers 28% between 2021 and 2031, with 56,600 job openings per year as the
demand for medical and health services managers grows with individuals leaving the field and
occupation or retiring. As the U.S. population ages, there is an increasing demand for healthcare
services with the need for the middle manager role to plan and facilitate operations in healthcare
organizations (U.S. BLS, 2021d). In May 2021, the mean annual salary for the medical and
health services manager role was $119,840 in the United States, $132,180 in California, and
$122,960 in the Los Angeles–Long Beach–Anaheim metropolitan area (U.S. BLS, 2021b). The
8

ability for an organization to meet individuals where they are in their developmental journey
provides support for the advancement and growth in their role and future career advancement.
Study Stakeholder Group
HCCC’s nursing department has experienced high turnover rates with the middle
manager role, impacting consistency and coverage for the organization’s clinical areas, both in
inpatient and outpatient settings. With a high turnover of the middle manager role, the
organization has experienced challenges in managing daily operations, accomplishing strategic
initiatives, and encountering a loss of expertise and continuity of organization knowledge. In
addition to middle managers not feeling prepared for their roles, the role is further impacted by
struggles to build a pipeline of future leaders through succession planning. From the
organizational perspective, the lack of development of the middle manager role to be a change
agent leads to hard and soft costs associated with the inability to sustain change initiatives. The
middle manager role in the study organization is key for frontline support and development,
peer-to-peer support, and organization success; however, without the support and development
of the middle manager role, the expectations may outweigh current skills and competencies to be
successful.
Purpose of the Project and Research Questions
Lack of development of healthcare middle managers in leadership and management
competencies to complement clinical expertise impacts sustainment of initiatives in healthcare
organizations. Healthcare organizations often lack the appropriate structure to develop leaders
that go beyond daily operational tasks. They need to focus on developing leadership
competencies that grow confidence and enhance nonclinical competencies such as strategy
change management and people skills (Fennimore & Wolf, 2011; Sherman & Pross, 2010). The
9

purpose of this study was to understand the gaps in healthcare organizations to support the
development of the middle manager role to meet training needs and grow leadership skills to
achieve successful strategic initiatives and sustained change management (Fennimore & Wolf,
2011; Sherman & Pross, 2010). The theory of change to approach the lack of leadership
development focuses on improving the structure of support and development of the role through
understanding the needs of middle managers in terms of resources and meeting the needs of
diverse individuals (Tuck & Yang, 2014). It is important to provide opportunities to all middle
managers to learn skills and competencies to supplement their clinical knowledge, regardless of
past or current experiences. Opportunities for growth and development should embody meeting
each person in their preferred learning experience so they feel supported and prepared for their
roles and responsibilities.
The following research questions (RQs) guided this study:
1. How do middle managers perceive their ability to facilitate change to achieve
outcomes?
2. What skills/competencies do middle managers identify as key to role success and in
sustaining change?
3. What are foundational elements of leadership support organizations need to provide
for middle managers to be successful in achieving sustainable change?
Importance of the Study
Organizations need to focus on creating programs to support the development of existing
middle managers and staff to become future organizational leaders. In 2013, U.S. organizations
spent an estimated $15 billion on leadership development, with only 50% of surveyed hospitals
having programs in place (Whaley & Gillis, 2018). An organization’s investment in training
10

nurses could create a reciprocal commitment where the employee competencies are grown to
benefit the organization and help employees feel valued; as a result, they may become more
committed to staying with the organization (Rondeau et al., 2009). The American Association of
Colleges of Nursing (AACN, 2019) summarized findings from a 2007 study that reported 13%
of early-career nurses changed jobs after only 1 year at an organization. Further compounding
the shortage is the estimated 1 million RNs who will be retiring between 2019 and 2034 (AACN,
2019). Investing in employees can build the commitment to stay for existing staff and attract
future staff.
Staff turnover negatively impacts healthcare organizations and the people who are left
doing the work in the organization when people leave. Turnover impacts organizations beyond
financial impacts and includes social effects such as workload, morale, well-being, productivity
due to onboarding of new staff, storming effects of a new team learning how to work with each
other, and job satisfaction and performance of the remaining team (Rondeau et al., 2009).
Swearingen (2009) found a 4% retention improvement with up to 24% retention improvement
for nurse leadership in specific hospital units through the implementation of a leadership focused
development program. The lack of investment in nurse leadership development leaves nurses
unprepared to meet organizational expectations (O’Neil et al., 2008). Healthcare organizations
have not been defining and building leadership practices and the connection to patient care, and
patient satisfaction (Wong et al., 2013). By creating a framework of leadership development,
organizations could foster the professional growth of formal and informal leaders in middle
management and frontline staff.
The inability to sustain change in healthcare organizations impacts the lasting
improvement of empirical outcomes related to nursing-sensitive indicators (NSIs) or measures of
11

nursing care framed in patient outcomes, and staff engagement (NDNQI, 2022). A lack of
sustained outcomes will remain if barriers to structure, implementation, and engagement
continue (Damschroder et al., 2009). The ability to achieve long term sustainable change requires
an organization to move beyond the initial implementation to facilitate continuous scaffolding
and support of teams to achieve sustainable change (Martin et al., 2012). The lack of knowledge
and skills to sustain change presents barriers to middle managers in supporting frontline staff
during times of change to foster success for organizations to meet outcomes.
Overview of Theoretical Framework and Methodology
To approach the study from individual and organizational perspectives, the conceptual
framework in this study combined two theoretical frameworks: (a) Clark and Estes’s (2008)
knowledge-motivation-organization (KMO) gap analysis and (b) Bandura’s (1986, as cited in
Schunk & Usher, 2019) social cognitive theory. The ability to understand an organization’s
current state and what individuals in the organization need allows the study to identify gaps that
need to be closed to achieve a desired future state. I used purposeful sampling to learn from the
healthcare middle manager role to allow for the greatest diversity in perspectives, experiences,
backgrounds, and demographics (Merriam & Tisdell, 2016). I conducted semistructured
interviews to facilitate open-ended questions that gained deep, rich information from middle
managers (Burkholder et al., 2019). I also included secondary data from the study organization to
layer in additional information and perspective. The methodology was designed to support the
acquisition of deep, meaningful perspectives of middle managers to understand what they
experience and what they need to be successful in their role and in sustaining change.
12

Definitions of Terms
This section contains definitions for key concepts and terms reoccurring throughout this
study. The inclusion of these definitions is to articulate how these key concepts and terms were
used in this study.
Clinical Manager
A clinical manager is a middle manager who has direct reports involved with patient care
and are “involved in patient care decision-making” (U.S. BLS, 2021a, para. 25).
Frontline Clinical Worker or Frontline Staff
A frontline clinical worker or frontline staff is an individual who is a clinical staff
member who interacts with and cares for patients directly and does not have direct reports (U.S.
BLS, 2021a).
KMO Gap Analysis
A KMO gap analysis helps to identify gaps in performance in individuals and
organizations through the lenses of knowledge, motivation, and organization (Clark & Estes,
2008). For the purposes of this study, knowledge refers to individual knowledge and skills,
including leadership skills and success in empirical outcomes. Individual motivation connects to
the ability to learn, apply, accomplish tasks and goals (Clark & Estes, 2008). For this study,
motivation is examined through the lens of an individual gaining and applying leadership skills
and sustaining change to achieve outcomes. Organization refers to the structure, culture,
facilitators, and barriers present in the organization and the organization’s support of the
individual (Clark & Estes, 2008). This study included leadership development structure and
ability to achieve recruitment and retention of middle managers.
13

Lack of Development of Leadership Skills and Competencies
Promotion of leaders based on clinical competencies and expertise rather than leadership
competencies leaves middle managers lacking key leadership skills to support their growth as
leaders to achieve patient and organizational outcomes (Wilmoth & Shapiro, 2014; Wong et al.,
2013), which is referred to as lack of development of leadership skills and competencies in this
study.
Lack of Leadership Development
As the role of the healthcare middle manager continues to grow in scope and complexity,
a lack of leadership development begins to emerge as they look to the organization to provide
leadership development to support them (Whaley & Gillis, 2018).
Middle Manager or Middle Management
Huy (2001) defined middle managers as “any managers two levels below the [chief
executive officer] and one level above line workers and professionals” (p. 73). The manager role
has “employees directly reporting to them, with whom they meet on a regular basis, and whose
pay and promotion they may be involved with” (U.S. BLS, 2021a, para. 25). The middle
manager role in healthcare tends to be a conduit between senior leadership and frontline staff
who is responsible for daily operations relating to patient care and strategic-type projects (see
Figure 2).

14

Figure 2
Study Organization Middle Manager Definition Illustrated

Nonclinical Manager
A nonclinical manager is a middle manager who has direct reports, but both the manager
and their direct employee are not involved in direct patient-facing care nor decision making (U.S.
BLS, 2021a).
Retention and Recruitment Issues
Retention and recruitment issues emerged from the literature in terms of future nurse
leaders, Sherman et al. (2007) identified the lack of desire of frontline staff and early career
nurses to obtain leadership positions in organizations is because of a lack of development and
orientation, leaving them feeling unprepared.
15

Social Cognitive Theory
Social cognitive theory explores the influences on how individuals learn, build, and apply
knowledge and skills; including individual growth in capacity and capability through applying
what is learned (Hartviksen et al., 2019; Schunk & Usher, 2019).
Organization of the Dissertation
This study is organized as a 5-chapter dissertation. Chapter 1 provided an overview of the
study, including overview of the problem of practice, study organization, stakeholders, goals,
methodology, theoretical frameworks, and key concepts and terms that arise throughout the
remaining chapters. In Chapter 2, I review literature relating to the healthcare middle manager
role and an organization’s ability to sustain change. The review of literature focuses on themes
including history of the role, barriers middle managers encounter, a middle manager’s place in
the hierarchy of leadership, middle manager lack of development, challenges faced and job
satisfaction in the role, organizational change and the middle manager role as change agents, and
the need for leadership development of middle managers. In Chapter 3, I detail the RQs,
qualitative methodology, data collection instruments, study limitations, study participants, and
my positionality as the researcher. In Chapter 4, I explain the RQ findings. In Chapter 5, I
present recommendations based on the study’s findings with a focus on healthcare middle
managers and their role in an organization’s ability to sustain change.
16

Chapter Two: Literature Review
The middle manager role in healthcare organizations is key to facilitating daily operations
while also driving forward strategic initiatives with expectations to achieve specific goals and
outcomes. Through examining the role of the healthcare middle manager, healthcare
organizations can identify gaps that exist in skill development (i.e., growth of leadership skills to
achieve successful strategic outcomes and facilitate change management; Fennimore & Wolf,
2011; Sherman & Pross, 2010). A lack of leadership development infrastructure in healthcare
organizations inadequately prepares healthcare middle managers to develop leadership expertise
and achieve sustained change, as evidenced through empirical outcomes related to organizational
outcomes and staff engagement. Moreover, by examining the struggles middle managers face,
organizations can understand needed support to grow engagement and satisfaction through
different levels of staff. For example, Hewko et al. (2015) highlighted how nurse managers
consider leaving their roles due to feelings of lack of empowerment, decreased job satisfaction,
emotional exhaustion, and lack of role orientation. Thus, a decreasing number of frontline nurses
are interested in future management positions. Although the literature presented as part of this
review has been applied to leadership development in healthcare organizations, this study
focused on the impacts a leadership development framework has on building the middle
management role to foster successful leaders who facilitate, implement, and sustain change to
successfully achieve outcomes and goals.
This chapter explores relevant research of healthcare middle managers and organizational
change and presents applicable theoretical and conceptual frameworks that guided the study. The
literature review focuses on the role of the healthcare middle manager: history, barriers, place in
the hierarchy of leadership, lack of development, challenges and job satisfaction, organizational
17

change and middle managers as change agents with barriers faced, and the need for leadership
development of middle managers.
At the conclusion of the chapter, I present the primary and secondary theoretical
frameworks, informing the conceptual framework created to guide this study. Clark and Estes
(2008) provided a theoretical framework of knowledge, motivation, and organization (KMO)
that I used as a method to understand gaps present in middle manager performance needs in an
organization. The KMO model allows for an understanding of current performance gaps in
support of an individual’s knowledge and skills, motivation to achieve goals, and barriers present
in the organization. In relation to this study, the KMO analysis can be used to examine the needs
of middle managers and applied to healthcare organizations to identify what gaps need to be
closed. The addition of a secondary theoretical framework of Bandura’s (1986, as cited in
Schunk & User, 2019) social cognitive theory provided a means to examine influences on an
individual and their behavior as they interact, learn, and build needed knowledge and skills.
Social cognitive theory facilitated analysis of the individual needs and behaviors of healthcare
middle managers. Through the combination of theoretical frameworks, I explored both
organizational and individual influences connected to leadership development and subsequent
ability to sustain change.
The Middle Manager Role in Healthcare and Nursing
The middle management role in healthcare is responsible for facilitating daily operations
to ensure patients and facilities are supported while also being seen as a critical contributor that
supports change, strategy, and implementation in their organizations. Embertson (2006) defined
middle managers as “any managers two levels below the CEO and one level above line workers
and professionals” (p. 226). The middle manager role in nursing would be the stratified senior
18

nurse manager/director and nurse manager roles in the study organization. According to the U.S.
Bureau of Labor Statistics (BLS, 2021a), the healthcare middle manager role is divided between
two designations: (a) clinical manager and (b) nonclinical manager, with both roles having direct
reports with which they meet, evaluate performance, and discuss pay and promotion. The main
distinction between the two manager classifications is the clinical manager is “involved in
patient care decision-making” (Zawacki et al., 2021, p. 7) and the nonclinical manager is not.
The U.S. BLS (2021d) aligned the healthcare middle manager to the medical and health services
manager in the Occupational Outlook Handbook as the role that plans, directs, and coordinates
activities in their healthcare facility (e.g., facility, unit, department, area). Healthcare
organizations depend on the manager role to bridge strategic development and leadership to
frontline staff to effectively support the organization’s work (Belasen & Belasen, 2016;
Embertson, 2006). Frontline clinical workers are defined as clinical staff who interact and care
for patients directly and do not have direct employee reports (U.S. BLS, 2021a). Nonclinical
frontline workers include support services staff not involved in direct patient care, such as
maintenance, food service, and housekeeping (U.S. BLS, 2021a). Through a combination of
knowledge and experience, healthcare middle managers support and strengthens their
organization (Embertson, 2006). The middle manager role in healthcare has a variety of
responsibilities (see Figure 3).

Figure 3
Key Activities of the Middle Manager Role in Healthcare

Note. The figure combines typical key activities of healthcare middle managers from various sources of literature (i.e., Belasen &
Belasen, 2016; Embertson, 2006).
Decision maker Bridge Change agent
Connection to internal
culture
Operations manager Model Information exchange
Supporter/encourager
of staff
Skilled in persuasion Technical Communicator Relationship builder Innovator
Interacts with
employees
Engages with employees Balance Leader
Organizational
goals/outcomes
Improves efficiency Delivers results Delivers quality
Current in laws and
compliance
Addresses staff
emotional needs
Assists staff Schedules staff Data/metrics tracking
Provides
structure/consistency
Provides
clarity/dependability
Problem solver Mediator Provides sense-making
Recruits and onboards
staff
Stakeholder
management
19
20

The U.S. BLS (2021d) estimated there were 480,700 medical and health services
managers in the United States in 2021, with 30% employed in hospital settings. The U.S. BLS
outlined how the middle manager role has expectations to adapt to change; be versed in legal,
regulatory, and compliance changes; facilitate daily operations and staffing to ensure patient
needs are met; facilitate efficiencies and obtaining goals; conduct employee recruitment,
onboarding, and training; and have the ability to communicate and work with multiple
organizational stakeholders including staff, colleagues, physicians, patients, and ancillary and
support services. The annual mean salary of the role in the United States as of 2021 was
$119,840, with the rate at $132,180 in California specifically (U.S. BLS, 2021b). This key role,
which fosters engagement in meaningful work to advance the organization, is forecasted to grow
28% by 2031, adding approximately 56,600 openings per year (Belasen & Belasen, 2016; U.S.
BLS, 2021d). The growth of the healthcare middle manager role and responsibilities continues as
the healthcare industry changes.
History of the Middle Manager Role in Healthcare Organizations
The healthcare middle manager role has changed with the evolution of the healthcare
system. Healthcare has experienced many changes impacting organizations and the roles that
support the work of the organization, such as increasing pressures and demands on financial
resources, the need to provide higher quality care to meet needs of changing populations, and
new developments in science and technology (Wikström & Dellve, 2009). The middle manager
role has long been thought of as a transition role on the leadership journey; however, the role is
key to the management structure (Torrington & Weightman, 1987).
The middle manager in healthcare has experienced many different trends throughout the
history of the role, at one point, fattening of an organization occurred with the gradual adding of
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new layers, functions, and roles because of the perception of more work needing to be done
(McConnell, 2005). In the early 2000s, the middle manager role in healthcare felt the largest
impact of the “flattening the hierarchy” (Embertson, 2006, p. 224) trend as part of organizational
restructuring to remove or reduce layers, where the number of middle management positions
were decreased to reduce costs and increase efficiency efforts (McConnell, 2005). Flattening in a
healthcare organization was a way to be more competitive while addressing regulatory
compliance and financial demands. The middle management level in organizations is typically
the first level to feel the effects of flattening (i.e., the middle manager role is either eliminated or
becomes a lower level of leadership). Embertson (2006) indicated the effort to flatten the
organization increased responsibilities on remaining managers and caused disruptions that
impacted continuity, momentum, and morale. The flattening also impacted change
implementation because of the loss of the connection to social structure and frontline staff.
Research has indicated the flattening trend also impacted middle managers’ abilities to grow and
advance into healthcare leadership (Embertson, 2006). With organizations focused on reducing
the number of middle managers, there were less opportunities for the middle manager role to
grow and evolve into a position that supports the variety of future activities and demands.
Following the early 2000s trend of reducing the middle manager role in healthcare
organizations, there was a shift for nursing to play a more prominent role, which pushed the
middle manager role into a position to support higher demands. In 2011, the Institute of
Medicine (IOM, 2011) released their Future of Nursing Report that outlined seven
recommendations for nurses to become full partners in their organizations and in their scope of
practice. These recommendations outlined the need to lead innovative solutions; seek and
implement change through collaboration; and focus on improving quality, efficiency, and safety
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for their organizations. The IOM (2011) included a call for “leadership-related competencies” (p.
8) in nurse education and through organizational culture that supports development and
mentoring of future nurse leaders. Torrington and Weightman (1987) found middle managers fall
into the “middle management trap” where they “feel obliged” to pursue leadership promotion
and advance their careers rather than view middle management as a “career aspiration” (p. 88).
The IOM (2011) called for middle managers to incorporate continuous improvement in their
daily work while aligning department-level improvement with organizational strategic goals. The
report highlighted the shift to higher demands placed upon the healthcare middle manager role to
ensure they are able to carry out the renewed expectations to do more. With the call to action for
nursing to be leaders and partners in their organizations, the middle manager role in healthcare
must also rise to meet growing demands placed upon them.
Current State of the Middle Manager
The shift from reducing to growing the middle manager role in healthcare has increased
demands and pressures placed on the role to meet the changing healthcare climate. Buchanan et
al. (2013) conducted a study in the United Kingdom applying the concept of extreme jobs to the
healthcare middle manager role, using the definition of extreme jobs as being an individual who
is a high earner, works 60 or more hours a week, and met more than five of 12 extreme job
characteristics. Using this concept, Buchanan et al. set out to highlight and define healthcare’s
own extreme job characteristics. They illustrated how 75% of healthcare managers aligned with
extreme job classification through the demands of: (a) being physically present in a work
environment requiring long hours, (b) being in a position to make difficult decisions, (c)
navigating different and changing priorities, (d) facilitating demands of operations with fewer
resources, (e) being prepared to respond to regulating authority site visits and inspections, (f)
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problem solving while engaging to embrace change, and (g) being the mediator with their staff.
These extreme job characteristics resulted in 50% of healthcare middle managers experiencing
work-related tension and stress.
Wikström and Dellve (2009) highlighted leadership in healthcare as having to meet
changing demands, which puts additional pressures and responsibilities on the role, creating a
struggle of excelling in clinical competencies and managerial competencies. In a qualitative
study of first- and second-line leaders on leadership practices, Wikström and Dellve described
three logics and associated dilemmas managers face in their roles, including: (a) administrative,
which has an overwhelming amount of tasks associated with budget, human resources, and
reports; (b) strategic, which focuses on long-term and future-focused initiatives; and (c)
employeeship, which focuses time on supporting, growing, and developing employees. The main
dilemma connecting the manager and the three logics is conflicting demands and priorities
placed on the role and fragmentation.
The role of middle healthcare managers, clinical and nonclinical, continues to grow while
the complexity of the role increases (Whaley & Gillis, 2018). There are increased expectations
on middle managers to do more, but they often lack the expertise in leadership because they are
promoted based on clinical expertise rather than leadership skills (Hallock, 2019; Wilmoth &
Shapiro, 2014). As healthcare organizations demand more from their middle managers, they
must understand the impacts of these demands on individuals and the organization.
Perceptions of Leadership: Middle Manager Role and Organizational Hierarchy
As the healthcare industry continues to evolve and grow, there is a need to have strong
leadership structures in place to support the growing amount of work. Organizations will
experience issues without thoughtful planning of the overall structure of nursing teams and
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departments. Issues with retention and an overall shortage of nurses has led to a growing focus
on the nurse manager level. For example, Sherman et al. (2007) found nurse managers often feel
unable to balance the multitude of challenges they face; as a result, they feel unqualified to be
successful in leadership roles. Additionally, there is a growing lack of desire in frontline staff
and early career nurses to obtain leadership positions in organizations because of the demands
they see placed on often unprepared, unappreciated, and unsupported middle managers (Sherman
et al., 2007; Titzer et al., 2013). The struggles of the healthcare middle manager also influence
the frontline nurses’ desire to grow into leadership positions, impacting the succession pipeline
in an organization. Leadership development can be a component of organizational succession
planning to ensure there are qualified and prepared future middle managers available to grow
into leadership roles. Of the 71% of healthcare organizations that have started succession
planning only 30% have started utilizing leadership development programs to fill the pipeline
(Phillips et al., 2018). Wong et al. (2013) outlined a gap in healthcare organizations defining and
building leadership practices and contributing to financial components, patient care, and patient
satisfaction.
In a review of nurse leader education studies, Brooks et al. (2014) identified healthcare
organizations as being on the brink of a nurse leader shortage. Additionally, future nurse leaders
also experience a lack of encouragement. A lack of investment in nurse leadership development
leaves nurses unprepared to meet organizational expectations (O’Neil et al., 2008).
Understanding the different perspectives along the succession pipeline provides insight into the
middle manager role, future growth of nursing leaders, and impacts to potential future middle
managers. Figure 4 illustrates the nursing department structure at the study organization.

25

Figure 4
Nursing Department Structure

Frontline Perspective of Leadership
The middle manager role facilitates relationships with frontline staff while ensuring daily
patient care, operations, staff coverage, and assignments can be accomplished. As the link
between senior leadership and frontline staff, a middle manager connects daily responsibilities of
patient care to overarching factors affecting the organization (Lee & Cummings, 2008).
Korsgaard et al. (2002) found an employee’s work ethic and performance can be influenced by
the positive and negative interactions between manager and employee; through the character and
behaviors they exhibit, managers can either build trust or undermine trust. The importance of the
relationship between manager and employee is reinforced in research on leadership by Baker et
al. (2012). Baker et al. found (a) people leave because of their managers and (b) manager
feelings of support from the organization are reciprocated to their staff and that feeling of
support transfers to the staff they support. Two main manager trustworthy behaviors that
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influence relationship development and employee reaction are communication and
demonstrating concern; employees connect these trustworthy behaviors to situations and causes
they are experiencing (Korsgaard et al., 2002). The relationship that is built daily influences how
an employee may react in different situations or events; thus, trust is used by the employee to
navigate a challenging or negative event. Middle managers’ connections to frontline staff
supports and pushes work forward to fulfill the organizational strategy to meet stakeholder goals
and outcomes.
Frontline staff perception of the middle manager role impacts their ability to execute
daily operations, accept change, and advance into management roles. A combination of middle
managers being faced with complex situations, middle manager attitude toward role and
organization, and a lack of encouragement by existing nurse leaders impacts staff retention and
deters future nurse leaders into pursuing additional higher education (Brooks et al., 2014; Shirey,
2006). Early career nurses lack interest in leadership roles due to the demands they see placed on
managers, often making recruitment difficult in nursing departments (Sherman, 2013; Titzer et
al., 2013). Kovner et al. (2007) reported 13% of early-career nurses changed jobs after only 1
year at an organization with 37% looking to find a new job within the following year.
Further compounding the shortage of registered nurses (RNs) and people interested in
management is the estimated 1 million RNs who will retire between 2019 and 2034 (American
Association of Colleges of Nursing [AACN], 2019). Phillips et al. (2018) proposed giving
potential future nurse managers an opportunity to explore the role before being placed in the role
to determine if the person and role are a good fit. This opportunity may decrease turnover rates,
which Phillips et al. (2018) estimated cost “75%–125% of nurse manager’s annual salary” (p.
239) in recruitment and onboarding. By making succession proactive, the organization can
27

prepare future nurse leaders to ensure they are equipped with the skills they need for senior
nursing leadership roles, which could also improve key patient and staff metrics and further
organizational outcomes for cost savings in retention (Titzer et al., 2013). Allowing a future
nurse manager to try out the position supports succession planning and potentially reduces
recruitment costs, which is important given middle or nurse manager roles need to ensure daily
operations are met and staff morale is high (Phillips et al., 2018). This opportunity also
contributes to an increase in retention and a decrease in direct care staff turnover. Prioritizing
succession planning and ensuring opportunities for leadership development along a frontline
staff member’s career journey increases potential for staff retention in the leadership pipeline.
Nurse Management
Organizations often lack a career ladder that facilitates the advancement of individuals
into the nurse manager role. Wong et al. (2013) discussed the different levels of nursing
leadership in an organization, such as senior nurse leaders and frontline leaders. Senior nurse
leaders are part of the senior management team and engage in strategic initiatives, decision
making, and expanding nursing practice. Frontline leaders ensure proper staffing and use of
resources, directly working with frontline nurses for decision making and continuous
improvement. The impacts of quantitative overload, defined in this specific study as “extra hours
worked per week,” and hostility experienced in the work environment which impacts the senior
management role that leads to intention to leave and negative job satisfaction feelings (Buttigieg
& West, 2013, p. 174). For purposes of this study and to align with definitions in literature and
U.S. BLS, the middle manager role is comprised of a combination of senior nurse
managers/directors and nurse managers. In a systematic study of nurse manager literature, Lee
and Cummings (2008) found the managers are satisfied in the role in the organizational structure
28

compared to senior leaders and frontline staff which may have different levels of job satisfaction.
Very few nurse leaders actively sought or planned for their leadership position and were either
asked to apply or had “fallen into the position” (Sherman, 2013, pp. 85–86) in a study of nurse
managers. Sherman (2013) found experienced nurse managers were satisfied with their roles
while new nurse managers were left feeling overwhelmed and ineffective in their role abilities.
Wong et al. (2013) pointed out the need to clearly define and build leadership practices,
influencing both resources and outcomes to successfully manage and lead frontline nurses,
leveraging both tactical and relational skills to balance understanding the care that is needed for
patients and how to retain, build, and empower staff. To effectively grow successful future
leaders, healthcare organizations need to build a structure that promotes leadership development
and creates a talent pipeline.
Senior Leadership
In the hierarchical structure, senior leaders in healthcare are positioned to facilitate a
connection between executive leadership, who focus on structure and organization, and with
middle managers, who are the primary connection to the frontline staff caring for patients and
daily operations (Cathcart, 2008; Wong et al., 2013). The senior leadership level of nursing plays
a key role in developing future nurse leaders and ensuring they are prepared to be true leaders
and not just promoted through clinical advancement (Boyal & Hewison, 2016). Senior leaders
face pressures to embrace change and move strategic vision forward for the organization while
ensuring financial stewardship needed to be successful and grow; thus, time and support are both
required to develop skills to be effective senior leaders.
Sorensen et al. (2008) found senior nurse managers play an important role in performance
management, improvements, and problem solving, both in challenging the status quo and in
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supporting others to pursue these activities to leverage opportunities. Senior nurse leaders place
importance on effectiveness as part of leadership and leading in times of change with a focus on
performance and outcomes, while supporting staff to achieve those performance outcomes
(Boyal & Hewison, 2016). Buttigieg and West (2013) illustrated quality of senior management is
connected to “social support [and] job design” (p. 172) and have an impact on decreasing the
impacts of stressors and strains on senior nurse managers. Sorensen et al. (2008) found senior
nurse managers play an important role in performance management, improvements, and problem
solving, both in challenging the status quo and in supporting others to pursue these activities to
leverage opportunities. Senior leaders, as part of the healthcare management structure, play an
important role in facilitating relationships that further nursing strategic goals.
Executive Leadership
As middle managers advance into leadership in healthcare organizations, it is important
to understand the leadership trajectory that leads to executive leadership. Nurse executives are
tasked with addressing needs that result from the rapidly changing healthcare environment. The
chief nursing officer (CNO) balances their role as part of an organization’s executive team with
the patient-focused nature of the nursing profession, focusing on organizational metrics and
nursing practice outcomes (Cathcart, 2008). Cathcart (2008) used the Benner competency
practice framework to illustrate the evolution of competence from a beginner level of a new
nurse to an expert level of the experienced nurse. CNOs engage staff and RNs to facilitate patient
care and operations while addressing different, changing priorities (Reistroffer et al., 2013). The
CNO role is integral with encouraging focus on initiatives that further nursing practice, patient
experience, population health, quality, and patient safety while also connecting nursing with
organizational strategy to meet goals and key outcomes to successfully advance the organization
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(Cathcart, 2008; Jones et al., 2017). The CNO is “accountable for the largest budget and greatest
number of staff” (Cathcart, 2008, p. 89). Often, CNOs have thousands of staff with
responsibilities to establish and drive the culture that facilitates clinical nursing practice through
skills and tasks for patient care while furthering operations (Jones et al., 2017). The CNO role
promotes intraprofessional and interprofessional collaboration to support furthering a shared
vision, engagement, patient safety, metrics and outcomes monitoring, data-driven decision
making, evidence-based practice (EBP), quality improvement, communication, and stakeholder
management.
Reistroffer et al. (2013) found key elements for executive leadership include:
engagement; participation in the development, coaching, and feedback or others; support and
training of people they supervise, and continued follow up. Losty and Bailey (2021) explored the
nurse executive role during 2020 and the ongoing COVID-19 global pandemic, finding it became
imperative in times of chaos to communicate effectively and frequently, be present and engaged,
and have “mental toughness” (p. 121). The pandemic posed a challenge to nursing executives by
necessitating the urgency to rapidly address the change circumstances and support patients and
their families, staff, and providers (Losty & Bailey, 2021).
A unique element of nurse leader role is a caring element that translates for nursing
practice to leadership, balancing caring while addressing patient, staff, and organizational needs
(Solbakken et al., 2018). Solbakken et al. (2018) posited the nurse leader must move between
work of different themes or contexts that creates competing priorities within the role, such as
priorities relating to patient, staff, superior, organizational and the often less prioritized self. The
nursing executive has a unique role in the organization as part of the executive team that
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balances organizational goals and strategic initiatives with the caring practice that comes as a
part of nursing.
Challenges of the Middle Manager Role
The middle manager role in healthcare is faced with growing demands and competing
priorities that must be balanced to ensure daily operations meet patient care needs while striving
to participate in organizational strategic initiatives as developing leaders. Healthcare middle
managers are often expected to do more in their roles, but they encounter struggles with the
complex role when they are not provided leadership skills to be successful (Hallock, 2019;
Whaley & Gillis, 2018; Wilmoth & Shapiro, 2014). In this section, I present literature that has
focused on the middle manager role, including impacts to middle manager well-being, job
satisfaction with intent to stay, and organizational factors that impact the role.
Factors Impacting the Role of the Healthcare Middle Manager
There are a variety of factors affecting the healthcare middle manager that influence job
performance, outlook, and capacity to support organizational strategy and goals. As the
healthcare industry changes, there are added expectations on nurse managers to do more with
less while maintaining high-quality patient care and meeting the expectations of multiple
stakeholders, such as patients, providers, employers, and insurers (Hallock, 2019). For example,
nurse managers face an ever-expanding role and are tasked with facilitating daily operations
while promoting engagement and excellence (Baker et al., 2012). Middle managers spend the
majority of their time on work and tasks that take time and energy but are not defined and
quantified as a part of their role and responsibilities. Insight into the struggle of healthcare
middle managers is gained through understanding role responsibilities, demands, performance,
and impacts.
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Role Responsibilities and Demands
Healthcare middle managers are faced with multiple demands, such as daily patient care
needs, initiatives to achieve organizational goals, and managing urgent and emergent matters.
The middle manager role creates an environment that supports performance and frontline staff
satisfaction, placing demands on the role to do more with available resources (Baker et al.,
2012). Middle manager responsibilities include creating a work environment for frontline staff,
modeling the way, developing staff, challenging the status quo, inspiring staff, ensuring patient
safety, managing daily operations and performance, and fostering staff satisfaction (Ericsson &
Augustinsson, 2015; Shirey, 2006).
Baker et al. (2012) explored amount of time and perceived importance of various role
responsibilities through a survey of nurse managers. The nurse managers in the study identified
top priorities of the role as: (a) connecting to patient satisfaction and service recovery (i.e., 97%);
(b) being involved in indirect patient care (i.e., 93%), including working with patients and their
families and ensuring staffing; (c) facilitating staff management and compliance to regulatory
standards (i.e., 90%); and (d) focusing on staff coaching and resolving conflicts, and working
with financial aspects of operations (i.e., 83%). Top uses of their time focused on tasks ranging
from being present on units/clinics and communicating with staff, developing and implementing
process improvement plans, developing relationships, meeting compliance and regulatory
demands, resolving issues with patient experience, reviewing financial reports, and spending
time in “unit meetings/councils” (Baker et al., 2012, p. 27). There are multiple perspectives of
importance and priorities for where middle managers spend and focus their time.
Healthcare middle managers have various demands and responsibilities placed upon them
that they must meet or exceed to be successful. To understand the different facets of the
33

healthcare middle manager role, Westmoreland (1993) conducted a study on nurse managers and
found three perspectives of self for the role: (a) nurse self, (b) nurse manager self, and (c) career
self. Through their nurse self and nurse manager self, middle managers find positive feelings
through connections to their purpose by helping others and through the power of human
connection that brings them back to their why. The role experiences a shift from being a frontline
employee and having direct patient contact to being a member of the leadership team with new
priorities and responsibilities. With the shift to the middle manager role, there is a responsibility
to know the needs and interests of nurses in the local environment, with staff looking to the
manager to give understanding to context and meaning of things happening in the organization
(Ericsson & Augustinsson, 2015).
Baker et al. (2012) found the largest employee base in healthcare organizations is often
nurses, placing a larger volume of demands onto the middle manager role in nursing. The
manager strives to continue to connect to the patient through technical nursing skills, such as
providing care, allowing them to affirm the feeling that they know what they are doing
(Westmoreland, 1993). Ericsson and Augustinsson (2015) found managers are less able to do
direct patient care, which is one significant difference in the progression from frontline employee
to manager. A key component of the nurse manager self that is a responsibility that falls on the
middle manager role is the responsibility to demonstrate to the organization the role and nature
of the nurse and needs of patient care (Westmoreland, 1993). Ericsson and Augustinsson (2015)
found managers described their role as the ability to move throughout the organization and then
“contribute to staff in a constructive way” (p. 290) by connecting different areas of the
organization to what they do in their ward, unit, or department. The healthcare middle manager
acts as a conduit in their unit/department to further organizational goals and strategy while
34

ensuring changing responsibilities and daily operations are met. With different perspectives of
competing demands and responsibilities, everything can be perceived as a priority, splitting time
and focus and leading to role ambiguity.
Role Ambiguity
Healthcare middle managers often feel their role is ambiguous with many daily
responsibilities, expectations, and duties. For example, Shirey et al. (2008) highlighted nurse
manager role ambiguity, finding 25% of their time was spent on manager tasks and 75% of their
time was spent on invisible work that facilitates getting things done but is not necessarily
leadership focused. As a perceived conduit of information and facilitator of operations, middle
managers encounter stress from competing expectations and demands that are unrealistic, often
exceeding available resources. A combination of lacking clearly articulated expectations and an
organizational structure that creates a lack of empowerment and power furthers middle manager
role ambiguity. The amount of administrative tasks and staffing take up most of their time even
though they desire to be more of a leader of their local area of the organization (Ericsson &
Augustinsson, 2015). The struggles faced by middle managers derive from role ambiguity and
unclear expectations that are detrimental to role empowerment and can have personal impacts on
the individual occupying the role.
Role ambiguity, in combination with demands placed on the healthcare middle manager
role, can impact personal wellness and well-being factors that impede role success. Zenger and
Folkman (2014, as cited in Belasen & Belasen, 2016) reported 5% of middle managers were
unhappy and 48% of current healthcare middle managers were planning to leave their roles
within 2 years due to factors including lack of a career ladder, fatigue, and burnout. Ericsson and
Augustinsson (2015) explored the work–life experiences of Swedish ward managers and found
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the shift to a manager role is a significant change from a previous supervisor role, which
contributes to less role clarity and expectations being evaluated by superiors and staff. Managers
experience a lack of inclusion in decisions and communications from senior leaders that impact
their staff, hindering expectations the staff have of the manager role. The range and variety of
different role perspectives is similar to Belasen and Belasen’s (2016) findings that there is
ambiguity in the healthcare middle manager role, which contributes to negative feelings of
people in these roles. There can be impacts to individual well-being of healthcare middle
managers because they face an overwhelming number of responsibilities, competing priorities,
and expectations to meet demands and achieve outcomes.
Well-Being of Healthcare Middle Managers
Examining the role of the healthcare middle manager goes beyond the role itself and
associated responsibilities into understanding the well-being of the individual who fills that role
and facilitates the necessary operational work. Hudgins (2016) found a connection between
increased resilience and positive impacts of increased role satisfaction to mitigate anticipated
turnover leading to increased intent to stay, influencing increased patient outcomes. Hudgins
(2016) identified the needs of a resilient nurse leader that aligned with Polk (1997) and Beeson’s
(2012) resilience concepts: focus on strength; understand weaknesses to grow self-confidence;
learn and use coping strategies and positive emotions and relationships; leverage developing
others though delegation; and connect to their why, which supports purpose and passion. The
nurse manager often experiences an imbalance between work and personal life further impacted
by “inadequate or inefficient information and support systems [that] contribute to excessive
workloads” (Westmoreland, 1993, p. 62) and additional duties, assignments, and projects, with
other projects not taken away to provide relief. Stressors and emotions resulting from multiple
36

responsibilities of the healthcare middle manager role impact an individual and the overall
organization.
Role Stressors
Understanding the components of the healthcare middle manager role that represent
stressors for the individual allows for insight into factors that contribute to the level of stress
experienced. Through the perspective of nurse manager self, there are often feelings of stress
from workload and quality patient care with operations management (Westmoreland, 1993).
Kath et al. (2012) found there are two job characteristics that moderate negative effects of job
stress on nurse manager role: autonomy and job predictability. Role stress can be reduced
through increasing job predictability and autonomy with information sharing, communication
and engagement in decision making, and sufficient support through relationships from staff,
peers, and senior leadership. Shirey et al. (2010) conducted a purposeful sample of 21 nurse
managers in three acute care hospitals in the United States that furthered previous research on
sources of stress. These managers mentioned stress associated with people and resources (i.e.,
86%), tasks and work associated with roles (i.e., 76%), and performing to meet outcomes (i.e.,
67%).
Kath et al. (2012) examined the amount of management experience and nurse manager
ability to manage stress and how that stress affects outcomes in U.S. hospitals. Less experience
in management indicates nurse managers are often less prepared to handle stress associated with
the job from staff, organization, physicians, and other department demands. Kath et al. (2012)
elaborated that job stress in the nurse manager role decreases with age and experience through
increased support to overcome negative outcomes that impact performance. Connecting role
stressors to the individual in the role provides a background to certain emotions or attitudes
37

healthcare middle managers may experience or express during their responsibilities and
expectations.
Emotions and Attitudes
Individuals experience the middle manager role and associated stressors differently,
impacting their achievements, which has implications on the larger organizational focus and
strategy. Middle managers experience positive emotions resulting from being able to connect
with and coach staff; however, negative feelings and increased withdrawal develop from anger
through experiencing sources of stress such as unclear expectations, frustration from multiple
priorities, and lack of support (Patrick & Laschinger, 2006; Shirey et al., 2008). Shirey et al.
(2010) found 48% of middle managers experienced stress increases through work associated
with the role and 62% through larger organizational factors and culture).
Healthcare middle managers often report feeling underappreciated and undersupported
while being expected to facilitate daily operations, support change, and be resources for the
growth of strategy and culture of the organization (Belasen & Belasen, 2016; Dainty & Sinclair,
2017). Middle managers often experience feelings of depression and increased pressures to
perform that leads to long hours, hyper-effectivity, and sacrificing their own personal time for
the organization (Belasen & Belasen, 2016). Stressor
s and unclear expectations impact middle managers and their performance in the role;
however, they persist in forming connections as part of the role.
Even with experiencing stressors from the role, middle managers seek the positive
aspects associated with the work. Shirey et al. (2010) indicated 91% of nurse managers enjoyed
and liked their jobs even though they experienced mixed, positive, and negative emotions in
different parts of their jobs. Laschinger et al. (2007) tested a theoretical model that explored
38

positive relationships between immediate senior supervisors and their direct report managers,
demonstrating the value of providing greater structure and psychological empowerment, which
promoted greater manager job satisfaction. Positive role feelings are fostered by the manager’s
ability to connect to organizational strategy, be part of communication and information sharing,
be given the opportunity to innovate, and feel valued through positive feedback and recognition
(Patrick & Laschinger, 2006). Given the connection between job satisfaction and intention to
stay at the job, findings suggested positive relationships create feelings of empowerment,
meaning in their work, and increased job satisfaction, which could increase intent to stay
(Laschinger et al., 2007). The different experiences of middle managers impact their individual
emotions and attitudes, impacting their overall job satisfaction, which carries implications for
both individual and organization.
Healthcare Middle Manager Job Satisfaction and Intent to Stay
Role job satisfaction is a measure that can be used by organizations to understand the
impacts on middle managers, influences on likelihood to stay, and related role success. Lee and
Cummings’s (2008) systematic review of 14 studies found there are contributing factors to nurse
manager job satisfaction that are influenced by organizational structure and support and that
increase job satisfaction when present, including empowerment of the role, ability to enact
change, specific characteristics of the role and responsibilities, and opportunities for
development. Similarly, a Canadian study of nurse middle managers conducted by Patrick and
Laschinger (2006) supported the impact empowerment and perception of support had on job
satisfaction of the middle manager role.
Westmoreland (1993) found a career self-perspective focuses on growth and satisfaction
over time; middle managers have a desire for work to be interesting and challenging and the
39

ability to make a difference for staff and patients. Exploring leader–member exchange theory and
resulting relationships connected four dimensions (i.e., contribution, affect, loyalty, and
professional respect) with growth of the nurse manager role through support and feedback while
also having access to information to increase power (Laschinger et al., 2007). The positive
influences on job satisfaction are only part of the story of middle managers; there are also
negative elements that contribute to role dissatisfaction.
There are many elements that contribute middle managers’ struggles, which often leads
to dissatisfaction. Nurse managers may leave their roles due to feelings of lack of empowerment,
decreased job satisfaction, emotional exhaustion, and lack of role orientation, resulting in a
decreasing number of frontline nurses being interested in management positions (Hewko et al.,
2015). Patrick and Laschinger (2006) identified how middle managers see they have access to
learning and growth opportunities, but not resources they need to be successful in their roles.
Unfortunately, many individuals are more concerned with their current role as manager than with
future positions (Westmoreland, 1993). Additionally, job satisfaction of the middle manager is
tied to amount of organizational change experienced, available organizational support, role and
responsibilities, and potential for growth and development (Lee & Cummings, 2008).
Job satisfaction impacts a middle manager’s intent to stay in the role and remain at the
organization, which has personal and organizational effects. Managers seek empowerment in
their role and reinforced growth through professional efficacy that leads them to be satisfied with
their job, leading to a higher desire to stay in their role (Hewko et al., 2015). In a survey of 291
nurse managers in the United States, Warshawsky and Havens (2014) found 70% felt satisfied
with their role and 68% were likely to recommend nursing management as a career path.
However, 72% or nurse managers intended to leave their role within 5 years, due to factors such
40

as retirement (i.e., 22%), career change (i.e., 27%), promotion (i.e., 15%), or the leading reason
of burnout (i.e., 30%). Given these findings, Warshawsky and Havens (2014) suggested there is
a lifespan of the nurse manager position of 5 years, with their intent to stay impacted by burnout
or development of a negative view on their position. Furthermore, the negative portrayal of the
position and nursing management could be conveyed to frontline staff which may deter the
desire to move into the middle manager role (Warshawsky and Havens, 2014).
There is a call for organizations to look at nurse manager workload and role expectations
and invest in growth and development (Warshawsky & Havens, 2014). In a study of Canadian
nurse managers, Hewko et al. (2015) explored the range of manager intent to stay in the role
across 15 factors on the spectrum of “intent to stay” to “intent to leave” (p. 1060) and found the
main factors influencing intent to stay fell into three categories: (a) organizational, (b) role, and
(c) individual. The stressors and associated emotions felt by middle managers impacts their
desire to stay in their roles.
There are mechanisms and behaviors that can be established to increase a middle
manager’s job satisfaction and intent to stay. Middle managers’ intent to stay focuses on having a
healthy work environment that supports employee health and reduces emotional exhaustion and
burnout (Hewko et al., 2015). Shirey et al. (2008) conducted a qualitative descriptive study of a
convenience sample of five nurse managers from a single major Canadian hospital system and
reported nurse managers loved their job, even with a lack of work–life balance. However, they
also expressed that “4 of 5 days per week were not good days at work” (Shirey et al., 2008, p.
130), stating an intent to leave due to conflicts between tasks and own values.
Mackoff and Triolo (2008a) conducted interviews of nurse managers in hospital settings
to examine 10 individual behaviors that should be learned and practiced to engage nurse
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managers to achieve “vitality and longevity” (p. 121) through increasing job satisfaction. The 10
individual behaviors are aimed at intention to stay for the middle manager role, including: (a)
purpose and intention in mission-driven daily work; (b) leader development and growth; (c)
excitement and dedication to role; (d) connections throughout organizational hierarchy; (e)
balance in operational and strategic tasks; (f) space for reflection; (g) self-regulation; (h) ability
to attune to understand unique experiences and perspectives; (i) change agents to challenge the
status quo; and (j) resilience through optimism, affirmation, and positivity. The nurse manager’s
connection and relationship with direct care nurses impacts future aspirations of leadership and
subsequent succession planning (Warshawsky & Havens, 2014). Through development of
individual behaviors and organizational support, a middle manager’s intent to stay in the role and
organization may be increased.
Organizational Factors Impacting the Middle Manager Role
Organizations have a key role in middle manager job satisfaction, intent to stay, and
success. Organizations have to demonstrate the congruence between the values that guide the
organization and how they provide support and balance to their employees to show that
employees, including middle managers, are supported, appreciated, and valued by the
organization and senior leaders (Hewko et al., 2015). Middle managers look to their organization
to provide clear expectations and work–life balance to support their intent to stay in the position.
Similarly, Mackoff and Triolo (2008b) examined five organizational factors that contribute to
“the longevity and excellence of the engaged nurse managers” (p. 167). The five organizational
factors included: (a) promotion of a learning culture with opportunities for growth and
development and resources available to promote continuous learning; (b) growth of esteem
through recognition by organization of role of nursing that builds well-being and commitment;
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(c) alignment of and connection to mission and values, creating meaning and engagement; (d)
growth of future generations and mentorship opportunities, including ability to see role models
and approachable leaders; and (e) a culture of excellence that enhances pride and connects to
retention. Likewise, Kath et al. (2012) found specific characteristics of the hospital, such as
union status, size and type of hospital, magnet status demonstrating excellence in nursing, and
where the interviewed nurse managers worked were not significant buffers to reduce effects of
stress; however, support from peers, upper management/supervisors, staff, subordinates, and the
organization was found to help reduce stress and increase job satisfaction. An organization’s
ability to demonstrate resources and support connects with a middle manager’s job satisfaction,
ability to carry out role responsibilities, and intent to stay in the role and organization.
Organizational Struggle to Sustain Change
Healthcare organizations face barriers to long-term sustainment of improvement, change,
and innovation, failing to meet strategic outcomes and impacting the lasting improvement of
empirical outcomes, such as nursing-sensitive indicators (NSIs) relating to patient outcomes and
staff engagement. Change is constant and always continuing as new evidence, technology, and
practice changes evolve in healthcare; however, 15% of money invested into strategic initiatives
is not realized with only 18% of organizations classifying themselves as being effective in
organizational change (Cabrey et al., 2014; Dombrowski et al., 2016). Sustained outcomes fail to
remain if barriers to structure, implementation, and engagement continue in organizations
(Damschroder et al., 2009). Bruskin (2019) compared organizational change to “drifting
phenomena [or] ever-changing phenomenon” (p. 616) with changes having the tendency to not
take hold, drift away from the original intention of the change, or even drift back to the way it
was before.
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Drivers and Barriers to Change
Change in healthcare organizations is often driven by various factors that contribute to
attaining strategic goals, empirical outcomes, or patient safety. Barnett et al. (2011) found four
factors either facilitated or posed a barrier to implementing an innovation or diffusing an
implemented innovation, that are new ideas to a group or unit, depending on how they are
leveraged, including: (a) evidence, (b) partnerships, (c) influence of champions or committed
leaders of the innovation and stakeholders, and (d) other internal and external factors through the
lens of diffusing innovations. Evidence provides the impetus to pursue an innovation and the
quantitative proof of effectiveness to show success and value to sustain the implementation;
attempting to diffuse the innovation without sufficient evidence can diminish buy in to embark
on innovation, subsequent sustainment, and further diffusion (Barnett et al., 2011).
Both material and symbolic partnerships and relationships enable success with
individuals (e.g., key stakeholders, champions, leaders), building buy in and support that may
foster positive feelings of innovative employees; furthermore, the lack of these drivers can create
negative feelings (Barnett et al., 2011). Additional facilitators of change include: (a) a consistent
vision for the change to motivate people to persist in achieving the vision, (b) alignment of
change with people in power in the organization, (c) buy in from frontline groups, (d)
organizational support and commitment, (e) involvement of champions from the leadership team,
(f) training to support that knowledge gain and application of people impacted by the change, (g)
continuous monitoring throughout implementation, and (h) promotion and celebration of success
and results (Chreim et al., 2012; Tappen et al., 2017). The literature has also discussed contextual
factors that impact the change process in organizations and further individual change and
innovative initiatives and the larger perspective of preparing the organization for future change.
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These contextual factors explore internal elements (e.g., consistency of organizational support,
systems, and resources in place, which are key in the perception of innovations being worked on,
implemented, and sustained) and external elements (e.g., economic climate and political power
influences; Barnett et al., 2011; Chreim et al., 2012). An organization can either leverage the
facilitators of change to their fullest potential to develop, implement, sustain, and diffuse change
or lose potential and create barriers to change.
Barriers to change exist in organizations that impact the ability to achieve, implement,
and sustain successful change. Using a simulation game that allowed hospital pharmacy leaders
to rank 35 key barriers on change, Guérin et al. (2015) found several primary barriers to sustain
successful change, such as lacking in urgency, leadership, collaboration, common vision, clear
strategy for change, support, communication, organizational culture to support change, and
management support and facilitation of change, noting any of the barriers had the potential to
“block a proposed change” (p. 444). Additional barriers to change included: competing priorities
or demands; change magnitude and change complexity; leadership changes that slow change
progress and implementation; resistance from stakeholders involved or impacted by the change;
insufficient people, time, and knowledge resources; and insufficient technical resources to
support change initiatives (Tappen et al., 2017). The barriers to change lead to an organization’s
inability to sustain and diffuse change across organizations, losing the ability to build buy in and
develop an organizational culture of supporting change.
Impacts of Inability to Sustain Change
Barriers to change that organizations encounter, combined with the rapid influx of
competing priorities and demands, places strain on people facilitating and experiencing change.
Jamrog et al. (2006) indicated change occurs at an increasingly rapid pace based on a survey of
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1,472 global/multinational organizations, with 82% reporting an increased rate of change and
69% reporting disruptive changes in the preceding year. Organizations face a failure rate of
sustainability and a threat of a lack of sustained outcomes if barriers to structure,
implementation, and engagement continue (Alexander & Hearld, 2011; Damschroder et al.,
2009; Jacobs et al., 2015). A continual cycle of change manifests into a saturation effect, leading
to stress, exhaustion, disengagement, and burnout (Bernerth et al., 2011; Ead, 2015; McMillan &
Perron, 2013). Change fatigue in nursing has implications to creating a sustainable change
management culture in an organization.
It is important to understand not only the impacts of the specific change or improvement
on the affected frontline groups, but also the compounding of the effects with daily operational
responsibilities of their roles. There is not a proven way to capture the complexities of a nurse’s
workload because there are both “endogenous” and “exogenous” (Ead, 2015, p. 506) variables
with many tasks a nurse responds to during a given day, including constant areas that are
expected and other areas that change based on the needs of the patient or the specific workload.
Jacobs et al. (2015) examined innovation implementations through the lens of perceived and felt
effects of organizational “implementation policies and practices” (p. 1) by people being impacted
rather than the structure in place in the organization. Individuals felt change fatigue as the effect
from ongoing, continuous change that complicated organizational change based on the
“perception that too much change is taking place” (Bernerth et al., 2011, p. 322). Too often,
change fatigue is explored in isolation rather than as part of the larger organizational change
process that may lead to experiencing change fatigue.
McMillan and Perron (2013) identified commonalities between change fatigue and
change resistance, including how they both result in (a) rapid change; (b) resistant-type behavior
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by staff; (c) feelings of lack of control by staff; (d) feelings of exhaustion; (e) feelings of
inequity; and (f) feelings of burnout that stem from roles and responsibilities of the nursing role,
staffing, and technology changes. Main differences between change resistance and change failure
is that change resistance tends to be more vocal, connects to cynicism, shows dissatisfaction in
physical/facial expression, and is often directed at people implementing the change (McMillan &
Perron, 2013). Change fatigue tends to be passive, with reports of disengagement and
ambivalence, and employees do not show outward expression of dissatisfaction toward change.
Change fatigue is prone to passive behaviors that may be missed, such as feelings of apathy or
lack of power, which parallels control that predicts feelings of “fairness, reward, and
community” (Leiter & Maslach, 2009, p. 336) as connected to implications from burnout
(McMillan & Perron, 2013). Bernerth et al. (2011) indicated there is a balance sought between
pushing forward change initiatives with maintaining employee commitment and satisfaction
while they are experiencing exhaustion and stress during times of change. Turnover intention
derives from how involved a frontline nurse feels in their work and connections to the work they
do (Leiter & Maslach, 2009). Understanding the differences between an individual being
overwhelmed by change versus being resistive to change impacts the implementation,
sustainment, and diffusion of change to fully execute improvements or a propensity to drift back
to the status quo.
Middle Manager Role in Sustaining Change
It is important that organizations review strategic plans, planned initiatives, and annual
goals to understand combined impacts of competing demands on staff and stakeholders, with
thoughtful leverage of middle managers as a conduit to facilitate change as change agents. Each
year, organizations plan their strategic roadmap for how they will reach their predetermined
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goals, but there is lack of consideration of the holistic approach to change (Ead, 2015). Ead
(2015) exemplified that there is an inherent danger of the saturation effect, experienced by staff
resulting from a lack of a “period of stability” (p. 507) between change initiatives, including
timing of these potential changes and the impacts to specific groups involved of continuous
changes with no reprieve. This saturation effect contributes to high stress, which leads to mental
and physical health risks and organizational and personal impacts in terms of time off work,
turnover, retention, and employee dissatisfaction. The middle manager role plays a part in
facilitating change to reduce the drain of an ongoing cycle of too much change continuously
occurring, which leads to stress (Belasen & Belasen, 2016; Bernerth et al., 2011). The stress that
occurs leads to creation of a cycle of exhaustion and subsequent conservation of self-resources
that could lead to turnover if it goes on for too long due to the loss of organizational commitment
(Bernerth et al., 2011).
The growing role of healthcare middle management is viewed in terms of role
characteristics, connections, and relationships, and this role has grown in terms of fostering
innovation because they are often the conduit for action, outcomes, and have “diverse insights”
(Belasen & Belasen, 2016, p. 1151) on problems and how to solve them (Birken et al., 2012).
Often, the measure of manager effectiveness is based on how well they are able to facilitate
quality and patient outcomes (Baker et al., 2012). It is the responsibility of the organization, and
middle managers, to create a stable environment with predictability to help with change and
thoughtful planning, taking into consideration impacts of changes and how well changes are
planned (Ead, 2015). Lack of development of the healthcare middle manager in leadership and
management competencies to complement clinical expertise impacts sustainment of initiatives in
healthcare organizations.
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The healthcare middle manager role has an integral part in change initiatives and their
ability to leverage skills necessary to implement and sustain change to meet organizational goals.
Martin et al. (2012) examined internal influences of change such as strengthening networks and
leveraging the relationships of change leaders to aid in long-term sustainability, which builds off
of the role of the middle manager—described by Belasen and Belasen (2016), Embertson (2006),
Kath et al. (2012), and Mackoff and Triolo (2008a)—as the connection between frontline staff
and larger organizational strategic perspectives and work. Dainty and Sinclair (2017) stated
middle managers’ purpose in the hospital setting is to navigate and support change initiatives
(e.g., quality improvement) and are faced with challenges the role encounters; additionally, they
shared it is the responsibility of the role to advance the organization’s quality initiatives to
achieve sustained outcome measures. The middle manager role creates a structure of change that
builds skills and knowledge in direct supervisors while leveraging existing relationships with
direct staff that could reduce staff resistance to change to improve implementation and
sustainment of changes (Aarons et al., 2015; Furst & Cable, 2008). Middle managers, as an
extension of the organization, should ensure the work environment supports a frontline nurse’s
comfort in providing open and honest feedback on change initiatives (Ead, 2015). The role can
be a facilitator of change to support organizational goals and strategy by allowing a middle
manager to be a connector between the frontline staff and the larger organization.
Needs of Middle Managers
It is key to acknowledge needed skills to fulfill the responsibilities associated with middle
managers and the role of change in healthcare organizations. Literature has pointed to middle
managers needing development in aspects beyond clinical competencies, such as change and
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leadership. Organizations can begin to build a structure of support and growth for this middle
manager role to be successful.
Needed Capability, Competencies, and Skills
The lack of leadership development structure in healthcare organizations insufficiently
prepares healthcare middle managers to be able to grow nonclinical expertise and achieve
empirical outcomes to meet organizational goals. The promotion of leaders is often based on
clinical competencies and expertise rather than leadership competencies, assuming they have the
leadership skills, which leaves middle managers lacking key leadership skills necessary to
achieve patient and organizational outcomes (Wilmoth & Shapiro, 2014; Wong et al., 2013). The
training for the middle manager role often falls to their peers who are expected to prepare new
leaders to ensure they have the tools needed to be successful (Fennimore & Wolf, 2011).
Organizations must strive to offer leadership development programs to supplement the daily
direct care competencies and layer leadership education throughout a nurse’s journey in the field
(Hallock, 2019). Phillips et al. (2018) pointed out an opportunity to learn and apply skills allows
time for employees to develop into successful leaders. Providing opportunities to develop
leadership skills allows organizations to plan for future leaders to prepare to lead prior to being
put into the position where they must learn while leading.
With the promotion of clinically competent staff into leadership positions, organizations
need to develop and execute targeted leadership competency development to support the new
leaders in their new roles. O’Neil et al. (2008) highlighted the tendency for healthcare
organizations to continue to develop and encourage the development of clinical education and
certifications rather than placing a focus on leadership development in nursing, which poses a
potential risk if the healthcare industry does not commit and invest in leadership development
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across all sectors of the organization, from frontline to executives. Wilmoth and Shapiro (2014)
outlined “aspects of intentional nursing leadership development” (p. 334), including: a
framework, necessary leader competencies, timing of leadership development, framework
implementation, and roles for forming the development plans with direct care nurses. An
organization’s investment in the training of nurses could create a reciprocal commitment where
the employee competencies are grown to benefit the organization, and employees feel valued by
the organization; as a result, employees are more committed to staying with the organization
(Rondeau et al., 2009).
Warshawsky and Cramer (2019) applied the Benner scale of competency development
progression of novice to expert to the nurse manager role, where individual experience and
knowledge advances competency. According to them, it takes approximately 7 years for nurse
managers to be proficient in these competencies. As with the cycle of continuous improvement
in many process improvement models, there is a similar continuous and iterative cycle of
development in nurse competencies that helps leaders grow (Wilmoth & Shapiro, 2014).
Warshawsky & Cramer (2019) demonstrate in their study that nurse manager competency
assessment aligns with the concept of individuals being promoted based on clinical expertise
rather than leadership competencies, in addition there are impacts associated with leadership
competencies with the influx of younger managers into the role due to retirements. Organizations
need to develop plans for professional development, provide employees opportunities to learn
through experience, provide mentoring, and offer time for reflection to support competency
growth, which increases nurse manager competency (Warshawsky & Cramer, 2019). Through
understanding specific needs of new managers, organizations can develop programs that focus
on building leadership competencies to be confident and engaged in their new leadership role.
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Taking note of the differences between the RN role and the middle manager role gives
perspective of the transition from a frontline nurse to a leadership role. Table 1 provides a
comparison between the RN role and the medical and health services manager role as
represented by U.S. BLS (2021b, 2021c) data.

Table 1
Comparison of RN and Medical and Health Services Manager Role
Employment and location
data
RN Medical and health services
manager
U.S. mean annual salary $82,750 $119,840
California mean annual
salary
$124,000 $132,180
Los Angeles-Long Beach-
Anaheim metropolitan
area mean annual salary
$116,110 $122,960
Work schedule Shift work
Day/nights/weekends/holidays
Full time: 40+ hours a week
Days/evenings/weekends
Job openings per year 203,200 56,600
Job growth (2021–2031) 6% 28%

Note. The data for medical and health services managers are from “Occupational Employment
and Wages, May 2021, 11-9111 Medical and Health Services Managers,” by U.S. BLS, 2021b
(https://www.bls.gov/oes/current/oes119111.htm#st). The data for RNs are from “Occupational
Employment and Wages, May 2021, 29-1141 Registered Nurses,” by U.S. BLS, 2021c
(https://www.bls.gov/oes/current/oes291141.htm#st).

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The U.S. BLS (2021b, 2021c) data demonstrate the slight differences between annual
salary in the different regional perspectives between the two roles. The two roles have vastly
different responsibilities between them. The RN role directly cares for patients while
collaborating with physicians and care teams to deliver such care (U.S. BLS, 2021e). RNs are
responsible for observation, assessment, teaching, and planning for patients. The medical and
health services manager role is responsible for efficiency, quality, meeting goals, onboarding
staff, managing a budget, staffing and scheduling, and collaborating with various levels
throughout the hospital or healthcare setting (U.S. BLS, 2021d). RNs tends to work shifts for 40
hours or less each week. They also have to be on call, often on short notice (U.S. BLS, 2021e).
The medical and health services manager role works full time, often greater than 40 hours a
week, needs to be on call for emergencies, and is expected to work evenings and weekends as
needed (U.S. BLS, 2021d). The transition from frontline RN to a middle manager role requires a
change in work schedule and a change in responsibilities that do not always fall in the regular
workday.
Leadership Needs and Leadership Development Needs
The transition to a nurse leadership position from a frontline nurse position can present
differences in work and experiences. New nurse leaders often move into the role with very little
formal role preparation from the organization, which impacts their experience and potential
recruitment of others (Sherman & Saifman, 2018). In looking at the development leadership
skills, Sherman and Pross (2010) discussed how nurses are moved into leadership roles based on
their “clinical and technical proficiency” rather than “soft-skills” (p. 4), and they need to have
opportunities to develop these skills. Sherman and Saifman (2018) stated the transition from
frontline nurse to a nurse leadership role can be complicated where frontline staff do not know
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what a leadership position will entail. Sherman (2010) studied a clinical nurse leader program
and found the transition to the leader role shifted from being task driven to having more control
and freedom in their day. Sherman and Pross discussed the use of competencies to identify
emerging leaders’ strengths and weaknesses to target specific knowledge and skill development.
Emerging nurse managers should be given opportunities to understand the full range of
responsibilities and experiences with becoming a new leader while being supported by the
organization to develop the needed skills and knowledge to succeed in the leader role.
It is important to provide opportunities for all middle managers to learn skills and
competencies to supplement their clinical knowledge regardless of their past or current
experiences. With a lack of leadership development framework to support the growth and
retention of leaders, healthcare organizations need to build a framework that will support middle
managers to attain personal and organizational outcomes (Abraham, 2011; Wong et al., 2013).
Nurse managers have a lack of confidence due to the expectation to learn after they have been
promoted and moved into a new leadership environment (Brooks et al., 2014).
Through evaluation of culture and work environment, healthcare organizations can
achieve supportive environments for the development and subsequent retention of middle
managers (Hewko et al., 2015). An increase of turnover results in an increase in costs with added
decrease in performance, morale, and continuity (Belasen & Belasen, 2016). Turnover impacts
organizations beyond financial impacts. For example, social effects, such as workload on the
remaining nurses, morale, well-being, decreases in productivity due to onboarding of new staff,
storming effects of a new team learning how to work with each other, and reduction in job
satisfaction and performance of the remaining team are other impacts (Rondeau et al., 2009).
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Hallock (2019) outlined the five practices of exemplary leadership. These practices
included: (a) model what is expected from others, show commitment, and show they believe in
the people supporting them; (b) know the purpose of what they are striving for and build this
vision to inspire others; (c) be ready for change, foster continuous improvement, challenge the
way things have always been done, and be innovative; (d) work as a team, collaborate, and
succeed together on a common goal; and (e) remember the team, ensuring every member is
successful and is able to make it through any tough times. By developing leadership
competencies, middle managers build confidence and skills needed to achieve organizational
results.
Healthcare organizations need to begin to assess, develop, and implement a structure that
promotes leadership development to grow successful future leaders and build a talent pipeline.
Whaley and Gillis (2018) found top management team members often identified variability
among skill sets of middle managers and individual motivation to close skills gaps, often due to
individuals being promoted into the role based on application of technical skills in a previous
role. These findings varied based on educational level and tenure of experience. Hallock (2019)
identified the importance of developing leadership in nurses throughout their journey in the field,
beginning in nursing school and continuing into their careers, ensuring their workplaces include
leadership professional development programs to supplement what the nurses do in direct care.
Swearingen (2009) outlined five elements a leadership development framework should include:
(a) assessment of needed skills aligned to expectations, (b) curriculum that extends across all
levels in the organization, (c) engagement by current leaders to support future leader growth, (d)
continuous evaluation of the effectiveness of the framework, and (e) evaluation of the efficacy of
framework against measurable organizationally driven outcomes. The healthcare industry is ever
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changing with the expectations to do more with less in direct care and leadership decisions
(Hallock, 2019). Organizations need development structures in place that are continually
reviewed and adjusted to meet the needs of the leaders who are advancing into new roles.
Needed Change Skills
Lack of leadership development extends beyond operational skills and competencies to
impacting the implementation and sustainment of change in an organization. According to
Hallock (2019), giving nurse managers time and opportunity to develop and practice leadership
competencies positions them to successfully lead change in organizations and the healthcare
system. If organizations are unwilling to create space and time for their staff to develop
leadership competencies, nurses will be unprepared as leaders to meet organizational
expectations and may underperform in key organizational outcomes (O’Neil et al., 2008). Middle
managers can grow quality improvement capabilities by learning to be role models in change,
communicating to highlight benefits successful implementation will have on various
stakeholders, and establishing trust with frontline staff and stakeholders (Drew & Pandit, 2020).
Quality improvement in healthcare relies on the ability to bring together groups to
embrace change while trusting in subject matter experts to further changes and keeping the
patient at the forefront of the work (Drew & Pandit, 2020). Tappen et al. (2017) pointed out
leadership involvement, authority, and support play key roles in change initiative implementation
while leadership turnover can negatively affect organizational change culture by the failure of an
intiative to implement and sustain. Decampli et al. (2010) found frontline nurse managers often
face changing priorities with a lack of preparation to take on the important organizational role of
interfacing with different organizational stakeholders. Two of the top 10 key factors that Guérin
et al. (2015) indicated were barriers to change revolved around the lack of management support
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in terms of prioritizing change, and supporting or encouraging staff to embrace change. Drew
and Pandit (2020) pointed to the need for managers and leaders to change approaches to quality
improvement through consistency and to engage frontline staff to further change intiatives. The
middle manager role has key involvement in change intitiaves impacting organizations. As
organizations struggle to sustain change to achieve empirical outcomes, it is imperative they
invest in targeted change skills.
Organizational Perspective
By providing opportunities for leadership development, organizations may increase their
chances of retaining staff and building their leadership pipeline of future organizational leaders.
Healthcare organizations often place too much focus on job-specific and task-oriented skills in
staff but leave future nurse leaders unprepared to take leadership roles by not including
development in topics such as strategy, change, time, or people management skills (Fennimore &
Wolf, 2011). Expectations of a leader are always growing, which leads to an evolution of
roles/responsibilities that need to be met. As research on leadership evolves, questions arise on
what is missing in the leadership role and if organizations are realistic in their expectations
(Sturm et al., 2017).
In a changing healthcare environment, building leadership skills can be viewed as
evolving, requiring assessment of current needs and potential future trends in leadership
development, such as developing soft skills like communication and confidence to position nurse
managers to work with their teams (Sherman & Pross, 2010). Sturm et al. (2017) proposed
organizations should bind together or entangle leader character (e.g., moral, judgement, well-
being, excellence) and competencies (e.g., knowledge, skills, motivation) through informal and
formal learning and ongoing application through experience. Organizations need to develop
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strategies for development of nurse leaders to focus on encompassing professional development
opportunities in conjunction with informal learning opportunities that address growing industry
concerns and organizational implications of nursing shortages (Abraham, 2011; Sturm et al.,
2017). With thoughtful development of current and future leaders, organizations can position
leadership to be successful in implementing, sustaining, and diffusing change that contributes to
the achievement of strategic goals and outcomes.
Dual Theoretical Frameworks: KMO and Social Cognitive Theory
The lack of sufficient development in the healthcare middle manager role, which leads to
an inability to sustain change to achieve empirical outcomes, can be explored through two
theoretical frameworks that explore the individual and the organization. The primary theoretical
framework is the Clark and Estes’s (2008) KMO gap analysis that explores organizational and
individual factors impacting leadership development of middle managers that focuses on leading,
implementing, and sustaining change. The secondary theoretical framework emphasizes the
individual person in the middle manager role through Bandura’s (1986, as cited in Schunk &
Usher, 2019) social cognitive framework. Viewing the focus of this study through two
theoretical frameworks allowed me to understand implications and connections of organizational
and individual factors involved in middle manager development.
KMO Framework
Understanding the struggle of middle management teams to sustain change requires
examining the individual and organizational aspects that contribute to development of needed
skills and competencies to be successful. Clark and Estes (2008) provided a theoretical
framework of KMO to understand gaps in performance and push forward changes that build
knowledge and skills in employees, which builds motivation and increased organizational
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performance. Using the KMO model to understand current performance gaps in the support of an
individual’s knowledge and skills, individual motivation to achieve goals, and barriers present in
the organization allows the healthcare organization to identify gaps that need to be closed (Clark
& Estes, 2008). The ability of an organization to increase an employee’s knowledge, skills, and
motivation allows the organization to leverage employees as assets to improve performance and
organizational goals. It is key to identify the root cause of performance issues and gaps to focus
on building employees to help the organization be successful. By identifying these gaps, an
organization can evaluate the needs of individuals, such as healthcare middle managers, to be
successful, and how the organization can create a structure to support that success.
Using the KMO gap analysis model to examine the problem of lack of leadership
development for middle management, especially for sustainment of change, allows researchers to
explore gaps and barriers for the individual and organization. Clark and Estes (2008)
demonstrated that “investing in employees brings positive and profitable results for the
organization” (p. 3). The theory of change focuses on how the perspective of a situation or
opportunity can be improved through understanding individual needs and perspectives (Tuck &
Yang, 2014). Clark and Estes (2008) identified “big three” (p. 43) factors that contribute to
issues in performance for organizations, including: (a) the knowledge of individuals that
comprise the organization, (b) individual motivation to achieve goals, and (c) organizational
barriers that inhibit support and facilitation to achieve goals. Organizations need to understand
the gaps present in leadership development to support the middle manager role in addressing
these gaps and making improvements to support the acquisition of new leadership skills and
competencies. While exploring these gaps, it is important for an organization to understand the
different needs of healthcare middle managers to implement the type of changes that will
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improve existing structures. The organization can develop a structure that supports all needs by
understanding at individual level. Figure 5 demonstrates the KMO theoretical framework of
Clark and Estes (2008).

Figure 5
Visual Representation of the KMO Theoretical Framework

Note. K = knowledge, M = motivation, and O = organization. The figure combines concepts
from Clark and Estes KMO theoretical framework created from “Turning Research Into Results:
A Guide to Selecting the Right Performance Solutions,” by R. E. Clark and F. Estes, 2008.
Copyright by Information Age Publishing.

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Social Cognitive Theory
Using a secondary framework, I emphasized the individual viewpoint to understand the
needs from the individual perspective to allow an organization to better address individual-
focused development needs. Bandura’s (1986, as cited in Schunk & Usher, 2019) social
cognitive theory provides a means to examine influences on an individual and their behavior as
they interact, learn, and build needed knowledge and skills. Schunk and Usher (2019)
highlighted how an individual’s learning, belonging, behaviors, self-efficacy, and attributes are
developed through the two-way relationships present in the reciprocal interactions between the
person, behavior, and social/environment components. Using the concept of these two-way
reciprocal interactions between person, behavior, and social/environment, information and
motivation can be translated into actions and behaviors to develop values, beliefs, and skills that
lead to achieving outcomes through the use of models and observations (Schunk & Usher, 2019).
An additional component of the sense of belonging that an individual experiences in an
organization or with their peer group impacts an individual’s ability to feel connected and valued
(Elliot et al., 2017). Understanding the learning needs of middle managers can build
organizational support of connecting knowledge, behavior, and environment to individual needs.
Figure 6 demonstrates the conceptual framework of Bandura’s (1986, as cited in Schunk &
Usher, 2019) social cognitive theory.

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Figure 6
Visual Representation of Social Cognitive Theory

Note. The figure combines concepts of the Social Cognitive Theory Framework from “Social
Cognitive Theory and Motivation,” by D. H. Schunk and E. L. Usher, 2019, The Oxford
handbook of human motivation (2nd ed.). Oxford University Press.
(https://doi.org/10.1093/oxfordhb/9780190666453.013.2). Copyright 2019 by Oxford University
Press and from C. Regur, Education 627, personal communication, February 13, 2021.

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With insufficient development of the middle management role in healthcare
organizations, there is an insufficient ability of the role to sustain organizational change
initiatives. It is important to develop necessary skills and knowledge of the middle manager role
to support change due to their important connection to frontline staff for sense-making,
dependability, and support (Belasen & Belasen, 2016). Social cognitive theory can provide a
perspective to support building skills in the healthcare middle manager role to facilitate capacity
growth and capability through knowledge acquisition, models, “system thinking” or the view of
interactions, and development of cognitive and social strategies (Hartviksen et al., 2019, p. 2).
Hartviksen et al. (2019) explored the connection between elements in the development of
“capacity and capability” (p. 16) with the advancement of the middle manager role to help
facilitate sustained change.
The absence of organizational development opportunities to support middle managers
furthers the idea that middle managers are often promoted based on technical competency rather
than leadership skills. Leveraging learning through enactive learning and acquiring strategies and
actions through vicarious learning can motivate middle managers to develop self-efficacy
strategies that will lead to success (Schunk & Usher, 2019). Examining the middle manager role
facilitates understanding of the impacts on an individual’s sense of belonging when their role is
often ill-defined, focusing on “what it is not” (Gutberg & Berta, 2017, p. 3) rather than in
concrete terms of what it is, impacting their ability to develop, implement, and support change
initiatives (Elliot et al., 2017).
Ramchunder and Martins (2014) explored the relationship of three components of
leadership: emotional intelligence, self-efficacy, and effectiveness in leadership positions in a
South African police organization. Ramchunder and Martins studied organizational implications
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to develop these psychological constructs in existing leaders and explored recruitment strategies
to seek these out in leadership applicants. Nielsen et al. (2009) focused on the link between self-
efficacy and collective efficacy that influences outcomes associated with transformational
leadership, well-being, job satisfaction, and commitment to a group or organization. There are
elements of transformational leadership style that impact efficacy and relationships with
employees based on leadership behaviors (Nielsen et al., 2009). Oppi et al. (2019) explored the
connection of creative self-efficacy and collective efficacy on innovative behaviors in clinical
managers with an Italian study that highlighted the effects of creative self-efficacy for the
clinical manager role and as a model for other innovative behaviors. Providing learning
opportunities strengthens organizational support for middle managers to develop knowledge and
behavior to obtain leadership positions.
Conceptual Framework: Intertwining KMO and Social Cognitive Theory
Understanding gaps present in existing leadership development structures through the
lenses of KMO provides an opportunity to identify what is needed to achieve supportive
leadership development programs for healthcare middle managers. Literature has presented
several key concepts that highlight healthcare middle managers’ struggles with being leaders in
their organizations, such as lack of leadership development structures in place in organizations
and insufficient leadership skills and competencies, which leads to the inability to achieve
outcomes and sustain change. O’Neil et al. (2008) demonstrated how organizations that lack
investment in leadership development leads to current and future leaders being unprepared to
meet the demands of the leadership role and risk low performance of outcome achievement.
Organizations need to have development structures in place to retain and grow staff to fill current
leadership roles and develop future leaders to advance (Belasen & Belasen, 2016).
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The study’s conceptual framework combined two theoretical frameworks to understand
the implications and connections of both organizational and individual factors involved in middle
managers’ abilities to support and sustain change: Clark and Estes’s (2008) KMO gap analysis
and Bandura’s (1986, as cited in Schunk & Usher, 2019) social cognitive framework. Through
the combination of KMO and social cognitive frameworks, this study was positioned to identify
the struggles of healthcare middle managers through individual and organizational perspectives.
Figure 7 is a visual representation of the conceptual framework. The blue arrow in the diagram
demonstrates the start of the current state for an organization and individual that moves through
the two theoretical frameworks to identify gaps in performance achievement and organizational
goals. The larger blue arrows represent how I made recommendations to align with future goals
once gaps were identified.

Figure 7
Conceptual Framework Using Gap Analysis of KMO and Social Cognitive Theory

Note. Figure combines the concepts of Clark and Estes KMO gap analysis with social cognitive theory. Adapted from “Turning
Research Into Results: A Guide to Selecting the Right Performance Solutions,” by R. E. Clark and F. Estes, 2008, Information Age
Publishing. Adapted from “Social Cognitive Theory and Motivation,” by D. H. Schunk and E. L. Usher, 2019, The Oxford handbook
of human motivation (2nd ed.). Oxford University Press. (https://doi.org/10.1093/oxfordhb/9780190666453.013.2).
65
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Knowledge and Learning
Individual knowledge is one component of the KMO model that ties to performance and
achieving organizational goals in the context of the knowledge and skills component of the social
cognitive triadic relationship. An individual’s knowledge and skills leads to their ability to
perform to the level needed to achieve goals (Clark & Estes, 2008). Clark and Estes (2008) stated
knowledge “tells us how to do things” (p. 80) through elements such as information, job aids,
training, and education. Information gives the ability to use past experience that is relevant to
apply to current goal achievement, with procedures that become routine for learners; education
that prepares learners to be able to solve problems or challenges; and reinforcements with job
aids, assisting learners to leverage related expertise. Organizations can evaluate gaps present in
performance as they relate to knowledge to critically assess the need for training, education, use
of prior knowledge, knowledge transfer, resources to facilitate knowledge acquisition and
transfer, and their appropriate timing. Through understanding an individual’s prior knowledge
and ability to acquire new knowledge with an organization’s support system, an organization can
determine how best to support an individual to further organizational goals.
Learning is facilitated through training to build individual knowledge and skills, often
facilitated by organizations for their employees. Clark and Estes (2008) discussed the ability to
deliver well-designed training to increase performance, at the right time, with the right people,
with the right content, and with the right delivery and mode for participants. Mayer (2010)
demonstrated the importance of designing training opportunities that manage both “extraneous
overload” and “essential overload” to not exceed a “learner’s cognitive capacity” (p. 44).
Cognitive overload can be reduced through designing learning experiences that provide pauses in
content to allow for reflection of delivered material. Furthermore, Ambrose et al. (2010)
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proposed allowing learners the opportunity to understand individual tasks or skills being taught
before moving additional material and allowing for layering of information so learners can
comprehend each element before adding on additional information. Ambrose et al. recommended
outlining clear goals and expectations at the beginning of training sessions so learners can focus
their attention and energy on learning that meets those outcomes. The ability to deliver training
that supports individual knowledge acquisition leads to the organizational ability to deliver
training that most benefits individuals and the organization.
Knowledge Creation and Behaviors
Understanding individual experiences and backgrounds allows organizations to better
facilitate training that supports the individual and organizational goals and outcomes. Alexander
et al. (2009) demonstrated the importance of creating connections between a learner’s prior
knowledge and the new knowledge acquisition a training is trying to foster. Creating
opportunities for a learner to interact with prior knowledge and new knowledge can impact new
learning. Ambrose et al. (2010) highlighted how the individual learner brings prior knowledge
into each new learning environment that will contribute to how they interpret, understand, and
connect to the new content being presented. Through assessment of prior knowledge, there is
opportunity to identify if prior knowledge was accurate and appropriate, helping the learner in
the current situation or hindering the learner if it was inaccurate or insufficient (Ambrose et al.,
2010). Ambrose et al. (2010) outlined five areas to consider when leveraging prior knowledge
assessment during trainings, including developing strategies to assess prior knowledge as it
relates to the training to connect to the “relevant prior knowledge” (p. 27) or fill in gaps that exist
to be able to appropriately make prior knowledge connections. The ability to understand and
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leverage prior knowledge allows for connections to learner’s cognitive processes that helps
create connections and retain new knowledge into long-term memory recall (Mayer, 2010).
Additional emphasis on fostering the learner’s ability to later execute leadership
competencies can aid the development of self-efficacy. Developing a learner’s skillset would
demonstrate their ability to progress toward achieving desired outcomes and increase the
assessment of their capabilities and foster self-efficacy (Elliot et al., 2017). A learner’s self-
efficacy is their assessment of their ability to employ the skills necessary to act and achieve
desired goals and outcomes (Bandura, 2000; Elliot et al., 2017). An individual’s efficacy is
fostered through a combination of satisfaction gained from attainment value of mastery and
accomplishments, focus on accomplishing a task over the actual outcome through intrinsic value,
and instrumental value of one goal leading to the accomplishment of other future goals (Ambrose
et al., 2010). Schunk and Usher (2019) outlined that, by leveraging outcome expectations,
building self-regulating behaviors, and fostering self-efficacy, individuals can adapt and sustain
behaviors over long periods of time. Organizations need to take into consideration how they are
able to leverage connections to prior knowledge to support development of leadership skills in
current and future middle managers.
Motivation
Motivation is the second individual component that connects to an individual’s ability to
persist to achieve performance that drives reaching organizational goals. Motivation pushes
individuals to work toward a goal, persist to achieve that goal, and ensure effort goes into
moving the goal forward (Clark & Estes, 2008). Motivation “gets us going, keeps us moving,
and tells us how much effort to spend on work tasks” (Clark & Estes, 2008, p. 80) through
supporting focus on achieving goals and eliminating or reducing performance gaps. Motivation
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supports an individual’s choice to pursue the goal, persist during continued work toward the
goal, and invest effort to achieve the goal (Clark & Estes, 2008). Clark and Estes (2008) pointed
to motivation developing self-confidence and team confidence through facilitating goal
ownership, recognition, feedback, and clearly articulated expectations to develop needed skills
for goal attainment. An organization must be aware of barriers and actively remove them to
facilitate the achievement of goals through creating a positive “emotional environment” (Clark &
Estes, 2008, p. 94) to work in through connecting values to goals and providing reasons for goal
importance. Creating avenues to build motivation in the middle management team can lead to
success in outcomes and sustained change for the individual and organization. Through
demonstration of continued goal attainment and sustained change, organizations can also attract
future leaders to the role of middle manager through succession planning, retention, and
recruitment.
Organization
The KMO framework goes beyond the individual components to achieving performance
goals; it also investigates organizational barriers that inhibit an individual’s ability to progress
toward achieving goals. Clark and Estes (2008) stated without the appropriate support in place
by the organization, there are barriers that necessitate individuals to find workarounds to
progress toward achieving goals. The potential to create workarounds can become detrimental to
the ability to sustain change. Austin (2016) shared an entire organization must be committed to
mission success and all moving parts must contribute to that success, which includes integrating
values and being committed to people of the organization. Organizations should use values,
vision, and strategy to maintain focus toward achieving goals that align with where the
organization is going or needs to be going (Austin, 2016). A key component of the
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organizational side of Clark and Estes’s (2008) KMO gap analysis is that organizational culture
drives performance and attainment of goals; the culture in an organization can either facilitate or
deter changes in performance and subsequent goal achievement. Individual performance
improvement is just one component that drives toward successful achievement of goals and
organizations also develop barriers that inhibit success such as work processes, resources, and
value throughout the “value chain” (Clark & Estes, 2008, p. 105). Organizational vision,
structure, processes, policies, procedures, communication, involvement, and engagement can
contribute to success.
Summary
An organization’s ability to support the healthcare middle manager role is imperative for
individual and organizational success. In the literature review, I described how it is key for
organizations to truly understand the struggle middle managers face in achieving desired
outcomes and sustaining change through barriers and challenges, such as competing priorities,
unclear expectations, role ambiguity, and the ever-changing environment of healthcare. The
analytical lenses of the KMO framework and social cognitive theory provide opportunities to
understand and fix gaps in organizational resources and support individual knowledge and
motivation, which resolves barriers and grows current and future leaders. This study aimed to
identify and understand organizational and individual gaps that inhibited healthcare middle
managers from successfully achieving outcomes and sustaining change.
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Chapter Three: Methodology
Healthcare middle managers seek organizational support to be successful in managing
daily roles, sustaining change, supporting job satisfaction, intending to stay, and aspiring
leadership growth. As seen in Chapter 2, literature has pointed to several factors that have
contributed to middle managers’ struggles in their role and in sustaining change, such as unclear
and changing expectations, role ambiguity, competing priorities, lack of sufficient development
of management and leadership skills, and stressors. The purpose of this study was to understand
the needs of healthcare middle managers to be successful both in role duties and in sustaining
change, from both the organizational perspective and individual attributes. As a result, the aim of
the study resulted in recommendations for an organization to support the role and facilitate an
individual’s ability to acquire knowledge and apply it through motivation in their work. I looked
at knowledge, motivation, and organizational factors that influence a middle manager’s ability to
be successful in sustaining change and exploring the social cognitive aspects of the individual in
the role (Clark & Estes, 2008; Schunk & Usher, 2019). These factors were evaluated based on
the Heart of Care Cancer Center (HCCC) culture, structure, values, and insights of middle
managers who comprised the role of nurse managers and senior nurse managers/directors.
Research Questions
This dissertation study was guided by three research questions:
1. How do middle managers perceive their ability to facilitate change to achieve
outcomes?
2. What skills/competencies do middle managers identify as key to role success and in
sustaining change?
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3. What are foundational elements of leadership support organizations need to provide
for middle managers to be successful in achieving sustainable change?
Overview of Research Design
This study’s research design was comprised of a qualitative methodological focus using
semistructured interviews and existing secondary data. I chose a phenomenology study to
describe “the lived experiences of individuals about a phenomenon as described by participants”
(Creswell & Creswell, 2018, p. 13), bringing together several lived experiences from multiple
individuals who experienced the same phenomenon. The study focused on the lived experiences
of middle managers in sustaining change in an organization. The ability to sustain change was
generally defined as implementing and maintaining for sustained improvement over time (Anand
et al., 2021; Harrington et al., 2015).
The primary method used in this study was qualitative with a focus on phenomenology
through interviews to capture the lived experiences of middle managers and their struggle to be
change leaders in organizations (Creswell & Creswell, 2018). I designed an interview component
using a semistructured approach to capture participant lived experiences and stories of healthcare
middle managers to answer the study’s RQs (Burkholder et al., 2019). To supplement the
qualitative study, I used secondary data to highlight existing data, information, and documents in
the study organization. Secondary data are additional data that exist outside the current study and
were used to layer additional information and insights into the study (Creswell & Creswell,
2018). The ultimate objective of this qualitative study was to collect deep, meaningful
information of the experiences of participants to learn more about the healthcare middle
manager’s struggle to sustain change in their organization. Table 2 provides an overview of the
RQs and associated data collection methods.
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Table 2
Data Collection Methods for Study Research Questions
Research question
Open-ended
interview
Secondary data
RQ1: How do middle managers perceive their
ability to facilitate change to achieve outcomes?
X X
RQ2: What skills/competencies do middle
managers identify as key to role success and in
sustaining change?
X X
RQ3: What are foundational elements of leadership
support organizations need to provide for middle
managers to be successful in achieving
sustainable change?
X

Research Setting
I conducted the qualitative research study at the HCCC located in Southern California,
which serves five counties throughout Southern California through a central campus and 35
clinical network sites. At the time of the study, the organization had approximately 7,500
employees, with 3,000 employees in nursing and patient care services and 1,600 nurses;
furthermore, they were in the process of expanding their employee counts. The organization was
a research and treatment center for cancer, diabetes, and other life-threatening diseases; and a
leader in bone marrow transplants, research, and personalized treatment aimed at advancing care
throughout the world. HCCC had an inpatient hospital with 215 patient beds and outpatient
services that served 1,200 patients a day in 2019.
The study organization was selected as the research site because it was my organization
of employment at the time of the study. The nursing department had focused on developing the
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middle management team to increase retention, develop leaderships, and sustain change. There
was a growing need to revisit change implementations because of difficulties in sustainment of
initiatives to achieve long-term outcomes. There was evidence that change initiatives had not
held sustained impacts to outcomes. For example, a specific unit was seeing progress toward
improvement in patient outcomes for several months only to see decreased effectiveness after 6
months. The ability to understand the middle manager role in change and the struggles they faced
to sustain change in the study organization gave insights on the needs of the study population.
Participants were from the nursing department of the study organization and comprised of
senior nurse managers/directors and nurse managers. I selected participants who met specific
criteria through purposeful sampling. The purposeful sampling focused recruitment of
participants to collect experiences that represented the typical experience and was used to ensure
participants recruited met the selection criteria, were from the correct setting, and provided
additional context to the research problem (Creswell & Creswell, 2018; Merriam & Tisdell,
2016). Participants were purposely selected based on criteria that included: (a) being a senior
nurse manager/director and nurse manage in the nursing department of the study organization,
(b) having been in the position for at least 1 year, and (c) were from different lines of business
and locations.
Researcher Positionality
Acknowledging my positionality in relation to the perspective and scope of this study
allowed for clear identification and mitigation of factors that may have overtly or inadvertently
influenced the study. Merriam and Tisdell (2016) defined a “researchers’ positionality [as] their
race, gender, social class background, and sexual orientation—particularly with respect to the
study purposes” (pp. 63–64). At the time of the study, I was a White, cisgender woman striving
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to grow into an executive leadership position in the service/healthcare field. A part of my role in
the study organization was to grow formal and informal leaders in the nursing department. I was
often responsible for developing leadership skills in registered nurses (RNs), nurse managers,
and senior managers/directors. This responsibility involved considering the different perspectives
and backgrounds that formed the organization’s workforce, ensuring everyone had needed
support. From the perspective of Cooper (2017), I had a variety of intersectionality points that
informed my career identity, which included being: (a) female, (b) White, (c) credentialed, and
(d) from an upper-middle socioeconomic class. Drawing on the social cognitive component of
this study’s conceptual framework as part of interpretative phenomenological analysis, there was
a focus on how participants of different backgrounds made different meaning and experiences
(Johnson & Christensen, 2017).
My perspective came from being a White woman raised in a Christian school that taught
colorblindness, which can cloud the view of barriers for other racial/ethnic groups. My view of
diversity, equity, and inclusion has evolved over time with education, conversations, and
exposure to diverse backgrounds and perspectives. A deeper understanding has grown through
my knowing it is not only the availability of opportunities for people, but also shifting to
recognizing the needed access and support to obtain these opportunities (Bogler, n.d.). It was
necessary for me to acknowledge, reflect, and challenge previous colorblind views in this
research to continue to grow understanding of different perspectives and take action to make
meaningful connections (Bonilla-Silva, 2006). Through reflection and acknowledgement of this
perspective, I made efforts to minimize undue influence on the study.
Additionally, I took into consideration intersections with White privilege. McIntosh
(1988) highlighted the advantages of White privilege that are present in everyday situations.
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These advantages create challenges for people of racial and ethnic diversity that must be
navigated to achieve advancement. It was important to include a holistic perspective of different
facets contributing to middle managers’ struggles to sustain change, including investigating the
diversity of backgrounds and experiences. My service/healthcare role has focused on supporting
the growth and advancement for middle managers, I need to keep in mind the potential for
colorblindness and consideration of all aspects that impact racial/ethnic diversity in healthcare
leadership.
Throughout higher-level education and career development, I always strived to obtain
levels of education and certifications that would advance my career, often without employers’
financial support or guidance. Mulhere (2018) indicated women must obtain higher degrees than
their male counterparts in career fields to be competitive in earnings. Thankfully, I was able to
access and leverage personal and professional networks to help with advancement (Bonilla-Silva,
2006). Additionally, growing up in an upper-middle socioeconomic class provided me the ability
to afford to pursue advancement opportunities, qualify for loans, or receive assistance from
family when needed.
I had to navigate an insider dynamic because I worked in the study organization and with
the study population (Merriam & Tisdell, 2016). As an insider, I had full access to the study
population but there seemed to be some participant hesitancy to be fully transparent with me.
The main element of positionality that I had to be aware of during interviews was my access to
education and development opportunities. It was key for me to be aware of this element of
positionality and ensure questions, responses, or demeaner did not influence participants. I
focused during interviews by suspending preconceptions and “learned feelings about a
phenomenon” (Johnson & Christensen, 2017, p. 445) and experience the moment with the
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participant, even seeking the essence and commonality across experiences. It was imperative for
me to continually assess alignment to the study because I was an insider and connected to the
organization.
Because I was also an employee in the study organization, I needed to ensure my
positionality did not influence interview participants so deep information could be gained. In the
discussion of fieldwork, Bogdan and Biklen (2007a) pointed to the importance of understanding
research through different points of view. To gain access to these different points of view, I had
to balance previously built rapport with neutrality. Participants might have been hesitant to fully
engage and provide rich, thick descriptions because of my current role in the organization and
connections to senior leadership (Bogdan & Biklen, 2007a; Merriam & Tisdell, 2016). I
reinforced the element of confidentiality for study participants in recruitment and semistructured
interview sessions.
An additional element of my positionality was experience in the role of middle manager
in a healthcare organization and with my work facilitating quality improvement and change
management. My lived experiences helped connect the study focus with participants. I was
aware of the influence of day-to-day interactions with participants as an element of positionality
and ensured questions, responses, and demeaner did not influence participants (Merriam &
Tisdell, 2016). As a support colleague to middle managers at the study organization, I was not in
a position of power over participants because my role was in a separate organizational chart from
the participants. As Robinson and Leonard (2019) highlighted in their discussion of power
dynamics, it was important for me to indicate how the information collected in questionnaires
and interviews was used as part of the research. Although I was a support employee in the
organization that supported the middle manager study population, there was an expectation that
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the research benefited the study population (Robinson & Leonard, 2019). This qualitative
research study provided for the capture of participant personal experiences. Through the course
of interviews, I formed connections to allow participates to feel open to providing insights. It
was integral to ensure the research maintained empathic neutrality by being mindful of the
connection and allowing for being open and present with participants during interviews (Johnson
& Christensen, 2017). I was transparent with the interview procedures and how they related to
the overall study and subsequent outcomes and implications.
Data Sources
This phenomenological study focused on understanding the ability to develop needed
leadership skills to successfully sustain change for healthcare middle managers (i.e., senior nurse
managers, directors, and nurse managers) at HCCC. A phenomenological study is used to
“describe one or more individuals’ experiences of a phenomenon” (Johnson & Christensen,
2017, p. 424). The study combined qualitative, semistructured interviews supplemented with
secondary data sources from the study organization.
Qualitative: Semistructured Interviews
The qualitative portion of the study is a phenomenology study through interviews to
capture the lived experiences of middle managers and their struggles to be organizational leaders
(Burkholder et al., 2019; Creswell & Creswell, 2018). The study captured qualitative data from
study participants through questions and observations on participant mannerisms, tone, and body
language during the interview process (Burkholder et al., 2019). I designed the interview portion
of the study using a semistructured approach to capture participant experiences and stories in a
more natural manner while also getting the answers to specific areas of focus. Using a
semistructured interview approach allows for an interview to be designed using an outline of
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questions with potential probes to help facilitate getting deeper information. Burkholder et al.
(2019) indicated questions may deviate from the predetermined questions depending on the flow
of the probe questions and overall semistructured interview. Leveraging a tool from open-ended
or unstructured interviews, I created an interview guide to help stay on task and ensure all
questions and subject areas were covered during the interview (Patton, 2002). This interview
guide also ensured consistency between and within interviews to be respectful of participants’
time (Patton, 2002). The interview protocol helped guide the execution of the interview to ensure
the methodology continued to align with RQs.
Participants
The target population of the study was the healthcare middle manager role in a single,
not-for-profit research and medical center organization, focusing on clinical areas. The study
consisted of 17 interviews during Summer 2022. The goal was to capture different participant
experiences, focusing on a sample that included different genders, age ranges, ethnicities,
backgrounds, and levels of experience. As of February 2022, the study organization had 17
senior nurse managers/directors and 41 nurse managers that comprised the nursing middle
management team.
I used purposeful sampling as recruitment for the study to allow for the greatest diversity
in perspectives, experiences, backgrounds, and demographics. Purposeful sampling provided the
opportunity to learn about the research topic and the sample was selected based on criteria that
was representative of the study population and area of focus (Merriam & Tisdell, 2016).
Purposeful sampling provided an opportunity for me to identify specific characteristics of the
population to select individuals for the sample that aligned with those characteristics (Johnson &
Christensen, 2017). The purposeful sample for the study focused on the healthcare middle
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manager role based on varying levels of experience, demographics, and roles in a healthcare
organization. The selection criteria facilitated deeper, richer content and narratives for qualitative
analysis by inviting participants representative of different demographics present in the
healthcare middle manager role (Merriam & Tisdell, 2016). For purposes of this study, the
purposeful sampling was based on “typical case sampling” with a focus on recruiting individuals
based on what would be described as an “average case” (Johnson & Christensen, 2017, p. 274)
representing the population. I aimed to collect 12–15 interviews through purposeful selection
criteria (see Table 3).

Table 3
Purposeful Selection Criteria
Selection criteria Desired participant type
Distribution in middle management roles 7–10 nurse managers
3–5 senior nurse
managers/directors
Service line distribution Inpatient participants
Outpatient participants
Clinical network site participants
Years of experience as middle manager at study
organization
Minimum of 1 year in the
position

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Of the total nursing middle managers, 14 of the senior nurse manager/directors and 26 of
the nurse managers met the inclusion criteria for the purposeful sample. The semistructured
study included 17 participants selected purposely from the population of nurse managers and
senior nurse managers/directors. My goal was to have an interview sample of roughly 30% of the
study organization’s nursing middle management.
Instrumentation
The main component of the phenomenological study was the semistructured interview
protocol. I designed the interview study using a semistructured approach to capture participant
experiences and stories in a more natural manner while also getting answers to specific areas of
focus. Using a semistructured interview approach allowed me to design an interview with an
outline of questions followed by potential probes to help facilitate deeper information and
conversation during the interview (Burkholder et al., 2019; Johnson & Christensen, 2017).
Patton (2002) recommended using a variety of six question types in interviews to
facilitate a range of questions that engage the participant and illicit richness in their responses.
The six types of questions in this interview protocol included: experience, opinion, feeling,
knowledge, emotion, and background. I also designed interview questions to be open ended to
gain information from interview participants to obtain in-depth participant views, thoughts, and
experiences (Johnson & Christensen, 2017; Patton, 2002). The interview protocol included 20
interview questions with additional potential probes that were used or modified depending on
information participants provided during individual interviews (see Appendix A). The focus of
the interview questions was to understand middle managers’ knowledge and motivations in
relation to their roles and their experience with organizational change and outcome achievement.
Interviews elicited insights into participant past experiences (Merriam & Tisdell, 2016). I also
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included interview questions that explored organizational resources, leadership development
opportunities, barriers, support, and what individual middle managers were seeking from the
organization.
The semistructured interviews followed a set interview guide of questions with probes
that were used more as prompts from the set questions to gain “response clarity or additional
information” (Johnson & Christensen, 2017, p. 231). I created an interview guide that helped me
stay on task and ensure all questions and subject areas were covered during the interview (Patton,
2002). The interview guide helped me maintain general consistency and standardization in topics
and questions while allowing for probes to arise and naturally flow (Johnson & Christensen,
2017; Patton, 2002). Based on how the target questions were answered, the potential probes
varied, but I made note of new probe questions and included them as options in later interviews
(Burkholder et al., 2019). Merriam and Tisdell (2016) indicated questions do not have
“predetermined wording or order” (p. 110) in semistructured interviews and may deviate from
the predetermined interview guide order depending on the flow of probe questions. I
incorporated set interview questions and potential probes in the interview protocol (see Appendix
A). I designed the questions to investigate both the individual perspective of self and the
organization.
Data Collection Procedures
The study consisted of 30- to 60-minute semistructured interviews using open-ended
questions. I also included targeted, closed-ended questions to capture participant demographics. I
conducted qualitative interviews during the summer of 2022 by facilitating two to four
interviews a week until I collected 17 interviews. I scheduled interviews at the day, time, and
location that worked best for individual participants, considering work location (i.e., on site
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versus work from home) and shift (i.e., day versus night). Location selection for participants was
based on convenience and allowed for a private, comfortable, distraction-free environment
conducive to recording (Burkholder et al., 2019). I began the semistructured interview session by
obtaining consent from participants. Additionally, I did not pressure study participants and
reiterated participation was voluntary, emphasizing they had the opportunity to resign from the
study if they chose (Creswell & Creswell, 2018). The introduction was a combination of a study
introduction and disclaimer to begin the interview. Each individual participant gave consent to
participate in the study via the initial recruitment questionnaire and verbal consent at the start of
the interview (Creswell & Creswell, 2018). The description included an introduction, overview
of study, estimated time of completion, confidentiality assurances, and the attestation of
informed consent (Robinson & Leonard, 2019).
I offered to administer the interview to participants through in person or virtual online
options. Merriam and Tisdell (2016) indicated online interviews allow for more opportunities to
reach participants. With the variety of work locations and schedules, the two different options
allowed for study participants to schedule the option most convenient and comfortable for them.
The ability to offer different options for the interview administration required the use of different
technology. The online interviews were conducted synchronously so they were as close to an in
person, face-to-face experience as possible (Merriam & Tisdell, 2016).
I assigned unique identifiers to participants for purposes of data collection and
transcription to ensure confidentiality of collected information, later converting the identifiers to
pseudonyms for purposes of the findings section of Chapter 4. The identifier and pseudonym
assignment, data collection, recordings, and transcripts were stored in a secure drive that was
password protected and required two-step verification. It was my responsibility to ensure study
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participants had a clear understanding of the interview procedures and were comfortable with
protocol execution.
These semistructured interviews followed a set interview guide with probes through
“individual interviews [of] person-to-person encounter[s]” (Merriam & Tisdell, 2016, p. 108) to
allow study participants the opportunity to speak freely and openly with the researcher
(Burkholder et al., 2019). The ability to conduct individual interviews aligned with the
phenological study design (Burkholder et al., 2019).
With new technology to facilitate recording and transcript generation, I used Zoom video
conferencing technology (https://zoom.us) with auto transcription of the recording for virtual
interviews. This technology allowed for the opportunity to have an audio or mp4 file and a
voice-to-text transcription to verify and ensure accuracy of the audio file. Alternatively, I
recorded in-person interview participants through a primary and secondary recording device, also
utilizing the Zoom video conferencing technology for subsequent transcription to text. Per advice
of Bogdan and Biklen (2007b), the interview introduction included information and sought
consent regarding the recording of the interview so participants were aware of the recording
while having the option to pause the recording as needed. I ensured both recording devices and
Zoom meetings were working, the cloud recording was on, audio was tested and working for
both parties, and the recording device, computer, or laptop were fully charged (Bogdan &
Biklen, 2007b).
For purposes of security and confidentiality, I uploaded interview recordings to a secure
drive and through the USC provided Zoom meeting account. The transcription process included
converting interview conversations to text immediately after each interview while the live
interview was fresh in my mind (Johnson & Christensen, 2017). I removed participant names
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from transcripts and assigned a numerical identifier to ensure confidentiality. All documents,
transcripts, and recordings were stored on my computer and drives, which were password
protected for security and confidentiality purposes.
Data Analysis
I conducted, transcribed, and coded 17 interviews for inclusion in this qualitative
analysis. Data analysis allows researchers to understand and make sense of collected data
through understanding meaning, which contributes to the development of study findings
(Merriam & Tisdell, 2016). Merriam and Tisdell (2016) demonstrated data collection and
analysis are often conducted simultaneously in qualitative studies because these types of studies
are emergent, and the data guides the path of the qualitative study. Moving through a cycle of
discovery and verification of the data collection and analysis leads to testing and eventual
confirmation. The data analysis component of this qualitative study was comprised of different
analysis strategies to evaluate and correlate trends and patterns in study participant interview
data. The data analysis strategies included: “unique case orientation” and “inductive analysis and
creative synthesis,” employing both context sensitivity and “voice, perspective, and reflectivity”
(Johnson & Christensen, 2017, p. 420). “Unique case orientation” (Johnson & Christensen, 2017,
p. 420) acknowledges each participant brings their own data and experiences of which the
researcher can draw direct quotations and capture insights. I used inductive analysis to leverage
the use of purposeful sampling to immerse in the lived experiences of each participant and allow
for exploration through the analytical process to achieve “creative synthesis” (Johnson &
Christensen, 2017, p. 420). I was cognizant to ensure context sensitivity by avoiding
generalization application and considering transferability and adaption. I considered individual
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voice, perspectives, and reflectivity to strive to be authentic and intentional in analysis and
representation of experiences. I compiled and evaluated the data to identify findings.
I conducted interviews with an audio recording and Zoom transcription. The study
consisted of an iterative process of conducting interviews, reviewing the transcription with audio
recording to ensure accuracy, and redacting identifying information to ensure confidentiality
through anonymizing participants (Gibbs, 2018). Throughout the interview process, I used
“interim analysis” (Johnson & Christensen, 2017, p. 567) to assess and analyze data. During data
collection, there was a cycle of interview, transcription, segmentation, and first stage and second
stage coding to organize, identify interrelationships, and enumerate into frequency of codes
(Johnson & Christensen, 2017). After each interview, I reviewed the transcription and added
reflective notes in a form of theme analysis, using the process of segmenting data to find
meaningful components leading to codes. I crafted reflection and interview memos following
each interview and transcription (Gibbs, 2018). I used empathy maps as a reflective tool to
capture insights and impressions from interviews on participant persona and impressions (e.g.,
feeling, hearing, seeing, thinking, and experiencing).
I coded interviews using a combination of a priori or concept codes and data driven or
open codes (Gibbs, 2018) using the ATLAS.ti qualitative data analysis platform
(https://atlasti.com). Merriam and Tisdell (2016) defined coding as shorthand designation
assigned to qualitative study data that can easily connect to specific aspects of the data. The
coding process was facilitated by creating a codebook and a master list of codes to facilitate
consistency (Gibbs, 2018; Johnson & Christensen, 2017). A priori coding was developed based
on the literature and theoretical framework developed in Chapter 2. Inductive data codes were
developed through examining interview transcripts and generated from what was emerging in the
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transcripts. In vivo codes were derived from participants’ own words (Johnson & Christensen,
2017). By leveraging two different types of data coding, there were opportunities to identify
emerging themes that aligned with the organizational culture, and provided insight into
participant connection to the organizational aspects being studied.
Johnson and Christensen (2017) recommended researchers be cognizant of “co-occurring
codes” (p. 576), which have overlap either in entirety or in part. As coding commenced, other
open codes arose based on reoccurring ideas that were seen in different interview concepts. I
identified new codes during the coding process, which were applied to previously coded
interviews. As coding progressed, they were refined using axial coding to make connections,
grouped by RQ, and themed as appropriate while leveraging ATLAS.ti to create coding
hierarchies (i.e., moving from broader concepts to specific concepts; Gibbs, 2018). Throughout
the coding and thematic development, I continually checked that emerging themes connected to
the study RQs and were: (a) exhaustive, (b) mutually exclusive, (c) sensitive, and (d)
conceptually congruent (Merriam & Tisdell, 2016). Coding allowed for organization of the data
and connections between the different sources and facilitated ease of access when reviewing the
data (Merriam & Tisdell, 2016). The process of coding collected qualitative data allowed me to
align RQs to study findings. The coding hierarchy allowed for additional stratification and
differentiation. I developed a codebook as a part of the coding and thematic analysis from
qualitative interviews.
As I gathered additional information, I could identify larger themes and participant
perspectives (Johnson & Christensen, 2017). Through segmentation and coding, themes began to
emerge identifying important ideas, which illustrated frequency. Johnson and Christensen (2017)
offered the use of tree diagrams to build hierarchical analysis by finding connections and
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relationships between various interviews, such as using “qualitative subgroup analysis” (p. 582)
to identify relationships and connections between themes and create groupings of factors and
subcategories. I explored typologies in the qualitative data, seeking to break relationships into
“different types of kinds” (Johnson & Christensen, 2017, p. 583) and look for different
categories of relationships. I drew from process improvement tools to diagram relationships
showing links, connections, and strengths or levels of relationships of variables and factors.
Merriam and Tisdell (2016) demonstrated an aim in phenomenological study analysis is
“to arrive at structural descriptions of an experience, the underlying and precipitating factors that
account for what is being experienced” (p. 227). The goal of data collection and analysis was to
reach some level of saturation through interviews. This saturation is achieved when no new
information, data, or themes are generated by study participants on the phenomenon being
studied (Johnson & Christensen, 2017; Merriam & Tisdell, 2016). The empathy maps, in
combination with coding the transcripts, allowed me to create research memos, with each memo
continuing to be built upon as interviews were conducted and focusing on emerging themes from
coding (Gibbs, 2018). The research memos continued to have layers added onto them as more
interviews were conducted and coded. The data analysis led me to study findings that identified
opportunities and pathways to guide recommendations.
Secondary Data
I used secondary data from the study organization to supplement the interview data.
Secondary sources are defined as reports on the “phenomenon of interest” (Merriam & Tisdell,
2016, p. 178) that are separated from the actual lived experiences, not directly connected or
experienced, and information is compiled later. The secondary data were meant to supplement
this study’s research by adding information beyond the people experiencing this phenomenon of
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interest (Merriam & Tisdell, 2016). The secondary data from the study organization
supplemented the study’s RQs and presented additional descriptive data.
Data Collection Procedures
I retrieved the secondary data from the study organization through a data use agreement
between USC and HCCC. Johnson and Christensen (2015) defined secondary data as “existing
data originally collected or left behind at an earlier time by a different person for a different
purpose” (p. 243) and is comprised of official documents recorded through the organization of
study and physical data connected to activities of individuals and the organization. Secondary
data sources are generally comprised of documents and artifacts that exist outside the current
study (Merriam & Tisdell, 2016).
The secondary data that supplemented this qualitative study included a review of
available education provided by the organization, metric and outcome data in nursing-sensitive
indicators (NSIs), and assessment results from an organization created learning needs assessment
derived from the American Organization for Nursing Leadership competencies. The purpose of
collecting these secondary data was to “learn more about the situation” (Merriam & Tisdell,
2016, p. 174) relating to middle managers’ abilities to sustain change and feel role success. One
of the strengths of using secondary data is there is often an ease of access for the researcher to
obtain secondary data and leverage the different expertise used to develop the secondary source
(Merriam & Tisdell, 2016). Merriam and Tisdell (2016) shared secondary data can be used in the
same manner as qualitative and quantitative data to provide insight and information to
supplement the current research study. Often, there can be a stability of the secondary data or
documents and they are considered objective because the researcher’s presence does not
influence the data; therefore, it is unobtrusive to the study organization. The secondary data from
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the study organization added additional information and depth to complement the qualitative
interviews.
The secondary data provided background details and context to the focus of this
qualitative study. One aim of secondary data is to layer additional information from relevant
information to inform the study focus (Merriam & Tisdell, 2016). I ensured the secondary data
were (a) relevant to the study RQs and (b) able to be acquired in a “reasonably practical [and]
systematic manner” (Merriam & Tisdell, 2016, p. 180). Additionally, I evaluated the authenticity
and accuracy of the documents by learning as much as possible about the documents provided by
the study organization (Merriam & Tisdell, 2016). I documented the collection and evaluation of
the secondary data as I conducted research to support validity and reliability of the study.
Data Analysis
Once I collected secondary data from the study organization, I conducted data analysis to
glean pertinent information to support understanding and connection to the study’s three RQs.
During my review of secondary data sources, I conducted a content analysis to analyze
information and determine the applicability and appropriateness of these sources for the study
(Merriam & Tisdell, 2016). I analyzed the secondary data using the following steps: (a) learn the
history, (b) review and identify if the document is complete, (c) determine if it is genuine and
authentic with no unauthorized edits, and (d) explore and identify if there are any other
documents connected to it that should be reviewed (Guba & Lincoln, 1981, as cited in Merriam
& Tisdell, 2016). Adding secondary data for document analysis to qualitative interviews allowed
for “convergence” and “corroboration” (Bowen, 2009, p. 28) across a variety of sources. For the
review of existing learning offerings, I analyzed offerings present in the organization that may
assist in the development of middle managers in both leadership competencies and their ability to
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sustain change, incorporating organizational context into the qualitative study and striving to find
“latent meaning” (Merriam & Tisdell, 2016, p. 180) to combine with individual lived
experiences provided by the qualitative interviews. I reviewed and evaluated documents and data
from the study organization because these sources aligned with this study’s RQs. The document
analysis added layers of meaning and understanding to the qualitative interviews by looking at
available organizational documents and data to supplement the current study’s research as a way
to increase validity/credibility through triangulation. The objective for the secondary data were
to (a) provide context and historical significance to the study, (b) inform study direction, (c) add
supplementary data to the study methodology and subsequent analysis, (d) see changes in the
organization, and (e) verify and corroborate or identify specific elements where contradictions
existed (Bowen, 2009). Finally, I used “archived research data” (Johnson & Christensen, 2015,
p. 243) from sources such as the U.S. Census Bureau to place the study organization and its
individuals in the larger context of field, state, and national perspectives. The secondary data
provided details that did not emerge from participant interview data analysis.
There is often researcher caution and uncertainty when deciding to use secondary data
because data could be incomplete or limited because it was not developed for research purposes.
It was imperative for me to be able to determine “authenticity and accuracy” of the secondary
date to be “illuminating” (Merriam & Tisdell, 2016, p. 181) and then fully incorporate it in the
study research. With consideration of online data sources, I was aware of the “changing
electronic landscape” and took into consideration what data sources may be considered “static”
versus “dynamic” (Merriam & Tisdell, 2016, p. 184). Static data are not community developed,
remain unchanged, can be accessed in an ongoing manner, can be downloaded, and can be
available offline. By contrast, dynamic data are fluid; can be changed; can be deleted, moved, or
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archived; and can be compared to an observation. For study purposes, static data I downloaded
included U.S. Census data, American Organization of Nurse Leaders competencies, and HCCC
RN satisfaction data. The dynamic data that could be classified more like an observation and
could change day to day included the study organization’s learning management system (LMS)
platform and learning offerings. The key aspect with the online data/documents as part of this
study was to include analysis and discussion on the potential impacts from the dynamic data
(Merriam & Tisdell, 2016). Merriam and Tisdell (2016) highlighted limitations of online data,
including that they are only as accessible as tools such as search engines, which have an
“inherent bias” (p. 187); the access or lack of access impacts what can be analyzed. I
documented, tracked, and recorded as I retrieved secondary data from different sources so the
study could be repeatable and replicable.
Validity and Reliability
Throughout the development of study data collection and analysis methods, I considered
and incorporated validity and reliability measures into the protocol. I took steps to ensure the
proper strategies were followed in semistructured interviews. Qualitative credibility and
dependability were addressed through study methods with some quantitative validity and
reliability based on the incorporation of survey type questions using a Likert scale in the
interview protocol. Three questions were incorporated into the qualitative study that incorporated
scales of measurement, including ordinal questions with additional open-ended questions to
capture insights from participants (Salkind, 2014). These three questions were selected from a
preexisting survey tool to assist in alignment with key study concepts of motivation, knowledge,
competencies, and organizational support, which supported validity. I selected an existing tool,
based on research and my work with professional organizations, to select specific questions that
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focused on key concepts aligned with this study (Pazzaglia et al., 2016). I adapted the tool to
include questions from the Nursing Quality Improvement in Practice Tool (Tschannen et al.,
2020). The selected questions focused on participant demographics and perceptions of certain
elements of their role in quality improvement and were incorporated into the semistructured
interview structure.
I employed multiple strategies to ensure study validity to facilitate data collection, data
analysis, and findings. Dependability of the qualitative portion resulted from coding the data and
having cross checks with other researchers or experts (Lincoln & Guba, 1985). I employed the
critical friend strategy to help support validity through peer review in action during research by
discussing study methodology and components such as interview questions with colleagues and
peers from the healthcare field (Johnson & Christensen, 2017). Johnson and Christensen (2017)
defined triangulation as a “convergence of results” (p. 299) from different participants and
methods, which included variation in participant demographics to ensure the sample was
representative of the study organization, allowing for a greater number of viewpoints and
descriptions (Merriam & Tisdell, 2016). Another strategy to ensure validity included “multiple
data sources” by looking at different data to understand the phenomenon from different
perspectives and through “multiple methods” (Johnson & Christensen, 2017, p. 299). This
strategy was achieved through layering additional information from secondary data sources. The
researcher ensured validity by considering all cause-and-effect relationships, taking into account
other influences occurring in the organization that could contribute to the snapshot of current
perspectives. The goal of the data analysis phase was to rule out all other researcher expectations
to ensure I uncovered the best explanation of the studied phenomenon (Johnson & Christensen,
2017).
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Finally, through the use of audit trails, procedures and audits were in place to ensure data
collection was recorded properly and questionnaires were attributed to the correct participants
(Merriam & Tisdell, 2016). After data collection and analysis, I used participant feedback and
member checking by discussing interpretations and conclusions with participants to seek
additional understanding, insights, and verification of analysis that led to findings (Johnson &
Christensen, 2017). One potential threat to validity that researchers must be cognizant of is
researcher bias due to the potential to seek results that align with what they want to see.
Throughout the data collection and analysis cycle, I practiced reflexivity by continually checking
self-awareness and self-reflection to limit and challenge researcher assumptions, biases, and
perceptions (Johnson & Christensen, 2017). I documented all processes to collect and analyze
data with reliability and validity measures to provide structure to this research study.
I used several methods to maximize validity and credibility in data collection procedures,
including triangulation, variation, respondent validation, and audit trails. Triangulation ensured
there were multiple participants who were representative of different middle managers in the
study organization (Merriam & Tisdell, 2016). It was important for anyone reviewing the study
or attempting to replicate a similar study to have a clear understanding of the protocols, methods,
and standards used. The study credibility was strengthened through triangulation of perspectives
and confidentiality of data (Creswell & Creswell, 2018).
Ethics
I took measures to safeguard the study to ensure ethical standards and behaviors were
upheld. Prior to conducting the study, I completed study procedures for the USC Institutional
Review Board (IRB) and study organization IRB to ensure I obtained approval to conduct the
study and work with the participants before study execution began to ensure potential impacts
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and subsequent study outcomes were evaluated (Creswell & Creswell, 2018). Merriam and
Tisdell (2016) emphasized a study’s validity and reliability “depend upon the ethics of the
investigator” (p. 260). I made every effort to ensure participants in the study had enough
information to give informed consent to participate, including understanding data integrity, data
use, and options for discontinuing participation (Creswell & Creswell, 2018; Glesne, 2011). I
also ensured information regarding informed decisions to participate in the study was
continuously provided throughout the study with written and oral communication measures
(Glesne, 2011). I obtained participant consent when participants committed to participating in the
study and again at the start of the interview through a recruitment questionnaire administration
and verbal agreement.
Confidentiality was at the forefront of the study data collection to ensure I respected
participant privacy and data were not wrongly disclosed (Creswell & Creswell, 2018). I
acknowledged power dynamics and made efforts to minimize power relations, including: (a)
attempting to build commitment with participants so I did not have undue power over
participants providing the data; and (b) collecting, analyzing, and drawing implications on data
for the greater good of everyone in the field (Creswell & Creswell, 2018; Merriam & Tisdell,
2016). I did not provide rewards or incentives for participation in this research study. I was
committed to taking all measures necessary to ensure an ethical research study was executed and
participants were protected.
There were specific ethical considerations in the online environment for secondary data.
All secondary data sources used in this study were either (a) publicly available and in aggregate
form or (b) organizationally available in document or aggregate form to ensure anonymity
(Merriam & Tisdell, 2016). I ensured the organization gave consent to use documents and data
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for this study, and secondary data collected were kept in secure locations. I ensured anonymity
and confidentiality for comments provided in the organizational data, documents, and artifacts.
Additionally, participants from the secondary sources had provided consent when participating in
previously executed organizational surveys and data aggregation. The secondary data were used
to supplement the participant lived experiences and not supersede participant collected data.
The results of this study can help healthcare organizations understand the structure
needed to support the needs of middle managers to achieve outcomes and reduce turnover.
Healthcare middle managers can benefit from findings of this research study by expressing their
needs for a leadership development structure to support success in their role. Creswell and
Creswell (2018) suggested planning for anticipating the disclosure of potential harmful
information before data collection to ensure participants clearly understand potential adverse
impacts of participating in the study.
My intersectionality and lived experiences contributed to the scope of research and
questions that guided the study. By examining this problem of practice through pragmatic
constructivism, I sought to understand the multiple perspectives of the healthcare middle
manager (Creswell & Creswell, 2018). The research study findings will be disseminated at a
local level in the organization to inform future strategic initiatives focused on leadership
development and potentially shared through publications or presentations in the field to enact
change at a larger level.
Summary
Through careful consideration and preparation, I followed research principles of the
phenomenology methodology to gather lived experiences of healthcare middle managers
sustaining change in the study organization, HCCC. Data collected as part of this study were
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safeguarded and confidentiality was ensured to protect the identity of participants throughout the
study. The information I collected supported the development of answers to three RQs that
guided this research study. In Chapter 4, I discuss information collected following the
methodology outlined in Chapter 3 to answer three RQs and provide evidence to develop
recommendations.
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Chapter Four: Results and Findings
I set out to understand the lived experiences of nurse managers and senior
managers/directors at Heart of Care Cancer Center (HCCC) to explore development of the
middle manager role in healthcare organizations and the needed support to achieve successful
and sustainable organizational outcomes. In Chapter 2, I described a variety of themes relating to
the middle manager role in healthcare through a comprehensive literature review, including
development, role definition, and guidance and support. Semistructured interviews allowed for a
deeper understanding of these themes in the study organization. This study explored the lived
experiences of healthcare middle managers through the perspective of their role in operations,
leadership, and change while identifying needed leadership support and organizational structure.
Each interview participant uniquely contributed their voice to provide their view of the role,
organization, change, and implementation.
This study leveraged a combined theoretical framework of the Clark and Estes’s (2008)
knowledge-motivation-organization (KMO) gap analysis and Bandura’s (1986, as cited in
Schunk & Usher, 2019) social cognitive theory. With these frameworks, I sought to identify
findings from the qualitative data to understand gaps between middle manager role development
and their ability to sustain change with sustained empirical outcomes (Schunk & Usher, 2019). I
used semistructured interviews and secondary data analysis to learn from participants in the
study and identify findings as they related to the study’s research questions (RQs). Guided by the
three RQs, I developed interview protocol to align questions with specific RQs:
1. How do middle managers perceive their ability to facilitate change to achieve
outcomes?
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2. What skills/competencies do middle managers identify as key to role success and
sustaining change?
3. What are foundational elements of leadership support organizations need to
provide for middle managers to be successful in achieving sustainable change?
Study Participants
Participants were nurse managers and senior nurse managers/directors recruited through
purposeful sampling from the nursing department at the study organization. To participate in
interviews, participants had to be (a) a nurse manager or senior nurse manager/director, (b) in the
position for at least 1 year at the study organization, and (c) a representative of the variety of
different service lines and locations in the study organization. I conducted 17 semistructured
interviews either virtually through Zoom or in person at the study organization based on the
participant’s preference during July and August 2022. Each interview consisted of 20 interview
questions, with 17 open-ended questions and three demographic questions. Interviews lasted an
average of 45 minutes with a range of 30–58 minutes. Interviews were facilitated based on the
interview protocol (see Appendix A) to maintain consistency in data collection. Table 4
demonstrates the breakdown of participants interviewed, including 12 nurse managers and five
senior nurse managers/directors who had an average of 8.2 years of management experience and
a range of 1–26 years of experience working in management.

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Table 4
Participant Purposeful Selection Criteria Summary
Purposeful selection criteria Summary of participant characteristics
Distribution in middle management
roles
12 nurse managers
5 senior nurse manager/directors
Service line distribution 6 inpatient participants
7 outpatient participants
2 clinical network site participants
2 inpatient/outpatient
Years of experience as middle
manager
Average = 8.2 years
Range = 1 year to 26 years
Highest level of educational
obtainment
7 bachelor’s degree (3 master’s degrees in
progress)
10 master’s degree

Table 5 illustrates the participant personas to differentiate between participants and to
demonstrate their adherence to the purposeful sampling criteria required based on role and years
of experience. Each participant represents the nursing middle management team from different
areas of the study organization to highlight each unique perspective and experience.

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Table 5
Study Participant Personas
Participant Current position Highest level of education Experience in
management
Justine Nurse manager Master’s degree 7 years
Stephanie Director Master’s degree 8–10 years
Danielle Nurse manager Master’s degree 7 years
Vivian Director Master’s degree 9 years
Veronica Nurse manager Master’s degree 1+ years
Amelia Director Master’s degree 11 years
Maryanne Director Master’s degree 26 years
Lindsey Nurse manager Bachelor’s degree
Master’s degree in
progress
5 years
Debra Director Bachelor’s degree
Master’s degree in
progress
22 years
Carla Nurse manager Bachelor’s degree 7 years
Penelope Nurse manager Bachelor’s degree 10 years
Irene Nurse manager Master’s degree 1 year
Nicole Nurse manager Bachelor’s degree 6 years
Marisa Nurse manager Master’s degree 6–7 years
Lily Nurse manager Bachelor’s degree
Master’s degree in
progress
5 years
Helen Nurse manager Master’s degree ~1.25 years
Colleen Nurse manager Bachelor’s degree 4.5 years

Note. Participant names have been changed to protect anonymity of interviewees.

As a result of the coding and thematic analysis of interviews, I identified several findings
across the 17 interviews. Chapter 4 aggregates the lived experiences of participants and presents
findings to explore the perspectives present in the study organization in more depth. Each
findings section presents a table with an overview of the data that led to the findings, which is
elaborated through participant voices and insights derived from interviews. Secondary data were
used to highlight and expand on themes presented by participants, including nursing-sensitive
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indicators (NSIs), leadership and management courses offered by the organization in their
learning management system (LMS), and courses accessed and completed by the middle
management level in nursing. The conceptual framework of KMO (Clark & Estes, 20018) and
social cognitive behavior (Schunk & Usher, 2019) were overlayed onto findings to identify gaps
to be investigated and resolved. The examination of gaps that arose from findings allowed for
recommendations to be developed to address the problem of practice.
Roles and Responsibilities
A key theme that emerged from the literature review in Chapter 2 was the vast number of
responsibilities undertaken by middle managers in healthcare organizations. To better understand
the middle manager role and responsibilities experienced in the study organization, I included a
question aimed at the responsibilities the manager role undertakes or facilitates. Additionally, the
perspective of the distinct types of responsibilities allowed for the examination of the
organization or environment component in the conceptual framework. Figure 8 represents the
study organization as an informal comparison to Figure 3 in the literature review, which
represents the literature perspective of the responsibilities of the middle manager role in
healthcare organizations. Across the 17 interviews, participants identified 57 responsibilities of
nursing middle managers at the study organization: 32 responsibilities being staff focused, 22
responsibilities being organization focused, and three responsibilities being patient care focused.

Figure 8
Key Activities of the Middle Manager Role As Identified by Interview Participants

Note. The figure is a compilation of all 17 interview participants’ responses to the question: “How do you describe your role and
responsibilities in the organization?”
Achieve
outcomes/goals
Advocate for staff
Being the
connection or in
between
Being visible
Budget/fiscal
responsibility
Change agent
Cheerlead/encour
age
Clinic/unit daily
operations
Coaching
Communicating
Conflict
resolution/
interpersonal
problems
Disaster
management
Educating Emails
Employee
engagement
Ensuring clinical
competency
Ensuring quality
and safety
Ensuring staff is
doing their
projects
Equipment and
supplies available
and maintained
Escalating
concerns
Facilitate trust Guide staff
Hiring/onboardin
g/orienting staff
Holding nurses
responsible/acco
untable
HR needs for staff Influencer Listening
Maintain fair
labor laws
Maintaining/meet
ing standards
Making things
equitable for staff
Metrics
Move service line
forward
Nursing
representative on
committees
Patient care
activities/patient
facing
People
management/disc
iplinary
Point of contact
for technology
issues
Policy and
procedures
Project work,
tracking of
projects,
resolutions, etc.
Removing
barriers
Reporting
Representative
for the
organization
Responsible for
staff
Resource for a
new manager
Role modeling
Seeking input
from staff
Seeking resources
to resolve barriers
Service recovery
Staff
requirements are
met: BLS, TB test,
licensing
Staffing,
overtime, time
and attendance,
payroll, LOAs
Supporting staff
Making sure the
team flourishes
Team morale Transparency Transitioning staff
Union
Upholding
mission vision and
creating for staff
Using evidence Visionary/leading
103
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Top Responses to Roles and Responsibilities
There are many different responsibilities associated with the nurse middle manager role,
and it is important to also understand responsibilities that most frequently occur across different
participants. Many participants’ perspectives varied on what they saw as their role
responsibilities. Vivian gave some insight into the different responsibilities of the middle
management team, sharing:
You peel back the onion and there are 10 more things that have to be done, and you don’t
know the people that need to do it and so you spend a lot of time hunting and pecking
trying to find, oh, are you the person? And then, sooner or later, the things fall by the
wayside and forget about them.
With the 57 responsibilities identified, three responsibilities emerged as most frequently
occurring across 17 participants: (a) managing daily operations, (b) being a connection to the
frontline, and (c) being a change agent. Each of these responsibilities are further explored to
better understand middle managers’ workloads.
The most frequently referenced role responsibility identified by 12 of the 17 participants
was the day-to-day operations of their clinics and units, including: ensuring quality and safety for
patients, maintaining appropriate staffing, facilitating human resource needs for staff, and
maintaining regulatory and compliance standards. Further stratifying the responses to
responsibilities, seven of 17 participants focused on operational responsibilities as the most
important part of their role for patient care. Five participants who identified operational
responsibilities specified patient safety and patient care as most important, including being
prepared and having knowledge, challenging the status quo, and ensuring operations were
staffed. Many of the daily operations responsibilities were focused on the middle manager role,
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ensuring safe and quality patient care are provided by the staff. The middle manager team
supported staff so they were prepared to deliver safe patient care.
Participants described the variety of components that comprised daily operations based
on their work environments. Veronica summed up daily management in terms of ensuring the
staff were doing what they needed to be doing, saying, “I would say, the lions share is like, the
daily management, like making sure people are here. they’re doing what they need to do.” Carla
and Danielle discussed the human resource administration portion that supported daily
operations such as hiring, firing, and coaching of staff; scheduling, timecards, budget meetings;
and “conflict resolution with staff disciplinary action.” Irene also highlighted the need to work in
the complexities of the union environment by speaking of “staffing labor like fair labor laws and
decisions, [which] are legal and in the bargaining agreement.” Colleen, Carla, Danielle, Irene,
and Veronica demonstrated the aspects that were part of the middle manager role that maintained
daily operations to ensure staff were supported so they could ensure daily patient care. For
instance, Colleen spoke about the importance of taking care of staff so they could provide care
for patients, stating, “You’re very much responsible for the day-to-day well-being of patients, of
course, but also your staff.” Debra spoke about the importance of the connection between her
supporting staff and the staff supporting patients in their care, saying:
It’s ensuring that the care that we give everything to our patients is of the highest quality,
and that the staff are well trained and supported, and they feel that they have a leader that
they can fall back on. . . . My job is to support them and to be the go between when they
have challenges. . . . My job is to kind of protect them.
Most participants saw their role being an integral part to facilitating quality patient care through
their continual support of the staff at the frontline. All participants interviewed viewed the
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importance of their role to make safe patient care a priority on their units/clinics and doing what
they needed to make sure their staff could deliver needed care.
Nurse managers and senior nurse managers/directors also spoke about their role being the
connection between upper leadership and frontline staff, with eight of 17 participants expressing
this view of being in the middle. Being the role in the middle was described as that of a coaching
staff, resolving barriers, providing tools, and advocating for staff. Fourteen of 17 participants
identified staff-focused responsibilities as most important, including looking to connect and
support frontline staff so they are taken care of, including removing barriers while advocating for
and inspiring staff. Carla saw the most important part of her role as interacting with staff,
managing breakdowns in workflows, handling concerns in the moment, and “just being present.”
Helen described the manager role, saying, “To really be in that space between the frontline staff,
the charge nurses, and the upper levels of administration; you really are sandwiched.” Helen
reflected how the role was designed that way, saying:
Very much in the middle, and it’s by design, and that is both a good and a bad thing as an
individual in that role. . . . I think the thing that works really well is that you are able to
be visible to the frontline staff and that you’re able to escalate their concerns.
Vivian felt a key part of her role was supporting her staff and being the person to “move the
furniture out of the way,” or remove barriers so staff could be successful in their role and doing
their work. Finally, Lily reflected on the role being in the middle as a representation of
leadership and frontline staff, saying:
You represent both sides, like you’re also trying to make sure that you’re doing what’s
best for the organization and its mission and vision and then creating that same
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environment into whatever department, big or small, having influence to influence others
to feel the same or have the same mission and vision.
This perspective of being in the middle demonstrated the importance of the role to balance the
needs of the organization with the needs of the frontline staff. The concept of being in the middle
illustrated the middle manager role in being a guide and a voice as needed to navigate change
that may be occurring in the organization.
The final significant responsibility of the middle manager role identified by participants
was that of change agent, with seven of 17 identifying their role in change. The change agent
part of the middle manager role can also be seen as an extension of being in the middle and a
connection to the frontline staff. Justine identified her role being in the middle as a manager and
supporting change through coaching staff while being the connection between upper leadership
and frontline staff in terms of “transitioning staff through changes that come from upper
administration.” Colleen also spoke of the connection to being in a position in the middle while
facilitating change. She spoke of her evolution in leadership roles being more focused on change
management, saying:
It’s not only being a part of it, but we’re actually driving the changes, and you feel like
you’re that person who’s almost delegating out to the different areas. Sometimes, you
feel like you’re the glue and you’re the middle person just trying to make sure that all that
needs to be considered and having the group together is really good.
Stephanie and Maryanne spoke of being role models during times of change, identifying
different elements that were a part of being a change agent when it came to facilitating change
with staff. Stephanie pointed out, “You have to maintain team morale, positivity, and role model
behavior we expect from staff.” Being a change agent is a part of facilitating transitions for staff;
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the nurse middle management team plays a significant role in making change happen by helping
frontline staff while balancing the management of daily operations.
Role of the Management Team
I asked participants a probing question during interviews to explore the perspectives of
their role as part of the management team. Participants had a range of viewpoints of the different
management team responsibilities focused on goals, alignment through collaboration, and tasks
that ensured safe and quality patient care operations. There were no significant findings in terms
of trends among participant responses, but ensuring alignment and focusing on metrics were
frequently occurring responses mentioned by four of 17 participants. Lindsey summarized
management roles, saying:
I am like, their boots on the ground kind of person to make sure whatever initiative they
want to roll out, I’m gathering data and giving them feedback to see if it’s really rolling
out. It’s advocating for the organizational goals, but also, I’m here personally for me. I’m
here to advocate for the staff because when the staff is satisfied and happy, I feel that
really contributes to higher quality patient care.
It is important to understand individual experiences as part of the management team, even
though there were no significant trends on management team role among participants. Figure 9
captures participants’ self-identified roles on the management team to understand more about
participants.

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Figure 9
Self-Identified Role on Overall Management Team

Note. The figure is a compilation of all 17 interview participants’ responses to the probing
question: “What is your role as part of the management team?”

Results and Findings for RQ1: A Nurse Middle Manager’s Ability to Facilitate Change
This qualitative study explored the problem of practice of a healthcare middle manager’s
inability to sustain change as evidenced through empirical outcomes. RQ1 focused on the
perceived ability of the middle manager role to facilitate change through understanding their
views of a nurse’s role in quality improvement and the impact on patient outcomes, problem
solving approaches, barriers encountered when implementing change, and exposure to training in
quality management and change management. Table 6 summarizes RQ1 findings in the
perspective of the conceptual framework and the gap identified in the current state. In RQ1
Alignment
Betterment of
organization
Collaboration Communicate
Cover each other Goals Meet challenges
Meeting
leadership goals
Meeting
organizational
goals
Metrics Peer support Share a vision
Staffing
Things run
smoothly
Unity
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findings, instances of smaller groupings are not meant to indicate typicality but influenced
recommendations in Chapter 5.

Table 6
RQ1 Findings With Conceptual Framework Elements and Gap Identified
Finding Framework element(s) Gap identified
Nurses have a
significant role in
change/quality
improvement
Motivation/behavior
Organization/environment
Confirmed participant’s belief that
nurses do play a significant role in
change/quality improvement with
acknowledgement that they cannot
do it on their own.
Quality improvement
plays a role in
patient outcomes
Knowledge
Motivation/behavior
Organization/environment
Alignment that quality improvement
plays a role in patient outcomes with
indicators that process, and skills
need to be in place.
Barriers inhibit
change
implementation
and sustainability
Motivation/behavior
Organization/environment
Gap in developed change infrastructure
in the organization. Multiple barriers
exist in implementing change
requiring barrier resolution and
hurting motivation.
Inconsistent training
or education in
quality
improvement and
change
management
Knowledge
Organization/environment
Nurse middle management team may
be unaware of
nontechnical/nonclinical trainings
that are offered.

Finding 1: Nurses and Quality Improvement Play a Role in Change and Outcomes
Through understanding the perspectives of nurse middle managers on sustaining change
in healthcare organizations, I adapted two questions from a study by Tschannen et al. (2020) to
allow nurse managers to rate their agreement on the role of quality improvement and nurses in
change and outcomes. There was also an additional opportunity for participants to elaborate on
their rating.
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RN Role in Change and Quality Improvement
Participants were asked to rate—on a scale of 1 to 5 (1 = strongly disagree and 5 =
strongly agree)—their view of a nurse’s role in quality improvement through the question of:
How much do you agree with the statement that nurses play an important role in a hospital’s
quality improvement efforts? A follow-up question asked why they rated the question the way
they did, to express their perspective on their answer. The 17 participants had an average rating
of 4.74 on the Likert scale, with a range of 3 (neutral) to 5 (strongly agree). Figure 10 illustrates
the distribution of responses.

Figure 10
Distribution of Responses to an RN’s Role in Quality Improvement

0 0 0 0
1
0
2
1
13
0
2
4
6
8
10
12
14
1
Strongly
Disagree
1.5 2 2.5 3
Neutral
3.5 4 4.5 5
Strongly
Agree
Count
Likert Rating
Strongly Disagree (1) to Strongly Agree (5)
On a scale of 1 strongly disagree to 5 strongly agree, how
much do you agree with the statement that nurses play an
important role in a hospital’s quality improvement efforts.
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With only 17 responses, findings would not be considered statistically significant, but the
participants’ expanded perspectives are important to understand their lived experiences. The
most significant theme that emerged regarding the importance of the role of nurses in quality
improvement was because they were at the frontline doing the work (n = 14). Stephanie saw a
nurse’s importance connecting to change and making an impact, sharing:
Because they’re the ones at the bedside doing the work, and they have the greatest
impact, and making any changes or improvement if they have to really have a full
understanding of what they’re doing. And you know, they’re the ones I think just out
there, and their work is very important.
Debra pointed out that frontline nurses are not only the leaders at the clinical front lines, but are
also the largest employee population group. She shared, “From a clinical quality perspective,
yes, they are the voices and the leaders, and they’re the majority of the employees. They’re your
biggest population of people who touch the patient.” Helen also noted the important role nurses
play directly with patients, sharing:
I think we also are the last line of defense between patients and physicians who maybe
are exhausted and are missing something and make a mistake and I think that that’s a
huge responsibility, and we also need to be a part of the changes that happened in health
care because we’re so integral to that that part of the team.
The nurse management team participants identified how nurses played a significant role in
quality improvement due to their proximity to the frontline and patient care. The nurse’s
connection to quality improvement also facilitated buy in when change happened so they felt
connected to work. The engagement of nurses at the frontline may contribute to subsequent
sustainment of change initiatives and empirical outcomes.
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Organizational and Environment Gaps Identified
Three of 17 respondents did not fully agree there was connection between nurses and
quality improvement. They pointed out differences in opinions that should be explored to
potentially understand how to better engage nurses in quality improvement. Lindsey pointed out
it is not just the nurses who play a role in quality improvement, but that it is more of a
collaboration with other departments, saying, “I’m hesitant to say 5 because it’s not just nurses,
because it’s in collaboration with other departments.” Amelia and Danielle remarked there were
barriers nurses encountered in quality improvement. Amelia pointed out nurses may not have the
right tools to accomplish an improvement project, saying, “I think they play a role, but
sometimes I don’t know if they have the right tools to kind of follow through with the whole
project.” Danielle explained the process a quality improvement project has to go through can be
discouraging, stating, “They can come up with great solutions and ideas, but it has to go through
so many councils and so many steps to just be heard.” These three perspectives presented gaps in
knowledge of nurses and organizational limitations that are important challenges to consider in
the lack of sustainment in outcomes. The lack of collaboration, lack of available tools to support
change, and extensive amount of processes involved in quality improvement and change were
indicative of organizational gaps that were not in place to support a nurse’s role in change. The
perception of a lack of structure to support change was detrimental for an environment that
supported change for individuals undertaking that change. These perspectives of challenges
faced by the frontline nurse are expanded upon during the discussion of barriers middle
managers encountered in implementing change and additional gaps are identified in the
knowledge and organization components of KMO.
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Importance of Quality Improvement in Achieving Patient Outcomes
I asked a second Likert-scale question to understand interview participants’ perspectives
of the importance of quality improvement in hospitals in patient outcomes. Again, each
participant was asked to rate—on a scale of 1 to 5, with 1 = strongly disagree and 5 = strongly
agree—their view of quality improvement in hospitals to achieve patient outcomes. I followed up
with asking them why they provided that rating to allow them to express their perspective on
their answer. The 17 participants had an average rating of 4.85 on the Likert scale, with a range
of 4 (agree) to 5 (strongly agree). Figure 11 illustrates the distribution of responses.

Figure 11
Distribution of Responses to Importance of Quality Improvement in Hospital’s Ability to Achieve
Patient Outcomes

0 0 0 0 0 0
2
1
14
0
2
4
6
8
10
12
14
16
1
Strongly
Disagree
1.5 2 2.5 3
Neutral
3.5 4 4.5 5
Strongly
Agree
Count
Likert Rating
Strongly Disagree (1) to Strongly Agree (5)
On a scale of 1 strongly disagree to 5 strongly agree, quality
improvement initiatives/projects are important for improving
patient outcomes.
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Looking at the perspective of quality improvements in improving patient outcomes, 14 of
17 participants strongly agreed and three participants agreed it improved patient outcomes. The
emerging theme from participants was quality improvements are necessary given the changing
field of healthcare. Lindsey spoke about the ever-changing field of healthcare and how
engagement in quality improvement can allow the organization to achieve patient outcomes,
sharing:
Healthcare is always changing. Patient demographics are always changing so unless
we’re tapping into what’s changing from the past, and what trends are happening in the
future, then we’re not going to be ahead of, you know, close to being ahead of the curve
in terms of getting better outcomes for patients.
Veronica expanded on continuous evolution in healthcare by putting it in the perspective that it
requires everyone to do more and be proactive. She shared:
It requires us to be at our best, requires us to be better than other any other place and the
only way that I feel like we can do that is through quality improvement . . . making sure
that we are proactive in and things that we can avoid.
The middle manager group saw the alignment between quality improvement and better patient
outcomes and how it connected to the continuous nature of change in the healthcare field. A part
of quality improvement was to make sure that what the organization’s patients were seeking was
provided. The connection of quality improvement to patient outcomes benefits patients, staff,
and the organization.
A few participants called out important barriers involved in quality improvements that
may make it difficult to achieve patient outcomes. Penelope warned it is important to monitor
how much work is undertaken, saying: “It’s always best to try to do the best you can . . . but also,
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you have to be careful, you can’t eat too much . . . [but] we should always be striving to do the
best we can to understand.” Debra pointed out evidence creates outcomes, saying:
I think it’s truly how we implement the evidence. It’s the evidence that creates the
outcomes, making sure that we are practicing to [what] the evidence [states] improves
patient outcomes, how I implement that [evidence] is the quality improvement use of it.
It was important to acknowledge alternative perspectives to bring greater understanding to the
gaps that existed in successful quality improvements to lead to successful patient outcomes.
Gaps Identified in Quality Improvement Supporting Outcomes
In a rapidly changing field, organizations need to be able to keep pace with change
through one method, such as process improvement to meet patient outcomes. Organizations need
to have processes in place to help guide quality improvement while providing opportunities for
staff to learn skills to facilitate quality improvement. Penelope and Debra pointed to needed
organizational and knowledge support to facilitate the successful use of quality improvement.
Being cognizant of how much work was being taken on and ensuring there was not too much
undertaken at a time was an organization’s responsibility and impacted the motivation of
stakeholder groups such as the nurse middle management team. The nurse management team had
to make active choices to pursue implementation change and be able to continue to put in efforts
to meet those goals (Clark & Estes, 2008). Clark and Estes (2008) found organizations have
adopted metrics and outcomes that not only benefit their organization and customers, but also
benefit the larger community and field. These patient outcomes need the support of quality
improvement to continue to meet and exceed the benchmark within the data but a comprehensive
structure must be in place for success.
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Finding 2: Barriers to Successful Implementations and Sustainable Change
The nurse middle management team faced barriers in successfully implementing and
sustaining change. During interviews, there were different opportunities for participants to
discuss their approach to problem solving and experiences with implementations. I identified
emerging themes experienced by the middle management group, which included inadequate
organizational structures that resulted in inconsistent problem-solving approaches, lack of
infrastructure to facilitate the change process, and a lack of change culture. There were also
motivation barriers, including competing priorities and feelings of lack of support. These themes
and how the participants were navigating or resolving those change barriers are outlined and
expanded upon in Table 7. Smaller responses to findings of barriers and resolution strategies, do
not indicate typicality, however, these smaller findings are used to support recommendations
presented in Chapter 5.

Table 7
Identified Barriers to Implementing Change and Current Resolution Strategy
Barrier to implementing change Current resolution strategy
Lack of support Four of 17 get buy in to make sure the right people
are in the room and leverage change agents.
Lack of change process and
infrastructure
Four of 17 seek clarification and understanding.
Two of 17 seek guidance through a mentor or a
colleague.
Two of 17 follow an approach such as evidence-
based practice and problem solving to navigate
barriers.
Organizational culture: resistance, lack
of communication, lack of
accountability
Five of 17 support staff by giving them time,
implementing change in smaller pieces, being
encouraging, acknowledging work, providing
support for staff, collecting data, and knowing
the audience.

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Lack of Support
Five of 17 participants mentioned lack of support in different forms as a barrier to
implementing change. Lack of support included lack of leadership support, which included
barrier resolution and follow through, lack of a project management resource, and lack of other
department involvement in change leading to feelings of the nursing department feeling they
must lead initiatives. Amelia described change implementations as being additional work on the
team and manager and she explained there was not enough support to make projects happen. She
shared:
There are so many different barriers where you get told no, or to make a change. It takes
so long. . . . It just takes too long, and you give up. You know as a manager too, I think
again, [you need] support [to] keep things on track when you’re pulled in so many
different directions.
Amelia focused on using her approach to navigating change barriers by engaging staff and
bringing together the right people to make the change happen. Similarly, Irene approached
barrier resolution by making sure the right people were involved in change projects and they had
been communicated with and been involved in the change decisions.
At an individual level, the nurse managers felt there were some barriers to change that
they had to struggle through to be successful. Irene believed the study organization fell back to
“how it’s always been done,” and she wished they “could get out of that mentality and approach
change as something wonderful and exciting.” Danielle saw the value of change but also
leveraged her relationship with a mentor to help navigate barriers and issues by seeking guidance
on appropriate approaches and navigation. Danielle resolved process barriers by figuring out
where the barrier started, brainstorming possible solutions, and making a plan to tackle it.
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However, if the barrier was too big, she let it be because she did not see there was anything she
could do. When faced with navigating barriers on their own, nurse manager participants noted
the perception of change was often the biggest barrier they had to navigate.
There were often barriers in ensuring the involvement of the right people or groups to get
the work done at the department level. Colleen explained, “I don’t think that one quality
improvement project can just be driven by nursing, or just be driven by another specialty or
profession. I think it takes multiple entities and groups and individuals and departments.”
Colleen approached barrier resolution by acting like a bridge between impacted groups, saying,
“It’s oftentimes me that has to bridge it and has to make sure that things still operate when our
system fails us.” Similarly, Helen spoke about having a vision in how to implement change,
especially when a monumental change occurred. Vivian believed it was important to make sure
they had the right people in the room because things could not move forward unless all the right
people were present. Not having the right people show up derailed decision making and barrier
resolution.
Lack of Process and Infrastructure
Six of 17 participants mentioned there was a lack of process and infrastructure for change
projects. Participants pointed out there were too many steps, inability to self-initiate, too much
bureaucracy, lack of oversight and sustainment, multiple people working on the same thing with
no connection, too much time to resolve barriers, lack of data available to make decisions, and
top-down type change rather than involvement of impacted parties.
Inconsistent Problem-Solving Approaches. An aspect of a middle manager’s ability to
sustain change included exploring problem-solving approaches. During interviews, I asked each
participant to describe their approach to solving problems. I found there was no standardized
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approach to problem solving described by the 17 participants, with each outlining their own
unique method to solving problems. This lack of standardized problem-solving approach also
emerged when I asked them to describe successful and less successful implementations.
Participants spoke about their problem-solving approach in different ways based on their
individual perspectives. However, they did have a few common steps, including engaging or
listening to staff and gaining an understanding of the problem through gathering facts and data.
Problem-Solving Approach Element: Engaging and Listening to Staff. Participants’
most frequently cited step in the problem-solving process was ensuring they heard staff
perspectives or engaging the team in problem solving, with 12 of 17 participants including a
form of this step. Amelia identified how essential it was to include the team impacted during
problem solving, saying, “Engagement is essential. . . . Come in an unthreatening way, so more
of that appreciative inquiry learning piece to ask the question.” Additionally, Stephanie spoke
about engaging the unit-based council teams in the problem-solving work, saying, “I always
include the unit-based council to help solve a problem, because if you don’t get their buy in and
their ideas, their input, how do you know you’re making the right decision? So, I always include
them.” Marisa also discussed the importance of bringing in people to understand the problem and
then solve the problem collaboratively to build engagement and feeling part of the change,
saying:
It’s a collaboration; it’s not only my solution, because if I do that, it’s very dictatorial and
it’s not going to go through; people will resist. Nobody likes change, right, nurses don’t
like change, but if they are part of the change, they want to make it better for a patient,
for themselves, for the team. . . . You start by saying, there is a need, and I need your
input, I know what we need to do, but tell me how we can, so their input is [included].
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Even with each different problem-solving approaches, participants commented on the need to
engage the team and get input from staff as part of the problem-solving approach. Many
participants also noted the view of team engagement to build support and gain buy in for change.
Problem Solving Approach Element: Begin With Understanding the Problem. In
continuation of the theme of team engagement in problem solving, eight of 17 participants
started by understanding the problem, which included engaging others to gain understanding.
Lindsey spoke about understanding the context of the problem from different perspectives before
jumping into the solving the problem, sharing:
I’d like to listen to all sides of the problem first, like I’m really big into context, because
sometimes maybe the person that’s giving the message is either making it into something
bigger than it is or it is really a big thing, but they’re not really communicating that it is.
So, I like to get a lot of information, a lot of context, and then I do take into consideration
who it’s going to impact, and I try to be one step ahead because I have to read, I have to
anticipate other people‘s reactions. If I’m going to make a decision, of course the goal is
to resolve the issue but then that has to also be prepared to deal with whatever
consequences it might cause.
Participants indicated they were able to understand the scope, span, and magnitude of the
problem before trying to solve it through engaging the team to identify the problem. This finding
indicates participants had some alignment in how they approached problem understanding, even
if they had varying methods of solving problems.
Lessons Learned From Past Implementations. To further understand the elements of
problem solving or change initiatives, I asked each interview participant to describe an
implementation they considered successful or less successful. This question sought after a deeper
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understanding of problem solving that middle management team members were using that led to
successful implementations. Understanding trends among implementations can inform possible
elements to form a potential standardized approach. Maryanne pointed out her view of how
change works in organizations, saying, “I look at change that it ebbs and flows as you’re going
through it, there’s waves as you go through it.” Figure 12 presents themes that emerged during
the conversations on successful and less successful past implementations.

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Figure 12
Understanding Lessons Learned From Successful and Less Successful Past Implementations

Collaboration and Engagement to Build Buy in. The theme of collaboration emerged
in highlighting the importance of including others in change implementations during
participants’ overview of their problem-solving approaches. Vivian spoke generally about the
importance of engaging in collaboration during change implementations where “a good example
of collaborating [is] having people take initiative, working with many facets, [and] different
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people to achieve the same goal.” Danielle spoke about the collaboration with staff so their
voices were a part of the conversation, saying:
I heard what they were trying to say . . . and now that minor change they were able to
make, their voice heard, and they feel validated . . . just that little change just made them
feel validated that they’re definitely a part of the team.
Maryanne demonstrated a less successful implementation where she directed rather than
collaborated with team members, which did not create buy in and the change was not accepted.
She said, “I kind of commanded it instead of involving people. Well, it went over like a lead
balloon. It didn’t happen; there’s too many other things competing things that went on at that
time.” Justine had a similar reflection with a less successful implementation where she realized
the importance of stepping outside of her own perspective to understand how change impacts
others. She stated:
I just dismissed it, and in retrospect, I really should have taken more time to invest in
listening to my staff and hearing their perspective without my lens of prejudice.
Essentially, because I knew it was going [to] happen kind of whether they liked it or not,
too. . . . So now, I get it you know, no decisions about us without us. But it still happens
but communicating that in a forum where at least they can feel heard would have been
better.
Understanding collaboration on change initiatives from the perspective of successful and less
successful instances shows the importance of engaging the right people in the right work.
Participants spoke about collaboration, connections, or alignment throughout their interviews.
The implications of collaborative initiatives provided insights into elements that should be
included in successful change or problem solving initiatives.
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Understanding Impacted Stakeholders. A second theme that emerged during
interviews was the need to understand the impact to stakeholder groups, which included people
who were upstream or providing inputs into the process, downstream receiving an output from
the process, or supportive ancillary teams. Justine mentioned having to consider the
“downstream effect” or “domino effect” of decisions. Lindsey spoke about the advantages of
working with stakeholders to ensure initiative success, saying, “It took a lot of time and patience
and involving key stakeholders and also making people realize that just because they’re used to
doing something one way, that might not always be the best way.” Connecting with the impacted
stakeholders allowed for awareness and feedback before an implementation happened. Irene
presented an initiative that was less than successful due to lack of communication and inclusion
of the appropriate stakeholders, which resulted in a change not fully supported by ancillary
groups. She saw a lack of communication when an order came through to do things, there was
insufficient consideration of the consequences of things leadership may be asking people to do.
She saw the lack of engagement of the right people as indicative of the organization work culture
with no communication between groups when trying to make a change or implementing
something. Participants noted, at times, they received a directive to go and implement initiatives
more as a test to see how it went. Engaging key stakeholders allows for the appropriate insight,
feedback, and support by different groups to facilitate a successful implementation.
Structure. Finally, participants mentioned a lack of clear infrastructure to support change
in the study organization. Danielle mentioned bypassing the standard process to achieve her
successful implementation, saying, “You have to take a lot of steps. . . . The bigger projects that I
want to actually create housewide, it has to go through so many councils and steps in order to
just be heard.” Vivian connected the lack of infrastructure to support project and change work as
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a contributing factor to a lack of implementation and subsequent sustainability. She said, “We’re
just moving forward and we’re not really making sure we have that infrastructure in place to
make sure it’s sustainable.” She thought there needed to be infrastructure in place to support
change because it takes a lot of people power to support, assess, provide feedback, do pulse
checks, make changes, and roll out new additions. Debra also saw the lack of structure leading to
feeling overwhelmed due to lack of resources and support, saying, “It’s a lack resources and lack
of ownership. . . . I was spread too thin, and I was one person still just coming off [a] project in
the middle of 20 other things.” Debra thought a lot of competing priorities and did not have
enough bandwidth to be able to do everything. She shared:
There’s never bandwidth . . . for quality improvement. Everybody’s got to be on the same
page. We’re all moving in the same direction. Problem is that if every person is pulled in
5,000 directions with competing priorities, I’ve got to give up focus on some part of this.
Helen also spoke about the extra energy that went into change projects on top of the manager
work she had to do, sharing:
I think that what doesn’t work well is that if you are that person, you don’t have the time
to give enough energy to that if you’re also expected to do [quality assurance] projects at
a higher level and be in a meeting all the time. That doesn’t work well because you’re not
doing either side very well. You’re pulled in two different directions; you can’t fully give
to either side.
This finding highlights how the lack of structure led to issues with replicability, follow up,
implementation, and sustainability. Additionally, the lack of structure also led to feelings of
being overwhelmed balancing competing priorities, which led to a lack of motivation.
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Organizational Culture as a Barrier
Nine of 17 participants pointed to implementation barriers stemming from organizational
culture. The nurse middle management teams saw the organization as being change adverse, with
competing priorities, a lack of system collaboration resulting in silos, lack of communication,
lack of holding people responsible and accountable, and navigating a union environment.
Veronica saw barriers resulting from not holding people responsible and allowing bad behavior,
saying there was lack of responsibility or accountability for the work they did. Veronica shared,
“It’s the blame game, it’s like placing the blame somewhere else. No one wants to take
responsibility, and no one wants to hold their person responsible. So, things are just allowed to
happen.” Helen described the organization as “change averse” with Stephanie and Nicole
expressing “resistance from staff” and “naysayers” as barriers to change. Helen also talked about
how people get in their own way with change at a “local level” and said, “[People say,] ‘We’ve
always done it this way, so let’s keep doing it that way’ or, ‘That’s not what we used to do so
let’s go back to that way we used to do it’ because I think they felt safe.”
Lindsey worked through project barriers, such as resistance, by acknowledging the
change and unpopularity of change and that it had to be rolled out. She anticipated the
unpopularity and resistance, let her team get things off their chest and vent, gave answers to staff
who needed more information (i.e., the more resistant people), and used evidence-based
methodology to present data on why the change was happening. Even with staff who continued
to be resistant, she asked them to try the change to see what would happen—what works and
what does not work. One tactic Lindsey employed was a town hall approach to get people
affected by a change on board with the change. This approach allowed her to communicate the
change and find early adopters or champions and people who were resistant. Justine also spoke
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about giving a forum where she was available to talk with staff about changes and to give them
the forum to speak. She said, “For me, it’s important to make that space and create a safe
environment for anyone to be able to share anything with me.” The middle managers at the study
organization were seeking an organizational culture that facilitated change acceptance and
capacity to conduct change implementations. Feeling as if they had to do the change
implementations on top of their daily operational roles led them to feel overwhelmed and like
they were constantly trying to catch up. This inability to have time to do the work to shift change
adverse perspectives compounded the feelings of competing priorities and had a detrimental
impact on their motivation.
Clark and Estes (2008) stated performance is impacted when there are not efficient
processes in place in organizations. The lack of a standardized problem-solving approach is a
gap that highlights a lack of processes in place to support work being done. Processes that seem
as if they do not add value—and rather, just add steps for managers to navigate while also not
monitoring the work placed upon individual middle managers—begins to pull down motivation.
Without a structure in place, change implementations begin to stall and middle managers start to
lose motivation because they feel overwhelmed. Clark and Estes’s (2008) motivation component
of the KMO model included individuals persisting on a goal even when there were competing
priorities or other work that may arise while working on change implementation. These
organizational barriers impact performance and exhibit the lack of organizational culture that
supports change and sustainability.
Finding 3: Quality Improvement and Change Management Training Experiences
To better understand previous knowledge associated with the ability to sustain change, I
asked each study participant about their education and training in quality improvement and
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change management. Most participants had some level of exposure to this type of training,
including 14 of 17 participants who had some form of education or training in quality
improvement. Furthermore, two of 17 participants took courses that touched on the topic but was
not dedicated to it, 13 of 17 participants took change management education and training in
change management, and two of 17 had some education but did not take a full course. Only one
participant had no quality improvement education and two participants had no change
management education. Responses of no education on quality improvement/change management
or saying they took education that touched on the topic were how participants expressed their
view of the education they had undertaken. Participants expressed they had education through a
variety of avenues through previous organizations, at the current study organization, formal
schooling, and via professional organizations.
To further understand the education opportunities available at the study organization, I
used secondary data to review the study organization’s LMS for quality improvement and
change management courses. Table 8 identifies training offerings through the study organization
using keywords associated with quality improvement and change management. The results
include the number of results returned via a keyword search and the unique training results
returned.

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Table 8
Review of Learning Management System Course Topics
Keyword searched Training results returned (n) Unique training results (n)
Process improvement 43 17
Quality improvement 12 1
Quality 61 46
Performance improvement 10 4
Continuous improvement 16 3
Change management 212 211
Lean 22 13
Six Sigma 12 4
Lean Six Sigma 7 0
Project management 194 183

Note. Study organization course offerings for quality improvement and change management
were as of October 21, 2022.

To gain more detail, I further stratified the LMS data to look at the delivery types of
content. Table 9 lists the variety of options available, including:
• Playlist: A compilation of online classes, videos, and micro-learnings created around
a topic. Individuals have the ability to earn individual certificates for each online
course or microlearning. Interested learners can follow playlists for updates.
• TED Talk: An online class on a specific topic, with TED Talks as the provider.
• Online Class/Content/Video: Asynchronous content on specific topics delivered by
different providers, which ranged from a few minutes to several hours.
• Event: In person or virtual individual courses delivered live/synchronously on
specific dates by instructors. Attendees can select specific sessions that work for
them.
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• Curriculum: Series of synchronous and asynchronous classes on a specific topic with
activities and supplemental material. Classes are a mixture of external providers and
study organization offerings. Individuals receive a certificate once all components are
completed.
Table 9 demonstrates the variety of instructional mediums employed at the study organization to
reach participants. Project management and change management topics had a lot of results that
needed to be reviewed and evaluated for appropriateness of learning topic before a potential
participant could select and register for a course.

Table 9
Review of Learning Management System Types of Course Offerings
Keyword searched TED talk
courses (n)
Online class/content/
video (n)
Playlist
(n)
Event
(n)
Curriculum
(n)
Process improvement 16 26 1 0 0
Quality improvement 0 12 0 0 0
Quality 1 54 1 5 0
Performance
improvement
0 9 0 1 0
Continuous
improvement
0 16 0 0 0
Change management 35 168 2 4 3
Lean 0 19 2 1 0
Six Sigma 0 10 2 0 0
Lean Six Sigma 0 5 2 0 0
Project management 16 169 7 0 2

Note. Study organization course offerings for quality improvement and change management
were as of October 21, 2022.

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Finally, I stratified the study organization LMS data by looking at the quality
improvement and change management type courses and other keywords. I included words such
as manager and leader/leadership in the course title to demonstrate the number of offerings
targeting the middle manager group. Table 10 demonstrates the reduced number of results that
connected these courses specifically to the middle manager group.

Table 10
Review of Learning Management System Courses Targeting Managers
Keyword searched Training results
returned (n)
Results that
mentioned manager
(n)
Results that mentioned
leader or leadership (n)
Process improvement 43 0 2
Quality improvement 12 0 0
Quality 61 0 2
Performance
improvement
10 0 1
Continuous
improvement
16 0 1
Change management 212 4 27
Lean 22 0 0
Six Sigma 12 0 0
Lean Six Sigma 7 0 0
Project management 194 3 7

Note. Study organization course offerings for quality improvement and change management
were as of October 21, 2022.

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The study organization offered many different quality improvement and change
management trainings and education offerings, but it appeared the nurse middle management
team may not have realized what was offered. Justine noted, “I do feel support in training.
However, I would say, there isn’t really like, a manager training program right, like each unit
kind of does it themselves, and we train each other.” She went on to say:
I guess I don’t know what we have, essentially. So, having maybe a leader-driven
catalogue of what would be helpful for leaders. Just to know what’s actually available in
[the LMS] because in searching and trying to teach staff how to find stuff I’ve seen that
there’s a lot of content so perhaps just knowing what all is there, and that we have access.
From the review of the LMS and what I learned from Justine’s perspective, I believe opportunity
is available to create content targeted at middle management teams. Potential learners may not
understand the full extent of learnings offered and how they can use the LMS to find appropriate
trainings.
The nurse managers and senior nurse managers/directors completed a review of training
and education in 2021 and 2022 and indicated the focus of trainings they accessed and completed
in the LMS were focused on orientation and clinical or technical training. The secondary data of
these access and completion records of the LMS indicated the subsection of nurse middle
managers at the study organization did not access or complete any quality improvement or
change management focused offerings in 2021 and 2022 (HCCC, personal communication,
September 29, 2022). Participants indicated most of their training had been through school
courses or nursing department offerings. Many participants spoke about educational
opportunities from the nursing department—including the evidence-based practice (EBP)
immersion class called Leading Empowered Organization, which was delivered by Creative
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HealthCare Management—and the hierarchy of accountability, responsibility and
professionalism program. The nurse middle management team at the study organization
mentioned the nursing department’s educational offerings were beneficial, they felt supported to
participate, and they integrated what they learned into their roles. The ability to offer courses
sponsored by the department participants worked in seemed to demonstrate there was
commitment and support to participate in these courses.
The lack of knowledge on training and educational opportunities available in the study
organization meant the nurse middle management group were not taking advantage of
opportunities that could increase their skills in quality improvement and change management.
This is an individual gap in knowledge that is perpetuated by organizational gaps in marketing
the different opportunities. A lack of education to build knowledge results in being less prepared
in the future (Clark & Estes, 2008). Nurse middle managers may not be completely prepared to
facilitate future implementations because they had not been building their knowledge through
education. The organization provided opportunities for knowledge and skill building, as
evidenced by the number of offerings in their LMS; however, there was a gap in awareness of
those offerings. It is important to have offerings available and have the middle management team
knowledgeable about those offerings.
Results and Findings for RQ2: Needed Skills/Competencies for the Nurse Middle Manager
In continuing to learn about a nurse middle manager’s ability to sustain change and
achieve empirical outcomes, RQ2 explored the needed skills/competencies middle managers
identified as key to role success and sustaining change. Smaller groupings within RQ2 findings
are used to build recommendation but are not indicative of typicality. Table 11 summarizes
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findings from RQ2 from the perspective of the conceptual framework and existing gaps
identified.

Table 11
RQ2 Findings With Conceptual Framework Elements and Gap Identified
Finding Framework element Gap identified
Varying degrees of role
preparation experienced.
Knowledge
Motivation/behavior
Organization/environment
Gap in consistent role preparation,
which indicates a lack of
organizational structure to
support knowledge acquisition
and subsequent motivation in
role
Varying definitions of role
success
Motivation/behavior Gap in role success alignment
leading to struggle to sustain
outcomes
Multiple role barriers exist
requiring active
resolution.
Motivation/behavior
Organization/environment
Gap in organizational structure
which leads to lack of
motivation
Varying levels of
confidence in quality
improvement with
different needs for
building confidence
Knowledge
Motivation/behavior
Gap between expectations and
education available in quality
improvement.
Varying abilities to apply
training/education
Knowledge Ability to apply knowledge gained
but a lack of feelings of active
application.

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Finding 1: Feelings of Insufficient Role Preparation
A component of being in a leadership role is feeling prepared to carry out the role and
responsibilities. To better understand this sense of role preparation, I asked participants if they
felt prepared for their role and responsibilities. The feelings of being prepared varied among
participants. Table 12 demonstrates study participant responses to role preparedness.

Table 12
Feelings of Role Preparedness
Feelings of preparation n
Feel prepared for role 1
Feel partially prepared for role 5
Feel self-prepared for role 3
Feel prepared now with experience in role 5
Do not feel prepared 3
Total 17

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Only one participant expressed they felt prepared for the manager role. Additionally, 13
participants felt only partially prepared, prepared for the role now, or felt they were self-
prepared, and three participants felt they were not prepared for the manager role. Maryanne felt
prepared for the role because of the years of experience she had in management. She
acknowledged that not everyone is always prepared and “when you first come into it, it’s a lot of
trial and error.” Most participants felt they eventually started to feel prepared but had to learn as
they filled the role and executed the responsibilities. Stephanie expressed that once she became a
manager, she had to learn as she went, and she relied on her formal education to help her as a
manager; however, formal education did not help when trying to learn the culture and systems of
the organization. She reflected:
[People have to] come in and be exposed and just do the work on a daily basis . . . so,
there’s no formal training for any of these upper leadership positions, and I wish there
was. There are classes that you can take, but they’re pretty broad. They’re not specific to
the stuff that we deal with as a nurse manager, so luckily, we have each other, and we
work together to get through difficult times like patient complaints, staff concerns,
change.
Veronica similarly stated, “I feel like I was prepared as best as I could have been. I feel like the
situation necessitated that I had to start the ground running.” She jumped into her role as a
manager because she saw there was a need for guidance and structure, saying, “I felt like I was
thrust into it because that is what the situation necessitated.” Irene did not feel prepared for her
manager role but also reflected that most managers would not feel prepared in their 1st year in
the role. She continued to talk about the tools she used and how everything she did as a manager
she learned by being a floor nurse. She shared, “I assess, I evaluate, I execute, and I reevaluate
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for the most part. I always feel like I can apply.” These different perspectives contributed to
understanding more about knowledge and skill development for managers, which could have
also contributed to their motivation in the role.
Nurse middle managers must meet performance standards as part of their role, but there
was a gap in their preparation at the study organization. There were gaps in all three areas in the
conceptual framework in knowledge, motivation/behavior, and organization/environment. Clark
and Estes (2008) identified a component on the knowledge portion of the model as making sure
leaders demonstrate how to achieve performance goals to individuals so they know how to act
and transfer the knowledge in action. Social cognitive theory points to the need to ensure
monitoring comprehension to build self-efficacy (Schunk & Usher, 2019). The variation in how
individuals feel prepared in a role can be an issue because they may not have the same
understanding of their goals and expectations, which can cause conflict in a team perspective
when they may not have the same role preparation experience (Clark & Estes, 2008; Schunk &
Usher, 2019). The gaps in knowledge and motivation identified in role preparation in this study
highlighted a gap in the organizational structure. Inconsistent and varied role preparation
demonstrated the organization had not created the infrastructure needed to ensure role
preparation and a standard role preparation experience.
Finding 2: Definition of Role Success
Understanding participant perception of role success led to insights into motivation in the
nurse middle manager role. Participants expressed empirical outcome measures of success
connected to the organization and more personal outcomes that provide feelings of satisfaction at
an individual level. Justine mentioned the nurse middle management team “all kind of have
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delegated goals for outcomes” associated with the role. Figure 13 lists empirical and personal
outcomes outlined by participants during the study interviews.

Figure 13
Self-Described Role Success

Empirical outcomes
• Documentation (specifically blood
documentation)
• Staff satisfaction and engagement
scores
• Patient satisfaction
• Nursing-sensitive indicators,
including hospital acquired pressure
injuries and central line associated
bloodstream infection
• Hours per patient day
• Revenue generation
• Staffing
• Budget
• Cost per patient visit
Personal outcomes
• Connection to staff
• Organizational mission to save
people
• External validation
• Leading staff
• Team growth
• Staff confidence
• Acknowledgment
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Similarly, the perspectives of role success were a mixture of operations/organizational,
personal, and staff-focused outcomes. Veronica spoke about ensuring she was working toward
reducing excess costs and increasing efficiency. Vivian felt success when she achieved a goal,
such as a “certain status” or forward movement of policies or a current project. She ultimately
wanted to see successful outcomes by being able to get to the point of implementation and then
measure that implementation. Looking toward the staff-focused success in roles, Debra, Carla,
Justine, and Stephanie measured role success through staff satisfaction and staff engagement
through engagement scores. Justine felt staff engagement scores were one of the more difficult
outcome metrics to demonstrate success in her role. Many participants aligned with Amelia, who
saw success in engaging staff in prioritizing and growing passion in patient care to deliver the
best care to patients and their families. She mentioned relational care as being essential in
nursing and the importance of staff feeling supported in times of need. Operationally, Amelia
also saw having a fully staffed unit and resources to deliver care as part of role success. The
converse of this perspective was demonstrated by Irene, who was candid when asked about role
success. She stated, “That’s probably why I don’t feel so good because of my definition of
success.” Role success and how middle managers defined success contributed to their feelings of
motivation, especially when it related to personal and staff-focused success.
Focusing on NSIs as a measure of empirical outcomes allowed for another perspective of
understanding role success for managers and for the sustainability of initiatives and
implementations. A few participants specifically mentioned NSIs as part of role success and
outcomes, including hospital acquired pressure injuries (HAPI) and central line associated
bloodstream infection (CLABSI), which are inpatient/hospital admitted patient data. The study
organization defined NSIs to determine the impact nurses had on their patients. The National
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Database of Nursing Quality Indicators (NDNQI, 2022) pointed to NSIs reflecting “the structure,
process, and patient outcomes of nursing care” (para. 1). The study organization examined NSI
data over 2 years through 8 rolling quarters (i.e., Q3 in 2020 to Q2 in 2022) using National
Cancer Institute designated hospitals as the comparison group. The data indicated performance in
HAPI outperforming the benchmark comparison with similar hospitals over the past 2 years in
seven of nine inpatient units (HCCC, personal communication, October 6, 2022). However,
CLABSI per 1,000 central line days only outperformed the benchmark over the past 2 years in
two of nine inpatient units (HCCC, personal communication, October 6, 2022). Participants
mentioned two NSIs that demonstrated the varied success in outcomes and may have impact the
feelings of motivation given that one NSI was outperforming and the other was not
outperforming.
The varied definitions of role success could point to different feelings of how participants
attained success and their capabilities to achieve that success. Schunk and Usher (2019)
demonstrated motivation and behavior are tied to where value is placed, which impacts self-
efficacy and how a person demonstrates behavior to achieve role success. The motivational gap
in the alignment of role success could have been contributing to the struggle to sustain change in
this study.
Finding 3: Role Barriers and Current Resolutions
Another finding that contributed to feelings of motivation by middle managers was the
perspective of role barriers they needed to navigate and resolve to find success. Participants had
varied perspectives of barriers they faced in their roles; however, there were no strongly
clustered themes among responses. The barrier themes included areas such as inconsistent access
and knowledge of systems, lack of connectedness and involvement, role structure, culture that
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did not have infrastructure to support change, lack of time, lack of transparency, and lack of
support. Carla spoke about barriers when she was attempting to fix problems or break and find
solutions but she could “only go so far to making a real impact of difference.” Each of these
themes are examined in depth through the views of interview participants.
Barriers to Motivation/Behavior
Several barriers emerged that centered on motivation or behavior connected with the
middle manager role. These barriers included feelings of lack of connections and involvement,
and role structure. Understanding these barriers and how middle managers were resolving
barriers could help an organization understand the role’s needs.
Lack of Connectedness and Involvement. Seven of 17 participants identified lack of
connectedness and involvement as a barrier in their role. This lack included a lack of
involvement in decisions, poor collaboration and alignment among leaders, lack of involvement
of the right people to make decisions, lack of enterprise connectedness, and leadership not seeing
the impact of top-down decisions. Poor collaboration among leaders was highlighted as one of
the symptoms of the lack of connectedness across the enterprise. Several participants spoke
about poor collaboration and how it impacted change the managers were expected to implement.
Irene said the poor collaboration was a hinderance to work culture due to a lack of
communication between groups when trying to make a change or implement something. There
was a belief that leadership would say “to go and do it” as a test to see how the change would go.
This idea connected to the difficulty Nicole found in trying to understand decisions that did not
make sense and how they were communicated, saying she believed “expectations are you just
have to get it done, you have to do it.” A lack of connectivity and involvement in decisions
created a lack of motivation for middle managers. This barrier could impact the active choice
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managers make to self-motivate and persist to achieve goals, which could result in a barrier to
implementation and subsequent sustainment (Clark & Estes, 2008).
Role Structure as a Barrier. Six of 17 participants identified barriers in the role,
including the lack of access to systems, fear of speaking up, unbalanced distribution of work,
unclear expectations, lack of authority, and not being heard. The barrier of access, specifically
relating to access to systems, was apparent in the views of participants. Carla felt the biggest
barrier to her role was not having knowledge of different systems. Throughout interviews, there
were barriers brought up that touched on knowledge, such as a lack of access to systems and
data; however, these barriers were presented more as an organizational barrier. There was also a
fear of speaking up because they ended up being responsible for whatever they brought up. A
divide began to grow between managers because some spoke up, which resulted in extra work,
while others stayed quiet and did not have to take on the extra work. Stephanie and Vivian talked
about a distrust that began to build because they did not know who was prioritizing themselves
over the organization, which also led to feeling lonely. A recent reorganization of the nursing
department led to some confusion on role description, unclear expectations, and full autonomy.
Additionally, Helen found it hard to have her voice heard when there were so many people
escalating concerns. As managers, she said, “We aren’t quite heard the same way as if you’re a
director or an executive director.” The concept of being the connection or an in between for
frontline staff and leaders at timed places a barrier on the manager role and what they were
expected to make happen. The middle manager role often lacked clear definition, which
represents an organizational structure shortfall and a deterrent to motivation because of the
barrier to the work they were trying to accomplish.
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Organization and Environment
Additional barrier themes emerged regarding the middle manager role centered on the
organization and environment. The organizational themes included culture, lack of time, and lack
of transparency and support. Understanding these barriers provided perspective of existing
organizational gaps.
Organizational Culture Barriers. Five of 17 participants identified organizational
culture barriers, which included a lack of infrastructure such as not holding people accountable,
the tendency for nursing to own initiatives, and a combination of rapid growth coupled with
rapid change. Vivian pointed to the lack of infrastructure and processes in place, which were a
barrier to get the right things done with the right people for the organization. Vivian mentioned:
So, everything is a time suck because we don’t have the processes in place. We don’t
have the infrastructure or the right people not at the table. There’s a lot of barriers again.
It’s the little stuff that’s not giving that infrastructure in place, having processes that are
broken, a lot of work arounds.
A component that exacerbated the lack of infrastructure was the growth and change that many
nurse middle management teams faced. Lily and Marisa mentioned the growth they experienced
in their roles. Lily felt the impact of change happening fast and organizational change could be a
barrier even though she said, “[It keeps] us on our toes and it helps us grow.” Similarly, Marisa
felt it was a challenge to be able to give individualized attention to each employee. She made
efforts to have contact with each employee on a personal level because she cared but the
organizational growth made it a challenge to address everyone in that capacity. She worried this
struggle demonstrated a lack of respect because she could not reach everyone every time. An
organization that does not create a culture that fosters an environment with the right
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infrastructure to facilitate change implementation while supporting the daily role of managers
creates additional barriers to navigate through. A lack of clear processes and structure made it
difficult to navigate through responsibilities and reach sustainable outcomes.
Lack of Time as a Barrier. Another organizational barrier that emerged from
participants was lack of time. Five of 17 participants identified time as a barrier, including the
number of tasks, being stretched thin, number of meetings to get things done, and time spent
identifying the appropriate person. For instance, Amelia felt the biggest barrier in her role was
not having “enough time in the day.” She sought resources to help project work and
administrative record keeping management. Additionally, Nicole faced “nonstop emails and
requests” that felt like a barrage and found it hard to keep up with the number of systems or
platforms. Finally, Helen felt time was a barrier, saying, “I think we are expected to, as
managers, do too much in an 8-hour day. If you really added up—there’s no way to do
everything that we’re expected to do in 8 hours, no matter how efficient you are.”
With lack of time, there was the feeling of competing priorities. Nonnursing departments,
such as accounting or payroll, lacked understanding that nurse middle managers had other
priorities, and those priorities may take priority over nonnursing department asks. Colleen shared
she worked additional hours to accomplish everything to try to resolve the barrier of lack of time.
She also spent more time fixing barriers and spending time following up with people in ancillary
or support departments. The lack of time barrier could be an indicator that the organization did
not align the appropriate responsibilities for the role.
Lack of Transparency. Three of 17 participants discussed lack of transparency as a
barrier, including the lack of understanding why something was happening, and their feelings of
not being given all information. Helen thought visibility was a barrier for staff to know what her
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role as manager entailed and them knowing what they were supposed to be doing in the manager
role. She thought there was a barrier of trust and understanding and a lack of transparency.
Penelope found a significant barrier to not being told the full story or given the information
needed when they were fighting for something. She believed she had to “not make waves.” She
also expressed the organization seemed to have shifted to more of a top-down organizational
feel, which created a barrier. She believed the organization had grown too big, and there was a
lot of energy going into things that “upper leaders don’t quite understand.” Justine, Penelope,
Marisa, Carla, and Lily spoke about not understanding the rationale behind decisions and having
to seek clarification from the chain of leadership to find out the reasoning. Another way they
resolved barriers included similar approaches, such as Vivian, who sought someone who could
help them; however, it often took multiple calls to get to the correct person. To navigate this
barrier, most participants spoke about seeking clarification and guidance to resolve the lack of
transparency. The nurse middle management team sought to be included in initiatives and
decisions so they could be a part of the process and be connected to staff.
Lack of Support. Seven of 17 participants identified lack of support from human
resources, ancillary departments, and leadership as a barrier. Stephanie talked about the lack of
support and information given by human resources led to distrust by staff because they were not
getting “straight answers.” Maryanne and Nicole identified hiring additional staff as a barrier
because of the process, amount of justification needed, and difficulty in posting openings. The
recent nursing shortage made it not “feel great to be a leader.” Lindsey felt she did not have
enough leadership support and often felt she was stretched in managing tasks. She had to support
nurses, “oversee all the clinical needs in the building,” and be a resource for many different
things. She commented, “I’m the go-to for many different things outside of nursing, not just
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patient care.” Danielle also experienced a lack of leadership support, needing to turn to her
mentor for support and guidance. Colleen found it hard to manage multiple different areas and
did not have the support of other teams, such as information technology. She felt the need for
better communication to develop stronger relationships with ancillary support teams, such as
information technology. She also felt that when things came up, such as disaster preparedness or
the COVID-19 global pandemic, the nurse managers were at the front line to handle issues while
being expected to also do their regular roles. Colleen explained, “So, things like that can
sometimes be challenging and how do you kind of continue with, you know, moving things
forward, and also survival mode.” Feeling as if they did not have the right support made their
role feel more difficult. The nurse management team needed support with current and future
tasks.
Role Barrier Gaps in Organization/Environment Result in Motivation/Behavior Gaps
With gaps evident in organizational alignment, culture, and prioritization, there were
impacts to middle managers’ motivations to persist toward accomplishing tasks and
responsibilities. A lack of organizational transparency and feelings of a lack of support resulted
in a lack of connectedness and involvement, which can be detrimental to the middle manager
role. Competing priorities and a lack of time were indicators of an organizational culture and
structure that did not clearly define priorities or offer guidance to accomplish tasks to lead to
success. When faced with different types of barriers, individuals may believe they cannot
continue toward their task or goal.
Strategies for Resolving Barriers
The most frequently referenced resolution to a role barrier was around leveraging
connections, with 12 of 17 participants using connections to resolve role barriers. For
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participants, using connections was exemplified by knowing who to go to for help; reaching out
by seeking advice, guidance, and clarification from leadership, stakeholders, and the team; using
delegation; and negotiating to resolve barriers. Vivian demonstrated how she tried to resolve
barriers immediately or at least find someone who could help her. She stated, “Phone a friend is
a big thing,” and she spent time searching for the correct resource to resolve an issue, which
often took multiple calls to the appropriate person. Vivian also saw the limitations of other
resources/support in resolving barriers. She realized she might have been transferring barriers to
someone else to resolve, and they may have been reaching out to other people, resources, or
relationships. Additionally, she saw a big part of her role was to remove and resolve barriers for
her staff for them to be successful. Irene resolved barriers by reaching out to build rapport with
stakeholders and asking stakeholders about their needs. Finally, Lily said:
[Having] to look at it and find the right people or ask people or my director who’s on
their level or who’s on my level that I can work with because that’s how I figured out
how you can make things happen.
The opportunity to discuss role and change barriers experienced by the nurse middle
management team highlighted the connection part of their role. Not only did nurse
managers/senior managers/directors serve as the connection between frontline staff and
leadership, but they also used the connections they developed throughout the organizational
system to get things done. This role of being in the middle, and between groups, made it easier to
leverage those relationships when needed.
Participants employed communication as another barrier resolution strategy, with nine of
17 participants being open, honest, transparent, and present for their staff. Debra resolved
barriers through communication and being open and honest. She also tended to speak out/speak
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up and articulated her case to get others to understand her rationale. Lindsey used the town hall
approach to communication, which was a suggestion from her mentor. Town halls gave people
notice about changes and allowed affected groups to “say their piece out in the open.” This town
hall approach also gave her the opportunity to identify allies and champions for change. Lindsey
explained:
I don’t want people feeling like they were never asked or never consulted. Yeah,
especially with nurses, you know, that’s something that I think it’s very important
because I know, living as a nurse, like we always feel like we get asked less. So, I’m
trying to change that where I’m trying to ask them ahead of time.
Using communication to gain support and get others to align with middle managers provided
opportunities to resolve barriers in their roles. There were a variety of different modes of
communication they employed, but the key commonality was open and honest transparency.
Finding 4: Confidence in Quality Improvement projects and What Is Needed
The third Likert-scale rating question in the semistructured interviews asked each
participant to rate—on a scale of 1 to 5, with 1 = strongly disagree and 5 = strongly agree—their
self-assessed level of confidence in their ability to develop a quality improvement project. I
asked a follow-up question to seek what they thought was needed to increase their feelings of
confidence. The 17 participants had an average rating of 3.59 on the Likert scale, with a range of
2 (disagree) to 5 (strongly agree). Figure 14 illustrates the distribution of responses.

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Figure 14
Distribution of Self-Assessment of Level of Confidence in Quality Improvement Projects

Understanding gaps between current confidence level and potential future confidence
levels can be analyzed through the combined lens of social cognitive behavior and Clark and
Este’s (2008) KMO model by looking at their stated needs of confidence through knowledge,
motivation, and organization. Participants indicated additional training or education on quality
improvement, hands-on practice in facilitating quality improvement projects with available
support and guidance, and resources to support this type of work would increase their confidence
in implementing quality improvement projects.
Gaining Additional Knowledge
Six of 17 participants stated the need for more training to increase their confidence in
quality improvement. Nicole and Maryanne indicated they would benefit from additional
training, tutorials, and refreshers. Irene and Danielle spoke about programs they had previously
0 0
1
0
6
3
4
1
2
0
1
2
3
4
5
6
7
1
Strongly
Disagree
1.5 2 2.5 3
Neutral
3.5 4 4.5 5
Strongly
Agree
Count
Likert Rating
Strongly Disagree (1) to Strongly Agree (5)
I am confident in my ability to develop a QI project
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participated in that provided education to gain knowledge and apply that knowledge to projects
with the guidance of a coach or mentor. The lack of knowledge and ability to apply that
knowledge made it more difficult to have confidence to execute quality improvement. With
organizational expectations to implement change initiatives, there was a gap in the needed
education for appropriate knowledge acquisition to fulfill that role responsibility.
Increasing Motivation With Hands-On Application
Building on knowledge acquisition that would be beneficial in building confidence for
managers is the inclusion of the ability to apply that knowledge in real scenarios related to their
roles. Again, six of 17 participants voiced the need for more experience and practice to build
confidence through application of knowledge. Vivian and Nicole applied knowledge on projects
focused on improvement at HCCC. Justine, Lindsey, and Marisa all spoke about practice in
relation to training and application to build confidence in skills. Lindsey discussed being exposed
to more projects, saying, “Just like, the structure and the bones of the project and making sure
that you’re not missing any of the steps.” Marisa also spoke about being able to practice and be
involved in quality improvement work to build confidence, sharing:
I think it comes with practice. You have to be involved, and as part of the group, you
know . . . there’s too many parts to one piece that you may forget or don’t consider that
aspect. . . . I’m not the expert yet.
The ability to apply knowledge increased confidence in their quality improvement skills, and the
increase of confidence helped motivate them to undertake these types of projects.
Organizational Support Resources
Eight of 17 participants stated they needed a team and project support resources to help
with their confidence in quality improvement. The need for project support resources was a
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theme that came up throughout several interviews. The need for this type of resource would help
keep projects on track and support the manager, who was also responsible for day-to-day
operations. Amelia pointed out the need to have access to the right people doing the right work
associated with quality improvement, saying:
You need the one that has kind of the vision of the project. You need those that are the
data collectors. You need those that are organizers to keep the project going. I think you
need the right team to get it through and it’s done right.
Penelope also spoke about the need for support to help relieve the feeling of being so busy,
saying, “It would also be nice if when we’re so busy, if there was one person that was not
necessarily us that was there to lead projects and keep everyone along.” The managers seemed to
indicate the lack of these types of resources provided by the organization impacted their ability
to successfully execute quality improvement projects.
Secondary Data
To add additional insight into middle managers’ perceptions of their competency levels in
areas such as quality improvement, change, and metrics, I reviewed a previously administered
learning needs assessment of the nurse management team’s self-rated proficiency. A learning
needs assessment was created by the nursing department of study organization using the
American Organization of Nurse Leaders Nurse Manager Competencies for purposes of
collecting baseline data prior to beginning one of the professional development programs for
nurse managers that was developed by the nursing department. The program was called
Hierarchy of Accountability Responsibility and Professionalism (HARP), and was a 10-month
leadership course for managers in nursing and patient care services that was developed and
delivered through nursing leadership on topics that managers are seeking to increase their
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knowledge and skills in the manager role. The HARP program took into consideration the
misalignment between expectations placed upon the manager role and the skill level of people in
the role. The self-assessment asked participants to rate their competency levels based on
Benner’s levels of expertise on a scale of novice, advanced beginner, competent, proficient, or
expert. The prelearning needs self-assessment was conducted in April and May 2021 and
received 43 responses from manager and senior manager/director levels (HCCC, personal
communication, October 6, 2022). The two questions relating to this study examined
performance improvement/metrics and EBP/outcome measurement and research. The two
statements participants rated were:
• Performance improvement/metrics: Identify key performance indicators; establish
data collection and evaluate data; respond to outcome measurement findings; assess
and develop strategies to address customer and patient satisfaction; monitor and
report sentinel events; participate in root cause analysis; promote and model the use
of EBPs; manage incident reporting; maintain a safe working environment; promote
intra/interdepartmental communication.
• EBP/outcome measurement and research: Use data and other sources of evidence to
inform decision making; use evidence for establishment of standards, practices, and
patient care models in the organization; design and interpret outcome measures;
disseminate research findings to patient care team members; monitor and address
nurse sensitive outcomes and satisfaction indicators.
Table 13 illustrates the results of the preassessment, with most responses falling in the competent
and proficient ratings. There were no expert ratings, and several novice and advanced beginner
ratings in competency areas.
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Table 13
Pre-HARP Learning Needs Assessment, April–May 2021
Metric Novice Advanced
beginner
Competent Proficient Expert
Performance
improvement/metrics
6 4 15 18 0
Evidence-based
practice/outcome
measurement and
research
4 6 20 13 0

Note. HARP = Hierarchy of Accountability Responsibility and Professionalism. n = 43 nurse
managers and senior nurse managers. From Heart of Care Cancer Center, personal
communication, October 6, 2022.

Table 14 illustrates the results of the postassessment, which was conducted at the
completion of the first HARP cohort. The postassessment asked the same competency questions
based on the Benner level of expertise scale and resulted in 26 responses from nurse managers
and senior nurse managers/directors. The postassessment demonstrated an increase of self-
assessed competency, resulting in no novice responses and including expert responses.

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Table 14
Post-HARP Learning Needs Assessment, June–July 2022
Metric Novice Advanced
beginner
Competent Proficient Expert
Performance
improvement/metrics
0 4 8 10 4
Evidence based
practice/outcome
measurement and research
0 3 13 8 2

Note. HARP = Hierarchy of Accountability Responsibility and Professionalism. n = 20 nurse
managers and senior nurse managers. From Heart of Care Cancer Center, personal
communication, October 6, 2022.

Figure 15 illustrates the comparison between pre- and post-self-assessment by nurse
managers and senior nurse managers. The weighted averages show an increase in self-
assessment competency ratings.

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Figure 15
Comparison of Weighted Averages Between Pre- and Post-Self-Assessment of AONL
Competencies

Note. HARP = Hierarchy of Accountability Responsibility and Professionalism. From Heart of
Care Cancer Center, personal communication, October 6, 2022.

The results of the pre- and post-learning need assessments related to the HARP program
seem to indicate that targeted, focused delivered training increases the self-perception of
knowledge and skill development. The HARP program is supported and sponsored by the
nursing department where the nurse managers and senior nurse managers/directors directly
reported. Many participants referenced the HARP program at different during their interviews.
A finding that emerged during interviews was the number of participants who talked
about or mentioned the HARP program even though there were no questions directly related to
3.05
2.98
3.54
3.35
1.00
1.50
2.00
2.50
3.00
3.50
4.00
4.50
5.00
Performance Improvement / Metrics Evidence Based Practice / Outcome
Measurement and Research
Expertise Self-Rating
Competency Area
HARP Cohort 2021 Learning Needs Assessment Pre and Post
Comparison Weighted Averages
PRE Weighted Average
POST Weighted Average
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HARP in the interview protocol. A total of 12 participants brought up the HARP program during
interviews, with 11 of 17 participants directly mentioning HARP and their experience with the
program. One participant indirectly mentioned the program by description but not by name.
Many participants referenced HARP as an example of their ability to apply education/training in
their roles. Participants also spoke about HARP being an opportunity to connect with the
management team. Lily spoke about her experience in the HARP program, saying:
Especially with HARP, oh my God, the HARP program, it’s really amazing, so that
brought us all together. And there’s no animosity, like people are just like covering just
for their own unit, or those type of thing like, we can reach out like, even inpatient
outpatient reach out to each other and talk to them and see if they’re going through the
same thing, and if there is a problem between units, usually, they report it to their
managers so we’re not like, unit this and that always does that, so, but we understand
each other and just say like, okay, I could reach out to [manager] and say like, [manager]
when we move this patient in [unit] there is so and so there’s a little bit of more like,
understanding each other and hearing from what’s happening there.
The HARP program provided direct opportunities for leadership development combined with
ability to use the skills and knowledge connected to the managers. Carla believed she had been
able to bring back HARP takeaways to her role, especially in the prior 2 years. She was able to
use some skills to address challenges that arose, even if it was not to the full extent of seeing
something all the way through. The HARP program provided a structure and support for the
curriculum. The program provided training, job aids, mentoring, and wellness strategies nurse
middle managers could use at their work environments.
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Gap in Perceptions of Supported and Directed Education Opportunities
Participants spoke about their role as change agents and facilitating change but their self-
rating scores about confidence in quality improvement ranged in score. The need for additional
education and ability to practice was identified as a gap. Guidance on available education and
opportunities to practice were stated needs of participants, which highlighted gaps in knowledge
and subsequent motivation.
Finding 5: Desire to Apply Training but Face Struggle in Actionability
The ability to apply knowledge gained through education and training supported an
individual’s growth of skills and competencies. However, the reality of being able to apply that
new knowledge in an individual’s role and responsibilities was not always done easily, which
impacted sustained acquisition of knowledge. The 17 study participants had different experiences
in their ability to apply knowledge from trainings to their work (see Table 15).

Table 15
Perception on Ability to Apply Training in Role
Ability to apply training n
Felt able to apply 11
Felt partially able to apply 4
Felt unable to apply 2

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Of the 17 participants, 11 indicated they felt they were able to apply knowledge obtained
in professional or personal trainings and education. Findings pointed to the desire to apply
knowledge, but there was a struggle to find time and space to apply the learnings because of
competing priorities the nurse managers faced. Two perspectives emerged regarding the struggle
they faced: (a) self or internal barriers to sustain and (b) external or institutional barriers. Lily
believed it was an internal function to ensure she could apply what they learned to their roles and
responsibilities. Justine saw the ability to apply knowledge during training or educational
offerings to her role but the actual application fell to the side when other priorities arose. Justine
noted her own lack of sustainability when other tasks, responsibilities, and projects arose and
needed to be prioritized, saying:
That’s a lesson on me, like what would help me remember things like OneNote is helpful,
but I don’t have it up and then it gets to be like, oh, I haven’t looked at that tab in forever.
So, it’s kind of like the same thing as having a pile of papers, like oh, gosh, I haven’t
looked at that in so long, but yeah having something to trigger your memory would be
really good. But yeah, I know in the moment I do take a lot of notes and but yeah,
sustainability is always my problem.
Justine expressed the lack of sustainability was an internal function because she let the focus slip
away. However, competing priorities and additional responsibilities placed on an individual by
the organization may contribute to the lack of continued focus to apply new concepts. The lack
of focused application of knowledge impacts the sustainability of that knowledge and subsequent
confidence in using those skills.
On the other hand, Lindsey was hesitant to commit to her ability to apply acquired
knowledge, pointing to institutional barriers inhibiting her application of acquired knowledge.
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When asked about her ability to apply knowledge, she stated, “Yes, but I hesitate and say yes, is
that’s always the hope that I can apply it, but there are institutional barriers where I can’t fully
bring all the concepts in into work.” Lindsey continued to describe attempts to apply knowledge
as a game of “whack-a-mole” with changes she was attempting to implement because of
different directions given by senior leadership. Competing priorities and a lack of clear direction
or expectations created perceived organizational barriers to applying acquired knowledge.
Irene presented a perspective of lack of knowledge retention unless there was an ability to
apply what was learned or get the experience to apply it with support or guidance to apply it. She
felt like she applied some concepts she learned in school through homework but not in real-life
scenarios. To feel better about being able to apply what she learned, Irene identified the desire to
be walked through it the first time and “have someone who you can turn to and ask for help
along the way—someone physically close.” Maryanne felt she was able to apply knowledge to
her role, but there were other limiting factors, such as a lack of resources and difficulty bringing
widespread change as one person. There were various support needs identified across the 17
participants to increase the application of training to roles and work. These stated needs for
support demonstrated the need to meet individuals where they were so needs could be met in a
targeted, focused way.
The study focus was to understand the lived experiences of individual middle managers
to meet them where they were to help them be successful. Participants had different experiences
in their ability to apply educational and training knowledge, but commonalities were evident.
Irene pointed out some people learn differently. There were self, internal, and organizational or
external influences that ether facilitated or deterred application. An organization needs to support
an individual’s ability to apply knowledge so they can have successful, sustained acquisition of
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knowledge combined with an individual’s willingness to apply the knowledge. Additional
needed support and resource findings are explored in the results and findings for RQ3, with
elements in each that also contributed to the nurse middle management team’s ability to use and
sustain acquired knowledge.
As seen in RQ2 of Finding 3, the HARP program provided education and training that
aligned with the needs of participants through using the learning needs assessment to guide
topics and activities. Many of the comments in interviews indicated there was a gap between
gaining knowledge and translating the application of that knowledge. Managers received
permission from the organization to participate in the HARP sessions and be present,
supplementing their feelings of motivation. The same structure would be beneficial for all
educational opportunities so participants can be successful in gaining knowledge and applying it
in their roles.
Results and Findings for RQ3: Needed Support and Resources for Nurse Middle Managers
In continuing to learn about a nurse middle manager’s ability to sustain change and
achieve empirical outcomes, RQ3 explored foundational elements of leadership support
organizations needed to provide for healthcare middle managers to be successful. Table 16
summarizes the findings that aligned with RQ3 through the lens of the conceptual framework
and the gaps identified based on the combined framework. Some findings in Table 16 may not
align specifically with the conceptual framework guiding this study, but they are taken into
consideration during the development of recommendations in Chapter 5.

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Table 16
RQ3 Findings With Conceptual Framework Elements and Gap Identified
Finding Framework element Gap identified
Needed resources and support for
successful manager role across
KMO.
Knowledge
Motivation/behavior
Organization/environment
Access and training, well-
rounded support, clarity,
and expertise.
Four key themes to assist a new
manager transitioning into the
role.
Not applicable Not applicable
Difficult road traveled in
transitioning from frontline to
manager.
Motivation/behavior
Organization/environment
Confirms the literature
review that often, middle
managers are promoted
based on clinical
competence but may not
have developed leadership
skills.

Note. KMO = knowledge-motivation-organization framework. Not applicable indicates the
specific finding did not contribute to the overall conceptual framework.

Finding 1: Needed Resources and Support for Successful Manager Role Across KMO
A theme that emerged from interviews included the need for support to balance both
daily operational roles and special projects furthering organizational goals. Additionally, success
for a nurse manager in their role in operations and in sustaining outcomes was to have access to
needed resources. The elements of support and resources overlapped during the interviews. Table
17 outlines the findings related to needed support and resources sought by the nursing middle
management team that aligned with the conceptual framework. Finding aggregation in Table 17
is representative of participants having multiple responses to needed support and resources.
Typicality is not indicated in Table 17; all participant perspectives of support and resources are
considered during the development of recommendations in Chapter 5.
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Table 17
Needed Support and Resources the Nurse Middle Management Team Sought
Needed support/resources Conceptual framework Finding
Need for access and
training
Knowledge Five of 17 participants sought access
to data and systems with
appropriate onboarding and
training.
Need for role clarity Motivation/behavior Eight of 17 participants sought clear
goals, scope, expectations, and
timelines.
Need for resources with
specific expertise
Organization/environment Twelve of 17 participants sought
resources for support to facilitate
day-to-day operations and project
work.
Need for leadership
support
Motivation/behavior Ten of 17 participants sought
approachable leadership support
to help them be successful.
Need for peer support and
connection
Motivation/behavior Seven of 17 participants sought
opportunities for collaboration.
Need for people and
equipment to facilitate
day-to-day operations
Organization/environment Nine of 17 participants sought
additional staff, funding, and
necessities to run operations.
Ancillary support Organization/environment Seven of 17 participants sought
organizational structure support.

Knowledge Need: Access and Training
A knowledge area that nurse manager and senior nurse manager/director participants
sought was the ability to be successful in a role by having appropriate access and associated
training to carry out responsibilities from their 1st day. In interviews, five of 17 study
participants expressed they were seeking access to data and systems with appropriate associated
onboarding and training. Danielle and Vivian spoke about needing the right access to be able to
do their jobs. Danielle pointed out it was difficult to do their jobs in the timeframes given
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without access “to a lot of things that a manager needs to have access to promptly do their job.”
Vivian expressed she experienced stress because she did not have the right access, sharing:
Making sure right out of the gate you have the system; you know how to use the tools
that are part of what makes this place run. Setting that up, I think, would take away a lot
of stress from me.
The ability to be successful in their role required the nurse middle management team to be able
to access the systems they needed to run operations or facilitate projects or change initiatives.
Without this component of knowledge acquisition to support someone moving into a new role,
expectations may not be able to be fulfilled.
Motivation/Behavior Need: Role Clarity
Understanding what their role in an organization entailed with expectations of
performance allowed the nursing middle management team to know what they needed to do and
prioritize. Study participants expressed their desire for additional role clarity, with eight of 17
participants seeking clear goals, scope, expectations, and timelines. Penelope spoke about
needing “clear expectations” to facilitate more transparency in her role as a manager. Stephanie
expanded on this idea of clear expectations through the perspective of knowing how to execute
and accomplish responsibilities of the role, saying:
Clear goals, clear expectations, I am pretty much one of those timeline people, I like to
set time framework to accomplish stuff, and what I feel like I don’t get now is like
specifics of what needs to be done and when to accomplish it by. If here’s a problem and
its pretty vague and, ok yes, it’s a problem but what role do I have to make a difference, I
don’t know that yet.
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The desire to have clearly articulated expectations gave understanding to their place in the
organization in the middle manager role. Koloroutis (2007) spoke about articulated expectations
in “Articulated Expectations: An Essential Tool for Clinical Managers.” Koloroutis pointed out
articulated expectations contribute to the culture in a work environment and involve assessing
the needs of staff to know what they need to be successful. Having clear expectations would
provide a resource to the nurse middle management group to be able to carry out expectations
and be successful in their roles.
In the same focus of role clarity, participants were also seeking greater knowledge and
understanding of where they fit into the bigger picture, opportunities to be heard, additional
ownership, and opportunities for them to expand their role with learning and growth. Veronica
spoke to “having access and having a seat at the table.” Maryanne expanded on this concept of
access by seeking opportunities to learn and grow, saying, “You know I’m provided
opportunities to learn and provided opportunities to fail. And some people are so afraid if they
fail, they’ll lose their job you know, but we shouldn’t be.” Many participants expressed the
desire to grow in their current roles while also having opportunities to grow outside of their
current roles. Colleen wanted to learn the business side of the study organization to benefit her
current role while also learning new knowledge that could push her to grow into her next role.
She said, “I feel like having that piece and that business side of it. I could learn from them and
grow, and my role to better be able to do that as well in my role.” Being given opportunities to
understand where they fit in the organization allowed nurse middle managers to excel and grow
their own manager competencies while also looking ahead at future growth opportunities.

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Motivation/Behavior Need: Resources With Specific Expertise
A majority of nurse manager and senior manager/director participants expressed their
desire to have specific resources with expertise in administrative support, education support, and
project and implementation support, including guidance, direction, organization, tracking, and
staying on top of the work they were doing. Twelve of 17 participants spoke about seeking this
type of expertise resource and support to feel they could facilitate the day-to-day operations and
project work. Vivian discussed project support to help with the facilitation of projects and the
associated workload, saying, “You need more than just a manager to get something off the
ground, if you have that project manager who’s doing those audits and checking, following up.”
Multiple participants specifically spoke about a resource that could guide them on projects and
assist with questions and barriers. Penelope elaborated on having a project resource that would
be able to guide her and allow her to use knowledge she gained, saying:
I think support looks like maybe having someone like who is more versed in that [quality
initiative], to be there for kind of help if you get off course to guide you into the right
direction, or maybe like okay, so this is how we do that, so we all stay on the same line.
And that doesn’t mean that every time there needs to be that person, say like you’re my
person like you’re the expert, but if I get really good at it and I can continue it, but I know
I can always call you.
Seeking the support of specific expertise in project management would give the middle manager
role the ability to learn how to facilitate a project or change initiative while also accomplishing
the work. It would support middle managers who may struggle to balance operations and
change/project type of work.
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In addition to a project management type resource, a few managers also sought
administrative support to assist with tasks. For instance, Amelia spoke about needing help
accomplishing tasks that accumulated, saying, “Sometimes, we just need some like, help with
that clerical or organizational support. You know, some of the things that we do that are
tedious.” Irene also spoke about seeking a dedicated clinical nurse specialist to help in moving
projects forward on the units with frontline staff collaborating the work. Participants seemed to
indicate their need for additional support to help facilitate work they were doing so they could
better balance all responsibilities assigned to them. The nurse managers interviewed sought the
ability to know who to go to for different expertise to give nurse managers additional support
that may have been more accessible than leaders. Participants stated a need for support in terms
of leveraging expertise of others to be successful in their roles, rather than feeling as if they were
having to drive everything forward seemingly on their own.
Motivation/Behavior Need: Leadership Support
Participants also connected the support they were seeking to the need for leadership
support, with 10 of 17 participants looking for approachable leadership support that could help
guide them through barriers and provide approvals as needed. Justine saw leadership support as
an opportunity to be mentored and guided, sharing:
Support from a superior is always really great because they can mentor and guide you
through any process. And again, for me, it’s like feeling safe and being able to approach
that person is key to me for feeling supported.
Penelope sought presence from her leaders, saying, “I were to reach out and say hey I really need
to support right now, and she tells me, ‘you know I’m there for you’ . . . at least I know
someone’s there, and she shows up.” The ability to have access to leaders to seek guidance gave
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nurse managers the support they were seeking to be successful. Lily continued to say, “I trust
that our leaders are also expert[s] in project initiation, so I would ask them questions about how
their experiences were in their different projects and just guidance.” Having the support of direct
supervisors and senior leadership was needed for approvals, decisions, and support in their role,
projects, and change. A key component included the approachability of leadership. These needed
leadership support elements led to success in the middle manager role, which could have
contributed to increased motivation for the role. The support from direct and senior leadership
assisted with the elimination of barriers that nurse managers encountered while providing insight
and experiences to help nurse management navigate their role.
Motivation/Behavior Need: Peer Support and Connection
A final motivation-focused support and resource was the need for peer support, with
seven of 17 participants seeking collaboration with other nurse managers, operations people, and
team members. The ability to connect with peers throughout the organization allowed personal
support and operations or project support opportunities. Danielle was seeking “cross
collaboration” so she would know what everyone was working on and whom to connect with
when needed. Maryanne wanted to connect on a personal level and have more of a “supportive
family” who was there when “you’re not at your best” and could use extra support. Marisa saw
peer support as an opportunity to share expertise, saying, “[I want to] depend on coworkers that
they will support me and vice versa if I know something that I’m good at it and they need it from
me absolutely I will share my knowledge and wisdom.” The ability to connect and support one
another would give the nurse middle management team an opportunity to grow together and
experience success together. The desire to seek support through peers in the nurse middle
management team increased their motivation to continue to pursue their work to achieve goals.
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Organizational Need: People and Equipment to Facilitate Day-to-Day Operations
An aspect of success for the middle manager role was to ensure they could keep daily
operations running smoothly. Nine of 17 participants spoke of needing more staff and funding
for adequate staffing along with necessities to successfully run their daily operations.
Colleen looked for adequate staffing to support patients and staff, sharing:
Having that support to have the staff that we need to provide a good service and to
provide good quality to our patients as well as help the staff to be able to feel like they
could take a day off . . . and you know, not feel obligated to work.
Often, there are a lot of process steps to navigate approvals for staff, supplies, and equipment to
find success in their role. As seen throughout the study’s findings, the nurse middle manager role
prioritizes patient care and staff well-being and needs. The ability to feel they had the essentials
in staffing, equipment, or supplies contributed to middle managers’ abilities to feel successful in
executing daily operations.
Organizational Need: Ancillary Support
Another organizationally focused support that was needed by the nurse middle manager
was support of ancillary departments to help accomplish their own work and goals. Seven of 17
participants sought organizational structure support from human resources, information
technology, and other ancillary support teams. Vivian pointed out the barrier of working in silos
without connecting and supporting one another, sharing:
That seems very big and very daunting, but it seems like every department needs a little
help in of creating a structure. . . . I think we’re still in silos, but if I have an idea of
where I fit in the wheel, it helps the wheel move smoother.
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A part of being supported is having connectedness and support in the work middle managers
undertake. Thinking in terms of how organizational processes work, it is rarely an individual
group that can make change happen. To find success in change, it is important to ensure
connections are made and stakeholders work together to realize that success.
Feelings of Support
Participants went beyond explaining what they sought in terms of support and resources
and spoke about what elements they needed to feel supported. Figure 16 demonstrates middle
managers’ perspectives of needed elements to feel supported in their role.

Figure 16
Participant View of Needed Elements to Feel Supported

Ability to be frank Acknowledgment Affirmation Appreciation Being available
Being listened to
Being physically
present
Communication
Constructive
criticism
Dedicated time
Encouragement Endorsement Feedback Grace Honest
Mentorship Open
Someone who
has your back
Someone who
understands the
workload
Space to practice
hands on
Transparency Work–life balance
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Each nurse middle manager in the study spoke about what it felt like to supported; some
were already experiencing this type of support, while others spoke about what they would like to
feel. Some participants had practical elements they wished to see such as communication, time,
and space to practice. Others furthered the idea of having access and being heard. Helen spoke
about support as “feeling like you’re heard, first and foremost, not necessarily that everyone’s
going to agree with you or make a decision based off of what you say, but just that you have a
voice at the table.” The common theme throughout the needed elements was the development of
a relationship with leadership. Carla talked about support as “being open and honest, in the area
for nonjudgment.” One theme that emerged among participants was the need for time and
bandwidth to do work outside of daily operations. Debra spoke about the need for tradeoffs to be
able to accomplish everything that was expected of the role, saying, “[I want to ensure] I’m
given the bandwidth to do a project if I have a full plate and this project’s really important then
you need to take something off. . . . You can’t just keep piling more stuff on me.” When looking
at needed support and resources, it was equally important for participants to understand what
support felt like or looked like to the ones receiving it, which better addressed individual needs.
The Need for Support and Resources for Role Success
Participants highlighted several needed resources and support structures to be successful
in their role, aligning with the different gap perspectives in the conceptual framework. The
organization needs to facilitate several elements in organizational support, access and training,
and the role itself to provide support for the middle manager. There were several opportunities to
create a structure throughout the organization that would support day-to-day operations and
change implementations through clarity, the use of subject matter experts, and well-rounded
support.
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Finding 2: Four Key Themes to Assist a New Manager Transitioning Into the Role
To understand the perspective of the existing nurse middle management team, I asked
participants to reflect on what advice they would give to a new manager beginning in this new
role. Four themes emerged from the responses to this question, including taking time to learn and
connect in this new role, building connections, being kind and trusting yourself, and setting
appropriate boundaries. Figure 17 graphically represents the four themes of advice for a new
manager.

Figure 17
Thematic Analysis for Advice to a New Manager

Advice
to New
Manager
Learn
Connect
Be Kind and
Trust
Yourself
Set
Boundaries
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Take Time to Learn
Many participants spoke about the need to give oneself time and grace to learn the new
role. Colleen and Irene cautioned it could take up to a year to understand the manager role and
all it entails. Colleen and Lily spoke about learning who to go to for different responsibilities.
Lily reflected that even if she did not know an answer, it might be something she would come
across anyway so, “Let’s just do it together.” When talking about advice she would give a new
manager, Lily spoke about being a support resource for a new manager, saying, “I’m here, if you
need help, don’t feel like you’re alone; you know you should always be able to reach out to your
peers.” The advice to give time and space to learn the role aligned with gaining knowledge and
having clear expectations. Reflection about the need to learn the role to be successful went
toward the need to obtain knowledge and motivation to keep persisting in the role.
Focus on Building Connections
Building connections was also a recurring theme in advice for a new manager to learn,
have support, and assist in role success and removing barriers. Connecting was expressed on
different levels, including with staff, a team, colleagues, and throughout the organization. Vivian
summarized the need to build connections by telling a new manager to take the time to establish
relationships by getting to know their team, know their resources, and really foster and develop
those bridges. In terms of connecting with staff, Justine spoke about the need to get to know
direct reports on a more personal level, while also assuming positive intent when getting to know
them. Vivian went on to continue the theme of connecting with staff, saying it is good to absorb
and learn what they can before making any changes so they know what is going on and can
better make connections using those relationships when it is time to make a change. Amelia and
Maryanne would tell a new manager to find someone they could connect with and who could be
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a “lifeline” when they need it. They recommended to have a person to go to when having a bad
day, running into barriers, needing to debrief, or needing to get advice. That person could help
them get through whatever they needed to get through. Building connections early in the
manager role helps to facilitate development of relationships that will help to provide support as
a new manager grows in their role.
Be Kind and Trust Yourself
The ability to be kind to oneself was a theme that many middle managers felt was
important in their growth in the role. Stephanie would tell new managers they have support, they
are not alone, and there are people who have their backs, saying, “I would want them to feel
supported so that they don’t leave.” Maryanne would tell a new manager just starting to “allow
yourself forgiveness,” because they are not expected to know everything, and there are other
managers who are there to help them be successful. She would want to make sure new managers
were successful, and she would be there for their success if they let her know what they needed.
Finally, Carla would tell a new manager to “just breathe, you will do it” and to know who their
resources are, not just in nursing, but also in other departments and teams. Aligned with that
advice about giving time and space to learn, the nursing middle management team advised
similarly to give space and time for self-reflection and being comfortable with oneself. It was
also very clear the current nurse managers/senior nurse managers/directors wanted to support the
next managers to be successful in their roles.
Set Appropriate Boundaries
A slightly different theme that emerged was the need for new nurse middle managers to
set boundaries around structure and to protect their own time and space in the role. Nicole spoke
about the many “trials” they may experience in the role, to keep focused on why they are doing
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what they are doing, and “shore up as much family and spiritual life as you can because you will
need all of that to be able to this job.” Penelope spoke about being very clear about boundaries
and that people cannot please everyone. She recommended they do their best, saying, “If you are
trying your best and giving what you can, even if it’s just 20% one day.” Marisa cautioned about
giving out their personal phone number and keeping some boundaries between personal and
professional life with staff and colleagues. Marisa also said to be consistent because staff may
test people to find out their work style, which could help build the trust between them and the
staff. Participants mentioned setting boundaries protected their role, their time, and even their
team, in working together to balance the expected responsibilities.
Finding 3: Difficult Road Traveled in Transitioning From Frontline to Manager
Another theme that emerged was the experience of transitioning into the role of manager,
from the perspective of frontline to a manager role, or when coming into the manager role
externally. Veronica felt she had to jump into the role, saying:
I felt like I was thrust into it, but that was because the situation necessitated it, and not
because the [study organization] did not do a good job of giving me training. I feel like
the whole past year has been training.
In terms of onboarding and access, Vivian spoke about the inconsistency in access because it was
based on the person who conducted onboarding rather than a standardized process, saying,
“Having an onboarding that is sufficient, making sure you have all the tools that you have to do
what is expected of me.” Veronica and Vivian’s experience demonstrated the lack of formal
transition into the manager role. Participants spoke about the lack of formalized or standardized
onboarding experiences when they transited into the manager role at the study organization,
leaving them to navigate on their own.
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One of the interview questions asked participants to think back to when they first
accepted the role of manager and what advice they would give themselves at that point in their
transition into leadership. This question gave further insight into the manager role transition.
Lindsey and Irene pointed out a lot of the skills they used in their manager role were concepts
they learned from becoming a nurse. Lindsey spoke about being a nurse for 23 years, saying:
I think a lot of the trust building, relationship, and rapport-building skills developed as a
nurse, just because that’s what you need to do with patients. And so, for me, that easily
translated into guiding or mentoring a team. So, a lot of it was self-learned and self-
taught, but like officially in a management role, it was a little challenging in the
beginning. But you know, I think it just takes experience and practice and also doing the
trainings.
Marisa and Lily spoke about the transition from being a frontline nurse role to being part of the
management team and establishing boundaries so their friendships would not hinder their
leadership role. Lily pointed out she had people tell her when she first started in the manager
role, “You’re alone in your office, you can’t vent to your team and say like ‘oh my God, this is
so hard’ because they don’t want to see that with their leaders.” Lily continued to say that things
had shifted organizationally, saying:
I think the culture has changed with leadership, so even though we’re in different
departments having the support team and hearing that they’re going through the same
thing, it really helps out and you don’t feel alone; you don’t feel like you have to do
everything by yourself.
Veronica also spoke about the transition from a clinician to a leader and noted the role was not
what she expected. She said, “This isn’t the job you think it is.” She did not know what the
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manager position intended and thought the role would be less involved, sharing, “It was a shift
from being a clinician-minded role to being a role that had to do a lot of different things.” Many
participants did not fully understand what the shift into a leadership position would entail. This
idea aligns with the literature review that identified promotion based on clinical skills does not
result in having the necessary leadership skills for manager roles.
Three study participants, somewhat jokingly, expressed they would go back to their first
week as a new manager and tell themselves not to take the role. They had mixed feelings about
the role due to the amount of work to undertake and a feeling of being stuck. A main difference
between a staff nurse and a nurse manager is they are “never going to finish all the tasks,” and
just have to “be gracious with yourself,” and keep prioritizing to make sure things are
accomplished. Another participant expressed that she would have chosen a different path and
gone somewhere where she would flourish. Finally, the third participant reflected that she told
herself “It all has to fall apart before it gets better. Something has to fall apart before it gets
better.” Even participants who spoke about not being sure leadership was the right path for them
continued the commitment to support their staff and patients who sought care at the study
organization.
Participants identified the struggle of being a new manager and were committed to
supporting the next line of new managers shifting into leadership positions. Helen talked about a
recent experience where she supported a new manager who appeared to be struggling. She took
the time to talk to the new manager and ask her what was going on, saying:
You know the one thing you need to remember, is the way you’re feeling is completely
normal. . . . We all felt that way and have moments when we still feel that way, and the
most important thing you can do is lean on others because you’re not alone in this role;
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none of us are ever alone in nursing and you just got to remember like, that there’s people
out there to help you.
Maryanne summarized her role as a manager as a “rough, glorious, painful, wonderful ride.”
Transitioning to the nurse manager and senior nurse manager/director roles were not always a
smooth transition, but people have navigated the struggles and can now pass guidance to new
managers who may be experiencing a bumpy transition.
One finding from participants was there were feelings of specific support missing in the
transition into the manager role. The organization needed to formally facilitate the transition into
a nurse manager role to prepare new managers for a leadership role. Several participants
mentioned their onboarding process or how their access rights depended on who was tasked to
facilitate the transition. The organization had a gap in formal onboarding support that would
provide knowledge for the role. In turn, this gap damaged the motivation for the individual in the
role by a lack of encouraging behaviors that could lead to success. The inconsistent experience
for a new manager may impact their preparation and how long it takes for them to feel like they
are a member of the leadership team.
Summary
The study findings indicated nurse managers from the study organization had the desire
to meet the expectations of their role but felt they faced barriers to gain and apply necessary
knowledge and receive needed support and resources. Nurse managers sought support and
resources to achieve success in their role, providing balance between daily operations with
staffing and patient care, and achieving organizational outcomes to support strategy and goals.
Figure 18 synthesizes findings into the study’s conceptual framework to summarize the gaps
identified.

Figure 18
Synthesis of Findings Through the Perspective of the Conceptual Framework to Identify Gaps

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In this study, I set out to meet the individuals where they were in their needs and
determine the needed leadership support and organizational structure to ensure nurse managers
were supported to be successful. Deep and rich information emerged to fully explore the needed
foundational elements in leadership and organizational support for the nurse manager role to be
successful and facilitate sustained change.
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Chapter Five: Recommendations
In Chapter 4, I presented findings and results aligned with the three research questions
(RQs) that guided this qualitative research study examining healthcare middle managers’
abilities to sustain change through the perspective of their role and development. The dual
conceptual framework provided a method to identify gaps in areas of knowledge,
motivation/behavior, and organization/environment based on participant lived experiences. I
used these findings to inform the development of recommendations to move toward improving
the problem of practice and shifting the organization into a new state of change sustainment.
Chapter 5 presents recommendations that provide ways to close the identified gaps
through the conceptual framework. Recommendations are presented based on themes that
address each of the three RQs using the perspectives of knowledge, motivation/behavior, and
organization/environment. I used the data and evidence to create recommendations, taking into
consideration findings exhibited by the nurse management team interviews along with
supplemental secondary data and the conceptual framework. Each recommendation is aligned
with specific study findings to demonstrate support in the improvement of the problem of
practice. The recommendations focus on the preparation of the middle manager role, which
includes nurse managers and senior nurse managers/directors in the study organization, the
creation of culture and infrastructure to support the individual’s ability to facilitate change, and
resources available to support the sustainment of change and outcomes.
Discussion of Findings
I conducted a qualitative research study with nurse managers and senior
managers/directors (i.e., a middle management team) in the nursing department at the Heart of
Care Cancer Center (HCCC), which delivered exquisite care and quality outcomes to patients
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under their care. I used purposeful sampling to select nurse managers and directors who had been
in their role for at least 1 year and were a part of the Southern California region of the
organization. The purpose of this study was to understand the gaps that exist in healthcare
organizations in their support of the development of the middle manager role to meet needs and
grow leadership skills to achieve successful strategic initiatives and sustained change
management. Using the Clark and Estes (2008) gap analysis with social cognitive theory
frameworks, I explored knowledge, motivation, and organization (KMO) factors that influenced
a middle manager’s ability to be successful in sustaining change while exploring the social
cognitive aspects of the individual that was in the role and the organization’s ability to support
individuals in the role (Schunk & Usher, 2019).
The middle manager role in healthcare is an integral part of daily operations supporting
quality patient care and is also tasked with facilitating projects and change initiatives that further
the overall organization strategy. The importance of this role was affirmed through evidence
presented in the literature review in Chapter 2 and supported by perspectives and lived
experiences of 17 nurse managers and nurse senior managers/directors interviewed as part of this
qualitative study. The themes found in the literature review were generally confirmed in the
study organization participant lived experiences, although there were some nuances that
indicated some special considerations based on the study organization perspective.
Middle managers had multiple responsibilities that often felt as if they were faced with
competing priorities to try and accomplish. The literature and this study demonstrated the
multitude of different aspects middle managers were responsible for in different capacities and
how much they felt they were expected to manage. A component of the theme of responsibilities
is associated role ambiguity experienced by middle managers. I identified a disconnect between
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role responsibilities and articulated role expectations. Middle managers experienced unclear role
expectations and were unsure about their job descriptions, which could have also resulted in
varying role success definitions and ability to achieve goals. Additionally, barriers experienced
in the role often carried over to additional responsibilities and additional time was spent
resolving those barriers, which impacted daily operations and change projects. Middle managers
were expected to manage multiple priorities, often competing priorities, but a lack of expectation
setting, goal setting, and role definition made it difficult to persist in a role and to know when
they were successful. Findings point to the organizational need to look at how the middle
manager role is connected to provide structure and opportunities to gain needed knowledge to be
successful in the role.
There are many barriers to change experienced in the healthcare setting and middle
managers are often tasked with navigating these barriers to be successful with a change initiative.
The evidence found in literature presented in Chapter 2 and the interview data from participants
presented in Chapter 4 align on the type of barriers to change. The barriers to change range from
organizational, such as a lack of structure, lack of culture, and insufficient resources; knowledge
based, such as resistance and insufficient skills and experience; and motivational in nature, such
as lack of support and lack of collaboration. It can be daunting persisting in a change initiative
when there are barriers, resistance, and insufficient resources or ability to make change happen.
There are a variety of different support elements needed through the perspective of KMO
concepts and support needed to resolve barriers to be successful in the change and to sustain that
change.
Just as in daily operations, the middle manager role in times of change is integral in how
a change is approached, accepted, implemented, and subsequently sustained. The expectation to
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facilitate change initiatives felt like additional work or responsibilities for middle managers who
were also tasked with managing daily operations for patient care. The middle manager role is
often seen as the connection or the in between to upper leadership and frontline staff. This
connection assists in making change happen and participants indicated they were not only a
connection between top leadership and frontline, but also a connection to other groups and
ancillary teams. The need to facilitate collaboration also pointed to a lack of organizational
structure to make collaboration a part of the culture and enterprise-wide expectation.
Additionally, middle managers expressed varying degrees of confidence in their abilities
to execute a quality improvement project, which could impact their ability to believe they can
facilitate change. Through barriers faced and a lack of confidence in quality improvement,
middle managers experienced feelings of a lack of role success, which could have impeded their
ability to feel motivated and persist. The consequences of not being able to sustain change also
start to manifest in the organizational perspective of facing change fatigue and lack of sustained
outcomes. Findings indicate there needs to be a combination of organizational structure and
culture with additional knowledge opportunities to both support the middle manager role and
increase motivation.
There are different skills and competencies beyond clinical competencies that are needed
for individuals in the healthcare middle manager role to be successful as leaders and in
administratively focused roles. Middle managers face a transition from being a frontline clinical
staff member to being responsible for leadership and administrative tasks they have not
necessarily been formally prepared to achieve. Participants had varying perspectives of their
level of preparation for the role, with many stating they did not feel prepared until they had been
operating in the role for a period of time, from one year to multiple years in the manager role.
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They indicated they had some exposure to quality improvement and change management type of
education offerings, but many participants indicated they did not have the ability to apply those
skills regularly and were missing support in that application. It is important to ensure
organizations provide opportunities for middle managers to learn, develop, and apply skills, with
a perspective of meeting those learners where they are so they feel supported.
Understanding the research study by aligning literature findings with study findings
allows for a comprehensive perspective of a macro level (i.e., literature findings) and micro level
(i.e., study findings) that can be placed in the conceptual framework. Elements of the KMO and
social cognitive frameworks emerged, and I identified gaps that contributed to the study’s
problem of practice. These findings informed recommendations to mitigate the problem of
practice and move toward closing the identified framework gaps. Ultimately, the goal of the
recommendations is to meet the middle manager role where they are to support them in
knowledge, motivation, behaviors, and skills and through development of a supportive
organization and environment for them to grow to facilitate change and sustain empirical
outcomes.
Recommendations for Practice Aligned With KMO and Social Cognitive Frameworks
I suggest three recommendations to address the three RQs and move toward improving
on the problem of practice. Each recommendation is connected to the ability to develop and
support middle managers in their capacity to successfully facilitate change and sustain empirical
outcomes. The recommendations focus on establishing an onboarding experience that starts
middle managers on a path to success, creating an infrastructure for change through establishing
expectations and creating opportunities for middle managers to learn and apply quality
improvement methodologies, and establishing a project support center to support middle
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managers in the change work they are tasked with achieving. Table 18 highlights
recommendations associated with the study findings they aimed to address and alignment with
conceptual framework elements.

Table 18
Recommendations to Support KMO and Social Cognitive Frameworks to Improve Problem of
Practice
Recommendation Associated findings Conceptual framework
Design
comprehensive
onboarding
program for middle
manager role.
Varying degrees of role preparation
Key themes for new manager transition
to role
Difficult transition from frontline to
manager
Varying definitions of role success
Knowledge
Motivation/behavior
Organization/environment
Create infrastructure
to support middle
managers in change
with opportunities
for knowledge
development and
guided application.
Inconsistent training and education in
quality improvement and change
management.
Varying levels of confidence in
qualitative improvement with
education and support needed.
Varying abilities to apply training
Knowledge
Motivation/behavior
Organization/environment
Create a project
resource center to
act as a project
support center in
nursing for middle
manager initiative
support.
Nurses have significant role in change
and quality improvement.
Quality improvement plays a role in
patient outcomes.
Barriers inhibit change implementation
and sustainability.
Multiple role barriers exist and require
active resolution.
Need support and resources to find
success in change initiatives
Knowledge
Motivation/behavior
Organization/environment

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I used the W. K. Kellogg Foundation (2004) program evaluation logic model to
demonstrate key implementation factors and subsequent phased evaluation methods for each
recommendation. This program logic model is a part of the recommendations to demonstrate key
program elements and short-, intermediate-, and long-term evaluation methods to understand the
individual recommendation from the perspective of its own success and from the overall
organization. The W. K. Kellogg Foundation presented the logic model structure as identifying
planned work, which includes resources/inputs and activities, and intended results in terms of
outputs (i.e., short-term results), outcome (i.e., intermediate-term results), and impact (i.e., long-
term results). By using the logic model, each recommendation is able to be systematically
planned and described to be thoughtful about the approach of developing recommendation
design aspects and subsequent implementation (W. K. Kellogg Foundation, 2004). The logic
model will also assist in planning, implementation, and evaluation as the recommendations
progress through the different phases of implementation. The linear approach in the presented
logic model should allow for both a clear understanding of the recommendation planning and
necessary stakeholder engagement that may be needed to support the recommendation.
Recommendation 1: Creation of a Comprehensive Middle Manager Onboarding Program
The creation of a comprehensive onboarding program for middle managers who are
either an internal promotion or an external hire includes focused access, training, and support for
individuals moving into the position to be successful from the beginning of the new role. This
study found interviewed middle managers had varying feelings of role preparation, often feeling
as if it took time for them to finally feel prepared for their role. They also indicated difficulties
transitioning from a frontline nurse to a nurse manager in a leadership position with different
experiences in gaining appropriate access and training as they moved into the new role. The
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previous two findings also contributed to the varying definitions of role success because of
inconsistent expectation setting and roles and responsibilities views.
Through a review of literature, a comprehensive onboarding program includes extending
beyond just the initial orientation touchpoint with new hires. Hills (2022) described the
onboarding process as including preboarding, 1st day activities, and a larger extended
onboarding experience. This type of onboarding experience would support middle managers as
they transition into a new leader role. Throughout the onboarding process, the focus should be on
engaging, empowering, and appreciating the new employee along the entire experience
(Caldwell & Peters, 2018). Each onboarding experience phase is outlined in detail to emphasize
the elements needed to provide essential support to middle managers as they transition into the
role.
Beginning the onboarding process before the 1st day in the position represents using
preboarding techniques to engage in the period between the offer extension and the 1st day in the
role. Preboarding focuses on the time between the acceptance of the employment offer and the
1st day with activities designed to get new employees excited and engaged, taking time to
connect with the new hire, and leveraging virtual opportunities and early communication
(Caldwell & Peters, 2018; Hills, 2022; Shufiitinsky & Cox, 2019). The focus during the
preboarding period would be to make the new hire feel welcome and start to acclimate to the
organization through a tour of the facility and welcome gifts (Hills, 2022). This period would
also include getting a head start by completing necessary paperwork and potential training, while
also taking the opportunity to expose the new hire to documents and literature to get them
excited for the role and expose them to the organization’s communication tools (Hills, 2022;
Shufiitinsky & Cox, 2019). The organization can also use the preboarding time to prepare
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itineraries and logistics for the 1st week in the new role and create an organized plan for
onboarding, including setting expectations for what should be accomplished (Caldwell & Peters,
2018; Shufiitinsky & Cox, 2019). Sending instructions and schedules with expectations for
onboarding can reduce anxiety for new employees and employees moving into new roles (Hills,
2022; Shufiitinsky & Cox, 2019). The preboarding period can be used to support new middle
managers, allowing them to ease into the role before they are met with demands of the new role.
The second phase in the comprehensive onboarding program is the actual day of
onboarding and orientation. Onboarding activities should encourage incorporating opportunities
to connect the new employee with their leader on the 1st day at the start and end of their days to
begin to develop their relationship and engage upper leadership in training and orientation during
onboarding (Caldwell & Peters, 2018; Hills, 2022). The day of onboarding also includes
facilitating the ability to connect to the organization’s culture and providing opportunities to
connect with other new employees and key stakeholders (Hills, 2022). It is important to leverage
transparency and access to information to get new hires accustomed to organizational definitions,
terms, acronyms, charts, stakeholders, and “clearly defined job description” on Day 1, including
using a type of “orientation booklet” (Shufiitinsky & Cox, 2019, p. 44) to help a new employee
become acquainted with the organization and role (Caldwell & Peters, 2018). Hills (2022) and
Shufiitinsky and Cox (2019) recommended including career development and advancement
topics in the onboarding process, and incorporating activities to engage and excite new hires
through illustrating the availability of professional development programs that come in different
forms, such as training, mentoring, and coaching. Finally, during onboarding, there should be
incorporation of organizational opportunities to participate in social justice to demonstrate
community impact (Shufiitinsky & Cox, 2019). These opportunities can be presented in the form
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of promoting volunteer opportunities, discussing sustainability initiatives, and demonstrating
connections between the organization and community (Shufiitinsky & Cox, 2019). The
combination of a preboarding program and a comprehensive onboarding day provides support
and information for middle managers as they transition into the leadership role, providing
knowledge for the role and support to be successful.
The larger extended onboarding experience continues the onboarding program beyond
the 1st week for up to 1 year. The longer onboarding experience will require leadership support
to provide time and space for new managers to fully attend and commit to the program
(Warshawsky et al., 2020). This extended onboarding experience includes time for role
alignment and goal setting while establishing priorities and expectations, which include
clarifying job responsibilities, outcomes, and performance measurements (Caldwell & Peters,
2018; Hills, 2022). A coaching process for new employees should be established with
checkpoints to help support the alignment to expected performance (Caldwell & Peters, 2018).
This process can include a commitment of mentoring and coaching by more experienced
managers, leaders, and peers in an interprofessional team model to give a source of support and
resources (Caldwell & Peters, 2018; Warshawsky et al., 2020). Management and leadership
involvement through communication and mentoring of a new hire demonstrates they are
involved in learning and onboarding, helping to create opportunities for new employees to build
relationships and their network (Caldwell & Peters, 2018; Shufiitinsky & Cox, 2019). The
element of coaching and mentoring helps to support middle managers in the transition into the
leadership role and start to develop relationships they will be able to leverage in their roles.
A part of the extended onboarding experience would include support for middle
managers’ transitions into a leadership role. The inclusion of focused courses that build nurse
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manager specific competencies that include didactic learning opportunities creates opportunities
to develop skills and motivation to persist in their roles (Warshawsky et al., 2020). These
opportunities can include an onboarding capstone project to present learnings from the entire
onboarding experience (Hills, 2022). This capstone project can take the perspective of the “100-
day action plan” (O’Neil et al., 2017, p. 712). Use of the 100-day action plan helps a new
manager grow into their role by facilitating opportunities to be exposed to aspects of the role that
are not acquired from their years of clinical experience, allowing them to learn more of the
administrative side, direct reports, and the new manager circle of influence, focusing on building
relationships and learning the dynamics of the team (O’Neil et al., 2017). O’Neil et al. (2017)
pointed out one goal of the 100-day plan is to increase circles of influence with people involved
in their work and with stakeholders by developing intradepartmental relationships between
departments that have similar goals or work areas. Supervisors and new managers work together
on expectations for developing the 100-day action plan, including assessment of the department,
expectations, resource availability, and expected communication. The new manager should also
have a schedule of shadowing so they can learn what their staff do in the department and
understand what is needed to ensure operations continue and how groups or individuals work
together. The use of the 100-day plan can support motivation of new middle managers and the
organization as a tool for assessment and improvement.
The recommendation to implement a comprehensive onboarding program reduces
identified gaps through the lens of knowledge, motivation/behavior, and
organization/environment. There are several elements incorporated in the onboarding program
that support the new manager as an individual through knowledge acquisition, motivation and
behavioral elements, and organizational and environmental elements that benefit the individual
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and the organization. Table 19 illustrates the elements of the conceptual framework that support
the comprehensive onboarding program.

Table 19
Recommendation 1: Alignment to Conceptual Framework
Alignment
element
Knowledge Motivation/
behavior
Organization/
environment
Conceptual
framework
elements that
support a
comprehensive
onboarding
program
Skill development Roadmaps to guide
onboarding
100-day plan
Assessments Networking Alignment with
culture
Checklists Mentoring/coaching Directed support
Orientation booklet 100-day plan Clarity in
expectations
Layer training through
progressive
onboarding phases
Performance feedback
Outcome expectations

Job aids Goal setting
Enact learning via 100-
day plan

Vicarious learning
through connecting
with others

Note. The table includes concepts of Clark and Estes (2008) KMO gap analysis and social
cognitive theory (Bandura, 1986, as cited in Schunk and Usher, 2019).

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Hills (2022) and Warshawsky et al. (2020) pointed out evaluation of an onboarding
program should be continuous to ensure it is keeping up with changes and trends in healthcare
through the engagement of new hires in feedback on the hiring process. This evaluation would
also include tools that support the transition, such as assessment, checklists, and roadmaps that
support the application of new leadership skill development to the role itself (Warshawsky et al.,
2020). Additionally, the 100-day plan can also be used as part of the evaluation plan to identify
quick wins, develop future RQs, and prioritize larger projects that may be beneficial to work on
(O’Neil et al., 2017). Table 20 presents the logic model to guide evaluation of the comprehensive
onboarding plan for new middle managers.

Table 20
Recommendation 1: Comprehensive Onboarding Programs for Middle Managers Logic Model for Evaluation
Outputs
(products of
program)
Outcomes (specific
changes)
Outputs
(products of
program)
Outcomes (specific
changes)
Outputs
(products of
program)
Outcomes (specific
changes)
Prepared
middle
manager in
transition
into
leadership
role
Knowledge of middle
manager role with
clearly articulated
expectations;
prepared for
responsibilities and
support to persist in
the role
Prepared
middle
manager in
transition
into
leadership
role
Knowledge of middle
manager role with
clearly articulated
expectations;
prepared for
responsibilities and
support to persist in
the role
Prepared
middle
manager in
transition
into
leadership
role
Knowledge of middle
manager role with
clearly articulated
expectations; prepared
for responsibilities and
support to persist in
the role
Inputs
(resources)
Activities (resource
activities)
Inputs
(resources)
Activities (resource
activities)
Inputs
(resources)
Activities (resource
activities)
Human
resource
time
Develop onboarding
program and
materials
Human
resource
time
Develop onboarding
program and
materials
Human
resource
time
Develop onboarding
program and materials
Leadership
time
Coaching and mentoring Leadership
time
Coaching and
mentoring
Leadership
time
Coaching and mentoring
Learning and
development
materials
Role development
Forms, job aids, training
materials
Learning and
development
materials
Role development
Forms, job aids,
training materials
Learning and
development
materials
Role development
Forms, job aids, training
materials
Facilities and
information
technology
Logistics support and
space for new
employee
Facilities and
information
technology
Logistics support and
space for new
employee
Facilities and
information
technology
Logistics support and
space for new
employee

Note. Figure created using the evaluation table modeled in W. K. Kellogg Foundation (2004). Used with permission of W. K. Kellogg
Foundation.
194
195

Recommendation 2: Create Infrastructure to Support Middle Managers in Change
Participants indicated they felt there was a lack of change and project infrastructure in the
study organization. The lack of infrastructure was seen as a lack of structure, including lack of
tools for project management, organization, communication, collaboration, and improvement
methods. An additional component included inconsistent training and education opportunities in
quality improvement and change management, with varying abilities to apply training. The study
also found participants had varying levels of confidence, education, and support in quality
improvement. To better support middle managers in quality improvement and change
management, the organization needs to create a structure for change, set expectations for the role
and alignment in job descriptions, and clearly articulate expectations and goals. Then, the
organization should also support the growth of knowledge in quality improvement with
opportunities for knowledge acquisition and organizational support in place to apply that
knowledge.
Creating an infrastructure of support for middle managers’ involvement in change is
comprised of different elements that need to be developed together to provide a well-rounded
support structure. Brandrud et al. (2011) specifically described infrastructure as improvement
knowledge, multidisciplinary teams, coaching, learning, and sustainability structures in place.
Brandrud et al. (2011) and Castiglione and Lavoie-Tremblay (2021) identified several success
factors to support improvement and change in organizations, including infrastructure, alignment,
engagement, knowledge, and resources. These success factors are described in the next section
using categories of information, engagement, and infrastructure (Brandrud et al., 2011).
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Information
Information must be available for role development, expectations, and to ensure the right
work is done to be successful in facilitating and sustaining change. The creation and
communication of clear expectations to people involved in change in the organization are used to
establish alignment of role and responsibilities, goals, and time to support change (Castiglione &
Lavoie-Tremblay, 2021). In looking at setting expectations for participating in and leading
change projects, the middle manager role needs to be defined as part of the change structure.
Birken et al. (2016) highlighted the key role of middle managers in providing frontline staff the
tactical tools and information they need for change and innovation while providing support for
them to do the work. This role contrasts the role of champions, defined as “top managers or
physicians who attempt to persuade employees to engage in innovation implementation,” who
supply the motivation to staff to implement initiatives (Birken et al., 2016, p. 4). Dopson and
Fitzgerald (2006) recommended including clearly defined and articulated role expectations,
indicating a part of the individual’s role is to facilitate change, evidence-based practices (EBP),
and innovation. A component of clearly, articulated expectations includes the ability and
empowerment to make decisions associated with innovation. The manager role assists in
bringing local context to the infusion of change and can make connections to the larger
organizational setting; furthermore, middle managers focus on facilitating communication to link
others together in the organizational setting (Dopson & Fitzgerald, 2006). Furthering the thought
about creating links is the ability to move work forward in the organization, which includes
ensuring best practices and current practices are provided and benchmarking is done when
applicable (Brandrud et al., 2011). Middle managers serve as a conduit for information and allow
for change to sustain in organizations.
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Engagement
Engagement is also essential in the creation of an infrastructure that supports change and
quality improvement. Improvement work should include key aspects of being anchored to
leadership, engaging patients and families in improvement work, anchoring in the professional
environment, and engaging staff throughout stages of improvement (Brandrud et al., 2011).
Castiglione and Lavoie-Tremblay (2021) pointed to the importance of engagement in an
organization’s change processes by stakeholders “at all levels of the organization and the
community” through a “participatory approach” (p. 266). This approach also includes leadership
being engaged in the facilitation of innovation and change and leveraging their “sphere of leader
influence” (Castiglione & Lavoie-Tremblay, 2021, p. 266) to promote
multidisciplinary/interdisciplinary involvement. Leadership should also assist in the fostering
and communicating of interactions and connections throughout the organization, creating
networks where relationships begin to develop to work collaboratively to reinforce values and
alignment. Incorporating elements of engagement into the infrastructure of change builds
transparency and encourages motivation for middle managers to participate in change.
Infrastructure
The creation of an infrastructure of change that facilitates alignment, engagement, and
learning across the enterprise to drive improvement in a coordinated manner brings together the
elements for change. Brandrud et al. (2011) and Castiglione and Lavoie-Tremblay (2021)
defined infrastructure as creating alignment in the culture of the organization to support and
prioritize change, improvement knowledge, engagement of multidisciplinary teams on focused
improvements, a tailored learning system that reaches multiple groups, and systems to facilitate
the work and sustainability. The concept of infrastructure is expanded to include resource
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support for the change and improvement work, including areas such as finances, people, physical
space, knowledge, and time availability (Castiglione & Lavoie-Tremblay, 2021).
Dopson and Fitzgerald (2006) encouraged the creation of processes to “include collective
collaboration” (p. 51) to support daily and project work. A key element throughout the literature
when establishing infrastructure for sustainable improvement is the inclusion and connection
through interdisciplinary and multidisciplinary work. There should be a focus on
interprofessional collaboration to share evidence and facilitate discussions, giving opportunity
for involvement across areas for input into changes that may impact employees (Dopson &
Fitzgerald, 2006; Stelson et al., 2017). Employees should build collaborative relationships
centered on trust and incorporate this relationship building in performance targets (Dopson &
Fitzgerald, 2006). A final infrastructure element to support sustainability includes the
establishment of aligned measurement of indicators and feedback processes to monitor results
and ensure sustainment and commitment to implementation (Castiglione & Lavoie-Tremblay,
2021). The creation of change infrastructure with commitment to knowledge building, resources,
and collaboration can provide a consistent experience that can be replicated and repeated across
projects. A more standardized approach to change also leads to more emphasis on measurement
and evaluation to support sustainment of the change.
Emphasizing Support of Middle Manager Development
Castiglione and Lavoie-Tremblay (2021) pointed out having these success factors in
place facilitates the ability of a structure or process that can be followed by the middle manager
and can influence the work regardless of specific project or implementation setting. It is
important for an organization to develop skills in middle managers to apply the skills they learn
to a variety of projects, without having to feel like they are an expert in the specific area they are
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working in. A support structure should be in place for the middle manager group to ensure these
success factors can be leveraged to facilitate change, improvement, implementation, and
sustainability to realize success.
There were a few key findings from this qualitative study that demonstrated the need for
support for the middle manager role as a part of the change infrastructure. Each interviewee had
different education and experiences in quality improvement and change management. The
differing education and experiences of the participants also connects to findings related to the
varying approaches to problem solving they demonstrated in the interviews. There are
expectations for middle managers to facilitate implementations and sustainability, but there is a
lack of clarity of what that looks like specifically for the role. There are several key skills in
literature middle managers should learn about, get a chance to apply, and receive support to
persist in applying those skills. Figure 19 outlines change skills from literature middle managers
should develop.

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Figure 19
Middle Manager Change Skills to Develop and Persist in Using

Note. Figure combines needed middle manager change skills as presented in Drew and Pandit
(2020), Stelson et al. (2017) and Tortorella et al. (2020).

Tortorella et al. (2020) conducted a systematic review and longitudinal mixed methods
study on behaviors that leaders should demonstrate relating to change and improvement
implementations. The leader behaviors were split into either task-oriented behaviors or relation-
oriented behaviors (Tortorella et al., 2020), which are further expanded on in the following
section with other evidence from literature.
Model role
behavior
Focus on
outcomes
Communicate
Remove
challenges
Disseminate
information
Encourage
innovation
Demonstrate
importance
Leverage
collaboration
Engage and
empower staff
Connect to larger
organizational
strategy and goals
Develop others
Monitor and
evaluate
Coach
Leverage
interdisciplinary
teams
Celebrate wins Be present
Provide
opportunities
Be open
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Middle managers in healthcare need to be able to demonstrate task-type behaviors in their
roles to be present, engaged, and involved in work. Stelson et al. (2017) and Tortorella et al.
(2020) highlighted the importance of communication, including communicating goals and
objectives and recommending managers should also tie project goals to the bigger organizational
picture. As leaders, middle managers should learn to not only recognize improvement
opportunities, but also to identify areas where frontline personnel can contribute to those
opportunities and “engage and empower them” (Drew & Pandit, 2020, p. 2) for growth and self-
development (Tortorella et al., 2020). Middle managers should focus on optimizing outcomes
through information sharing and connecting “management, leadership, and quality
improvement” (Drew & Pandit, 2020, p. 2) and balancing control and influence to allow people
to come together and work toward quality improvement as a fundamental principle, which
includes monitoring and evaluation (Tortorella et al., 2020). Task-oriented behaviors also include
being present where the work is being done so managers can identify opportunities while also
being visible in their use of quality improvement concepts (Tortorella et al., 2020). Organizations
need to develop training and development programs that support middle managers’ acquisitions
of these task-oriented skills while providing opportunities for application of skills. These
opportunities for application also include support and coaching to be able to try out these skills
without worry they are alone in trying out skills.
Additional relation-oriented behaviors for middle managers include more motivational
and behavioral elements and a focus on developing others while they grow in their roles. This
focus includes being able to show support in the work and demonstrate commitment to the
change infrastructure being developed—not just manager support, but also top leadership
support—to remove challenges and move work forward (Stelson et al., 2017; Tortorella et al.,
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2020). Role modeling of behavior by senior leaders demonstrates the importance of quality
improvement and that it is a priority. Using coaching to develop changes in leader and manager
behaviors and practices to align with the priority of change demonstrates an investment in the
growth of the individual in the role (Drew & Pandit, 2020; Tortorella et al., 2020). A focus
should also be on developing staff through training, facilitating an open learning environment,
encouraging opportunities to learn, and empowering staff to apply what they have learned
(Tortorella et al., 2020). Using focus groups and observations of healthcare middle managers and
resident family members, Hartviksen et al. (2020) studied Norwegian care homes with a focus on
healthcare middle managers’ abilities to develop capacity and capability to influence quality
improvement. Hartviksen et al. demonstrated a healthcare middle manager’s role in developing
staff knowledge in quality improvement, which includes being a guide for staff through
continuously empowering staff and creating a routine for guidance on improvement areas.
Additionally, Stelson et al. (2017) and Tortorella et al. (2020) emphasized the focus of the
manager to celebrate and recognize success, even small wins, to grow confidence before moving
into larger projects. These relation-oriented tasks demonstrate not just skills and behaviors, but
also a commitment to the change infrastructure.
Knowledge Gain and Application
Participants also spoke about other organizations they worked at that facilitated
opportunities for them to learn EBPs or quality improvement methodologies with application
through focused, self-directed projects that were required, but also provided support to
accomplish. Tortorella et al. (2020) emphasized the need to design education and training that
support the acquisition of manager task-oriented and relational-oriented behaviors. Based on
their integrative review, Castiglione and Lavoie-Tremblay (2021) recommended creating a
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“learning organization” (p. 267) where there is a continuous engagement and assessment of the
process of change and performance. Engaging in active participation for adoption cannot be just
the manager and project manager alone pushing it forward; there should be buy in and
engagement to get people involved in the work to diffuse the innovations (Dopson & Fitzgerald,
2006).
Providing a tool or guide for middle managers to use with targeted support and
mentorship during real project experiences can help middle managers understand their role in
change. Millar (2013) examined national leader guides to support improvement. These guides
allow for a way for an individual or group to apply the tools and techniques to the situation they
are working to improve. Millar identified the need to also include support and communication in
the application of these leader guides to help make connections. An important note is how tools
and techniques are tailored and communicated specifically to the group using them. Millar also
highlighted the ability to use these guides in real examples so people can see how things work in
their own environment. The opportunity for application to real projects for continuous
improvement work connects real work experiences with opportunities to learn (Millar, 2013;
Stelson et al., 2017). Kakyo and Xiao (2017) found participation in quality improvement
education by all levels allows them to be able to learn proactive skills while also being able to
learn and discuss different projects they are working on. Hearing experiences from others who
are implementing quality improvement allows them to learn what projects entail and what they
could experience in their own improvement projects (Kakyo & Xiao, 2017). By incorporating
education with application opportunities, the middle manager role is provided reinforcement of a
successful change infrastructure. Table 21 outlines the alignment of change infrastructure to the
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conceptual framework. Table 22 outlines the logic model for evaluation for the change
infrastructure development program.

Table 21
Recommendation 2: Change Infrastructure Alignment to Conceptual Framework
Alignment
element
Knowledge Motivation/behavior Organization/environment
Conceptual
framework
elements that
support
creating a
change
infrastructure
QI training Expectation and goal
setting
Performance outcomes
Leader guides Relation-oriented skills Communication
Task-oriented
skills
Collaboration Competency assessments

Table 22
Recommendation 2: Change Infrastructure for Middle Managers Logic Model for Evaluation
Outputs (products of program) Outcomes (specific changes)
Creation of a change infrastructure for nursing department Middle manager ability to sustain change and achieve sustained
empirical outcomes.
Inputs (resources) Activities (resource
activities)
Outputs (products
of activities)
Short-term outputs
(changes in
learning)
Medium-term
outputs (changes in
action)
Long-term impacts
(change in
condition)
Training and
development
division of
human resources
Training programs
focused on
quality
improvement
Increased
knowledge and
application by
middle manager
Middle manager
involved in
change initiatives
Quality
improvement
knowledge
application tool
(Chen et al.,
2020)
Sustained empirical
outcomes;
sustained nursing
sensitive
indicators
exceeding the
benchmark
Development of
tools such as
leader guides
Tools to support
middle manager
knowledge
application

Leadership time Sponsorship of
projects;
reinforcement of
change
infrastructure
Buy-in;
commitment to
change

Note. Figure created using the evaluation table modeled in W. K. Kellogg Foundation (2004). Used with permission of W. K. Kellogg
Foundation.
205
206

Recommendation 3: Creation of a Project Support Center in Nursing
A recurring theme during interviews was the need for targeted support to help the nurse
middle manager team maintain daily operations for patient care while also upholding the
expectation to work on projects and improvement initiatives. Study findings demonstrated
participants perceived nurses had a significant role in change and quality improvement and that
quality improvement played a role in patient outcomes. However, the middle manager role is
faced with barriers that inhibit role success, change implementation, and sustainability, which
require active resolution. All participants indicated needing support and resources to realize
success in change initiatives and many participants sought a project manager type position for
this support. Upon review of evidence presented in literature, there are a couple of different
structures that could be leveraged to provide this type of initiative, change, and project support
such as project management offices (PMO) or transition support offices (TSO). The creation of a
project support center (PSC) would provide the support and resources that middle managers are
seeking for increased success in their projects by combining PMO and TSO activities. For the
purposes of this recommendation, a PMO or a TSO would be a similar structure created in the
organization.
A PSC can provide subject matter expertise and bandwidth to support improvement
projects sought by middle managers. The TSO in Richer et al. (2013) was created to act as a
PMO to support project teams. This TSO was led by a nurse with healthcare innovation studies
at the doctoral level and consisted of project managers with different expertise and experience
who guided projects from initiation through completion, based on experience and learning from
projects. The TSO model offers guidance in project management, change, and performance
management, including evaluation (Richer et al., 2013). Similarly, Lavoie‐Tremblay et al. (2017)
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found PMOs provide an efficient way to execute successful projects through structure and
rigorous methodologies. Brandrud et al. (2017) pointed to the importance of having access to
subject matter experts who share expertise and act as guides and coaches. They understand best
practices in improvement and in measurement and assist the team in organizing “improvement
efforts well in spite of the difficult resource situation (time and personnel)” (p. 8). The
establishment of a TSO or PMO type group can help to provide access to these identified needs.
Lavoie‐Tremblay et al. (2017) summarized the need for a PMO type model in an organization by
“changing the organization one project at a time” (p. 663). Participants in the Lavoie‐Tremblay
et al. study demonstrated the PMO assisted in effectiveness, efficiency, and ease of approaching
the work. The PMO also supported the work by making connections and avoiding duplication of
work. This type of model would help middle managers execute many of the task-oriented and
relation-oriented tasks that are outlined in Recommendation 2.
Key Elements in a Transition Support Office
The literature presented four key areas where a TSO model can support project-based
work and implementation. The key areas included access to support and expertise, alignment
with infrastructure in place, support in skill development, and sustainability implications. Each
of these areas are expanded upon in the following section.
Access to Support and Expertise. The ability to access subject matter experts seeking
support in improvement and project management through the TSO allows for support through
expertise for the healthcare middle manager. Using the Lavoie‐Tremblay et al. (2017) learnings
regarding establishing a PMO model, this access to expertise facilitates a way to gain efficiencies
by connecting to subject matter experts who have knowledge and expertise to provide structure
and methodology support in project/change success. The PSC would facilitate connections to
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resources to resolve barriers so middle managers do not need to spend time searching for a
correct resource. A TSO model leads to project success through prioritization and objective
setting and establishes standard practices that encourage rigor in the work, from problem
identification to solutions conceptualization. The PMO model also provides connections and
partnerships that can assist in work being accomplished through collaboration and serves as a
liaison to make connections among groups and people to facilitate the work getting done and
providing communication and structure (Lavoie-Tremblay et al., 2012, 2017). Lavoie-Tremblay
et al. (2012) illustrated results from a PMO/TSO perspective, which included: (a) increase in
manager morale through support in the change process, (b) increase of competencies and
knowledge that can be applied to EBP initiatives, and (c) gain experience in the transfer of that
knowledge. The use of a PMO/TSO also includes a focus on cohesion to bringing people
together and establishing control through creating structure while providing expertise and
guidance (Lavoie-Tremblay et al., 2012). Kaplan et al. (2012) brought forth a similar perspective
that added to the concept of a PSC, which included establishing a quality improvement team that
focuses on the development of leaders. This group of quality improvement experts support
managers to feel prepared to execute improvement projects, is interprofessional and diverse in
experiences, brings different perspectives to the improvements, and engages with physicians and
teams who have the needed skills to be successful (Kaplan et al., 2012). Access to support and
expertise takes over some of the barriers middle managers experience in implementing change.
Alignment With Infrastructure. A second component of a TSO is to maintain
alignment with infrastructure put into place in the organization. This specific recommendation
aligns with the infrastructure proposed in Recommendation 2. Lavoie‐Tremblay et al. (2017)
described this model as a piece of the puzzle that provides “structure, guidance, planning and
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tools for properly understanding the objectives to be reached and how to reach them” (p. 662),
and they also learn from the expertise and guidance offered by the PMO. The use of a TSO can
also support the infrastructure perspective in their ability to classify project typology into
process, people, and practice, which use targeted strategies to support work to move toward
project success and contribute to the infrastructure of change for the organization (Richer et al.,
2013). The view by Lavoie‐Tremblay et al. (2017) aligned with what was found in this
qualitative study that time is a factor; even with the PMO support and learning from experts, they
still have to find the time to do the work during competing priorities. Kaplan et al. (2012) noted
organizational factors could influence success in quality improvement, such as developing
leadership and governance to help guide and support improvements, leadership commitment to
champion projects, and alignment with culture and value. The proposed PSC would help to
facilitate this type of work, providing structure and support for projects and improvement
initiatives so middle managers do not feel as if they are navigating barriers or facilitating the
work on their own. Finally, Lavoie‐Tremblay et al. (2017) described the “non-partisan approach
of PMO members” (p. 662). The neutrality of a PSC would help to facilitate the work and
connection of interdisciplinary teams and support middle managers in their role in change.
Support in Skill Development. A third component of the TSO model is support in
applying skills related to improvement and project management. One part of Recommendation 2
includes helping to build skills of middle managers so they could excel in their role in change
and help to pass their knowledge and skills onto others. Lavoie‐Tremblay et al. (2017) discussed
how a PMO model can provide experts for learning opportunities so staff can work together with
experts to develop skills through practice. Kaplan et al. (2012) presented an additional
component of this success factor through providing quality improvement support and the ability
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to build capacity, illustrating support includes data availability; making resources available to
support the work including money, people, and time resources; and providing training and
setting expectations. Experts can accompany the people doing the work rather than doing the
work for projects, which was a challenge identified by Lavoie-Tremblay et al. (2012) because
they had too high of expectations of the TSO group. A TSO model applied to the PSC concept
can support knowledge acquisition and application for further development of needed skills and
behaviors.
Sustainability. A fourth component is focused on sustainability in improvement and
change initiatives as it relates to the TSO model. Proctor et al. (2015) examined sustainment of
health innovations and associated factors with sustainability, including: use of a common
terminology on sustainability definitions, value of sustainability as part of prioritization
decisions, establishment of measurements to ensure sustainability, and establishment of feedback
loops to monitor interventions. The proposed PSC that combines successful elements from PMO
and TSO models would be able to support not only the project component, but also the
sustainability of implementations to achieve sustained outcomes.
PSC’s Connection to Supporting Skill Development in Middle Managers
A connection can also be made between Recommendation 2 in the creation of
infrastructure to support middle managers in change with opportunities for knowledge
development and guided application and the establishment of the PSC in nursing. van Dam et al.
(2020) found time as a barrier to full engagement in quality improvement type of projects,
similar to what was found in this study, and effective coaching and sponsorship are key to
advocating for time and resources for projects to be successful. van Dam et al. (2020) also
proposed project-based learning to grow organization “effective coaching and sponsorship skills
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and knowledge” (p. 12). The proposed PSC can be the conduit for coaching the middle manager
role to lead project success. The PSC can develop the middle manager role in aligning
knowledge and experience to support knowledge acquisition and application.
There is an interesting perspective of creating a learning environment from a community
engagement change called the neighborhood story project, which can be incorporated into the
workings of a PSC (Thurber, 2019). Drawing on this work, there are concepts applicable in
creating a learning environment that can be used to engage staff and reinforce the ability for
middle managers to apply learning to the work they do. Engaging existing knowledge and
scaffolding new knowledge and information to it facilitates the opportunity to learn each
person’s expertise through encouraging the reflection on change and connecting personal
experience drivers of change (Thurber, 2019). In a similar perspective, the ability to create this
type of learning environment can give opportunities to put knowledge and skills into practice to
further project work through activities, such as data collection and analysis and research
contributions (Thurber, 2019). The neighborhood story project also illustrated the importance of
taking the time to “foster intergroup relationship” through activities that encouraged members to
get to know each other and work together to enhance “a sense of cohesion and belonging”
(Thurber, 2019, p. 1691). Leveraging the strengths and expertise of others to help one another
through the project highlights interdependence facilitated throughout the neighborhood story
project (Thurber, 2019). Incorporating this concept into the facilitation of improvement projects
in the healthcare setting starts to close some of the gaps identified in the dual conceptual model
guiding this study. Table 23 highlights the key conceptual model elements that move toward
closing the identified gaps. Table 24 presents the evaluation logic model related to the
implementation of a PSC.
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Table 23
Recommendation 3: Creation of a Project Support Center Alignment With Conceptual
Framework
Alignment
element
Knowledge Motivation/behavior Organization/environment
Conceptual
framework
elements
that
support
creating a
project
support
center
Quality improvement
Competency
development
Coaching and mentoring Performance measures
connected to sustained
outcomes
Knowledge on
middle manager
role in change and
improvements
Partnerships to resolve
barriers
Commitment of resources
Tracking of outcomes Support to accomplish
project-related tasks

Note. The table includes concepts of Clark and Estes (2008) KMO Gap Analysis and Social
Cognitive Theory (Bandura, 1986, as cited in Schunk and Usher, 2019).

Table 24
Recommendation 3: Creation of a Project Support Center Logic Model for Evaluation
Outputs (products of program) Outcomes (specific changes)
Operationalization of a Project Support Center (PSC) in
the Department of Nursing
Provide expertise to facilitate projects from identification through
sustainability aligning with the change infrastructure.
Inputs
(resources)
Activities (resource
activities)
Outputs (products
of activities)
Short-term outputs
(changes in learning)
Medium-term outputs
(changes in action)
Long-term impacts
(change in condition)
Staffing Staffing with
expertise in
methodologies
Staffed PSC Awareness of the PSC
and PSC offerings;
engagement with
PSC by middle
managers; middle
manager
understanding of
improvement and
project management
skills and
competencies
Appropriate middle
manager
involvement in
improvement
initiatives and
projects. Successful
completion of
annual projects
(moving into
ongoing
sustainment
monitoring).
Sustained empirical
outcomes;
sustained nursing
sensitive indicators
exceeding the
benchmark;
sustained staff
engagement scores
Ancillary
support
Commitment to
collaborate on
initiatives and
barrier resolution
Resources to call
on when needed
System
development
Technology to
support project
work, tracking
Inclusive system
to support those
working with PSC
Marketing Print and digital
media to market
services
Materials for
promotion of
services
Training
development
Development of
training to
support the
acquisition and
application of
methodologies
Skills in
improvement
and project
management for
all levels in the
organization

Note. Figure created using the evaluation table modeled in W. K. Kellogg Foundation (2004). Used with permission of W. K. Kellogg
Foundation.
213
214

Integrated Change Theory to Support Implementation
The dual conceptual framework of this qualitative study guided the change theory
approach of design for equity, which expands design thinking to ensure inclusion of impacted
stakeholder perspectives to encompass to the support the implementation of the three
recommendations presented in Chapter 5. A key consideration in the dual conceptual framework
was to meet the individuals impacted by this problem of practice and make recommendations to
best address their needs. The design for equity change theory incorporates the user perspective
into the work, which is a key component to meeting the healthcare middle managers where they
are in their lived experiences.
Traditional design thinking is based on human-centered design, which focuses on
understanding the people who are impacted by a problem while also engaging them in the
solution, based on the notion that people who are impacted also hold the greatest insight into
how to solve the problem (IDEO, 2015). Design thinking incorporates interdisciplinary groups
approaching problem solving together and sharing expertise and perspectives, with a focus on the
people involved in the work and impacted by both the problem and the solution (Brown & Katz,
2011). Design thinking emphasizes innovation with stages that progress the work through
inspiration, ideation, and implementation to find the best solution to solve the problem (Brown &
Katz, 2011). Design thinking is a nonlinear practice that cycles through five stages: emphasize,
define, ideate, prototype, and test, which allows for feedback and touching back to the users
themselves (Dam, 2022). The steps of the design thinking process allow for understanding the
user that is being designed for (i.e., emphasize), defining the user needs and requirements (i.e.,
define), ideation of potential solutions to solve for the user needs (i.e., ideate), create prototypes
215

for the user to interact with and test based on the ideation (i.e., prototype and test), and
implement a potentially scalable solution (see Figure 20; Dam, 2022).

Figure 20
Design Thinking Illustrated

Note. Adapted from “An Introduction to Design Thinking: Facilitators Guide,” by H. Plattner,
n.d. Institute of Design at Stanford.
(https://web.stanford.edu/~mshanks/MichaelShanks/files/509554.pdf).

216

For purposes of this study, I adapted the design for equity in higher education for the
healthcare organization, emphasizing the expansion of the design thinking model to include
“equity-minded practices” that address “identity, power, and values” (Culver et al., 2021, p. 5).
The building of relational trust occurs in the team through acknowledging and addressing aspects
of power, positionality, identity, and values (Culver et al., 2021). The design thinking model was
expanded to encompass eight steps that comprised the design for equity model. These eight steps
included: organize, empathize, (re)define, ideate, choose, prototype, get buy in, and test through
a cycle of evaluation and refinement incorporating user interaction like the original design
thinking model (Culver et al., 2021). The design for equity model adds three additional steps to
promote equity: organize, choose, and get buy in. The addition of the organize step in the model
allows for intentional team formation that encompasses inclusion and representation, being
mindful of the stakeholder groups that are impacted or will be engaged in the work. An
additional aspect of the organize step connects to “political will” in the organization and focuses
on fostering “commitment” and “investment” (Culver et al., 2021, p. 8) in the work. The second
added step in the design for equity model is choose. During choose, emphasis is placed on how
ideas are selected to move into prototyping in the choose step, which gives voice to different
perspectives to select the ideas to move forward. The third additional step in the design for
equity model is get buy in, which represents the negotiation that occurs between stakeholders to
come to alignment on which prototypes will be tested. These three additional steps added into the
design for equity model demonstrate the ability for the different stakeholders to have a voice and
build greater perspectives into the design (see Figure 21).

217

Figure 21
Design for Equity Change Model Illustrated

Note. The additional steps in the model are indicated in purple. Adapted from “Design for Equity
in Higher Education,” by K. C. Culver, J. Harper, and A. Kezar, 2021, Pullias Center for Higher
Education, University of Southern California. (https://pullias.usc.edu/download/design-for-
equity-in-higher-education/).

Leveraging design thinking for equity in implementation of each recommendation will
allow for open and honest conversations and feedback on the specific design and implementation
strategies. The use of design thinking for equity acknowledges potential researcher bias and
power dynamics and engages people impacted to have a say in the work that will be done. Using
this change theory guided the recommendation development and implementation to allow for a
greater ability in meeting middle managers where they are to best address their needs.
218

Limitations and Delimitations
Research studies are influenced by limitations and delimitations, and it is imperative for
researchers to understands them and acknowledge them in the study. Limitations are outside the
researcher’s control and delimitations are choices in the researcher’s control. I identified several
limitations that may have had influence on this research study:
• Participants may have had self-selection bias, given they were purposefully recruited
through emails and could opt not to respond or participate.
• The research had limited ability to influence the straightforwardness and truthfulness
of participants in their responses to the interview questions.
• Given that I was a member of the study organization, there may be limitations to how
transparent participants may have been in interviews.
• Given that I was a member of the larger nursing department who led a team in
process improvement and project management, participants may have been
expressing their need for certain resources to align with my current sphere of control.
• There may have been barriers in the ability for participants to make connections to
study focused on terms of role quality improvement and change. I provided
definitions and examples to help facilitate understanding, but this may have still been
a barrier.
• A reorganization occurred in the nursing department a few weeks before I conducted
study interviews; the interviewee perspectives may have been influenced by these
changes in structure and job descriptions.

219

I also identified several delimitations:
• Achievement of a typical participant sample to meet the purposeful sample
requirements for the study; ultimately, participants had to self-select to participate.
• I recruited through purposeful sampling, which may exclude certain members.
• The research study was conducted in a single healthcare organization, which may
have unique implications and may not be generalizable or relatable to the larger field.
Recommendations for Future Research
Further research is needed to learn more about specific skills and competencies
healthcare middle managers need to be successful. This research would need to include a larger
approach by understanding not only individual middle manager needs, but also expectations
from the larger organization. The larger organizational perspective would include leadership,
ancillary teams, peers, and direct reports. It would also be interesting to engage with academic
institutions and professional organizations that have the perspective of education focused on
leadership, quality improvement, and change management skills and competency development.
Because this study was conducted at a single healthcare site in California, it captured
only a small subset of middle manager perspectives. This study captured the uniqueness of being
a manager in California, the only state with state-mandated ratios, which results in a higher
middle manager span of control and additional complexities with labor unions. Future studies
should include multiple sites across multiple states to gain additional perspective of the nursing
middle manager role. Additional studies could also include exploring the middle manager role
across healthcare organizations to identify larger implications for leadership skills and
competencies. It would also be interesting to explore how the perception of the struggles of the
middle manager role impacted succession planning and the ability to fill the middle manager
220

role. These larger perspectives would allow for more information on an enterprise approach to
change and sustainment that could inform future interventions.
Conclusion
With this qualitative study, I set out to understand the struggles healthcare middle
managers experience while trying to balance daily operations with advancing organizational
strategies and goals. Literature and study findings demonstrated middle managers’ abilities to
implement and sustain change is complicated by a difficult transition into leadership and barriers
that inhibit progress. Middle managers truly keep work moving as additional competing
priorities are added onto their already long list of responsibilities. Even with competing
priorities, they take responsibility for being the connection for frontline staff to upper leadership
and many different aspects of the organization.
The biggest finding that resulted from this study was the overwhelming sense of
obligation each middle manager brought in being supportive of frontline staff and representing
their interests in the larger organizational perspective. All study participants voiced their
responsibility and commitment to frontline staff. The recommendations contained in this
dissertation study are aimed at bringing the same sense of responsibility and level of
commitment and support to middle managers in the work they are responsible for accomplishing.
221

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Appendix A: Protocols
The study interview protocol was guided by the following research questions (RQs):
1. How do middle managers perceive their ability to facilitate change to achieve
outcomes?
2. What skills/competencies do middle managers identify as key to role success and in
sustaining change?
3. What are foundational elements of leadership support organizations need to provide
for middle managers to be successful in achieving sustainable change?
Respondent Type
Individuals in the healthcare middle manager role as demonstrated by the study
organization’s nursing department nurse managers and senior nurse managers/directors. Table
A1 illustrates criteria to select interview participants.

Table A1
Interview Participant Selection Criteria
Selection criteria
Distribution in middle management roles 7–10 nurse managers
3–5 senior nurse managers/directors
Service line distribution Inpatient participants
Outpatient participants
Clinical network site participants
Years of experience as middle manager Minimum of 1 year in the position

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Consent to Participate in Study
This dissertation study is focused on the role of middle managers. You will be asked to
participate in an interactive interview with Amy Altomare. The study has been designed to keep
your responses confidential with no direct identifiers tied to you; all information collected will be
for study purposes only and data collected may be reported in a de-identified way in sharing the
results at an aggregate level. You may withdraw from participation at any time without
consequences or refuse to answer questions if so needed. You may withdraw your consent at any
time and discontinue participation without penalty.
• Name:
• Email:
• Do you consent to participate in this study? Yes or No
Introduction to the Interview
Thank you for agreeing to participate in my interview study. I really appreciate you
taking time in your day to answer my questions. As I mentioned in my email, the interview
should take no more than an hour. Does this time still work for you?
Just to go over a few things before we get started. This interview is a part of my
dissertation study for my EdD in Organizational Change and Leadership program through
Rossier School of Education at USC. I am focusing my work on the role of middle managers in
healthcare. I want to assure you that this interview and your responses are confidential and today
I am a researcher and not the program director. My only goal is to learn from you and not make
any judgments. Your responses will be held in confidence, and I will not share or use your name
or unique identifiers in any of my research; however, phrases/quotes from this interview may be
reported in a de-identified way in sharing the results at an aggregate level. All information
246

collected will be password protected and stored in a secure environment. We will destroy any
notes and records after we have completed our study and disseminated the results.
Thank you for completing the questionnaire. If you do not have any concerns, I would
like to record this interview for notetaking and analysis purposes. Do I have your permission to
record this session? Please know, you can ask me to stop the recording at any point where you
feel uncomfortable. Do you have any questions before we begin? Let’s get started. Table A2
exhibits the semistructured interview questions.

Table A2
Study Interview Questions With Associated Concepts and Question Types
Interview question Potential probe
RQ
addressed
Key concept
addressed
Q type
(Patton)
What is your current
position?
– – Demographics Background
What is the highest level
of education you have
achieved?
– – Demographics Background
How many years of
experience do you
have in management?
– – Demographics Background
What kind of
educational courses or
trainings have you
had in quality
improvement?
As a part of school,
work, online,
informal?
RQ3 Demographics Background
What kind of
educational courses or
trainings have you
had in change
management?
As a part of school,
work, online,
informal?
RQ3 Demographics Background
What process
improvement or
improvement or
professional
development type
Where was it
conducted? (or
through who?)
What was the
content?
RQ3 Leadership
development
and support
Background
247

Interview question Potential probe
RQ
addressed
Key concept
addressed
Q type
(Patton)
courses have you
participated in?
What was the
knowledge
gained?
How did it make
you feel?
What did you bring
back to your
work?
How do you describe
your role and
responsibilities in the
organization?
Ask about activities
they regularly
participate in at
the organization.
What is your role in
the management
team?
What do they feel
they are solely
responsible for?
Do they share any
duties?
RQ2 Role
identification
Change as part of
role
Background
What would you say is
the most important
part of your role?
Why?
Do you feel
prepared to do
that?
RQ2 Role
identification
Change as part of
role
Opinion
How do you define
success in your role?
What do you see as
key to your
success?
RQ2 Knowledge
Motivation
Opinion
What barriers do you
face in your role?
How do you
typically resolve
barriers you
encounter?
RQ2 Knowledge
Motivation
Opinion
Describe your approach
to solving problems
on your
unit/department.
Who is involved?
What tools do you
use?
RQ1 Role in change
initiatives
Skills/capabilities
Knowledge
Share about a time when
a change or
implementation was
successful.
What was the
change?
When was this
change?
What was your
role?
How were you
involved?
How did you feel?
RQ1 Success in
outcomes
Experience
Feeling
248

Interview question Potential probe
RQ
addressed
Key concept
addressed
Q type
(Patton)
Share about a time
where a change was
not successful.
What was the
change?
When was this
change?
What was your
role?
How were you
involved?
How did you feel?
RQ1 Success in
outcomes
Experience
Feeling
What barriers do you
find in implementing
change?
How do you
typically resolve
barriers you
encounter?
RQ1
Motivation
Success in
outcomes
Organizational
support
Opinion
On a scale of 1 =
strongly disagree to 5
= strongly agree, how
much do you agree
with the statement
that nurses play an
important role in a
hospital’s quality
improvement efforts.
Why?
RQ1
Role in change
initiatives
Opinion
On a scale of 1 =
strongly disagree to 5
= strongly agree, QI
initiatives/projects are
important for
improving patient
outcomes.
Why?
RQ1
Success in
outcomes
Experience
On a scale of 1 =
strongly disagree to 5
= strongly agree, I am
confident in my
ability to develop a QI
project.
Why?
RQ1 Knowledge Experience
What does support look
like to you?
How do you think
you would benefit
from this
support?
Do you think this
support would
help remove
barriers?
RQ3
Leadership
development
and support
Feeling
249

Interview question Potential probe
RQ
addressed
Key concept
addressed
Q type
(Patton)
What resources do you
need to be successful?
Why would _____
help you be
successful?
RQ3
Leadership
development
and support
Opinion
What would you tell
yourself if you could
go back to your first
week as a manager?
What would you tell
a new manager
just starting?
RQ1
Leadership
development
and support
Emotion

Conclusion to the Interview
Thank you again for taking the time today to allow me to ask you questions. Your
interview is valuable to my research, and I appreciate your willingness to participate. Thank you
and have a good day.

Abstract (if available)

Abstract This qualitative study sought to identify a healthcare middle managers’ role in change and the healthcare organization’s ability to develop leadership and change competencies for their success in achieving sustainable outcomes. A dual conceptual framework guided the study, including the knowledge-motivation-organization gap analysis combined with social cognitive theory to understand both the organization and individual perspectives. The focus of this study was to identify the needs of the middle manager role so the organization can meet them where they are and provide opportunities for development. Semistructured interviews and secondary data were leveraged to gain understanding into the role and responsibilities of the healthcare middle managers, barriers they encounter, and elements needed for success in role and sustaining change. Several findings emerged that indicate healthcare middle managers’ competing priorities, struggles with resolving barriers, and need of directed support and assistance for their success. Recommendations are presented to establish organizational structure for the healthcare middle manager to develop skills and competencies to support change implementation and the sustainment of outcomes.

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Asset Metadata

Creator Altomare, Amy Elisabeth (author)

Core Title Middle management’s struggle to sustain change: perspectives of the middle management team in nursing

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Degree Conferral Date 2022-12

Publication Date 12/14/2022

Defense Date 12/05/2022

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

Tag Change,change management,Environment,gap analysis,healthcare middle manager,KMO,Knowledge,leadership development,Motivation,OAI-PMH Harvest,quality improvement,social cognitive theory.

Format theses (aat)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Spann, Rufus Tony (committee chair), Kim, Esther (committee member), O’Leary, Colleen (committee member)

Creator Email aaltomare@gmail.com,aealtoma@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC112620888

Unique identifier UC112620888

Identifier etd-AltomareAm-11375.pdf (filename)

Legacy Identifier etd-AltomareAm-11375

Document Type Dissertation

Format theses (aat)

Rights Altomare, Amy Elisabeth

Internet Media Type application/pdf

Type texts

Source 20221214-usctheses-batch-997 (batch), University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

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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 cisadmin@lib.usc.edu