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Improving exempt nurse leader work-life balance: an innovation study

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Improving exempt nurse leader work-life balance: an innovation study

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IMPROVING EXEMPT NURSE LEADER WORK-LIFE BALANCE:
AN INNOVATION STUDY
by
Shelly Hicks

A Dissertation Presented to the
FACULTY OF THE USC ROSSIER SCHOOL OF EDUCATION
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF EDUCATION

August 2020

Copyright 2020 Shelly Hicks

ii

DEDICATION
It is my honor to dedicate this dissertation to exempt nurse leaders everywhere, especially
the nurse leaders who participated in this study. Having firsthand experience to the absolutely
overwhelming responsibility inherent in the position, I commend every nurse who steps into the
leader role. Please remember to put your oxygen mask on first.

iii

ACKNOWLEDGEMENTS
I want to thank the many professors and support personnel in the USC community for
making this a rich, student centered, learning experience. Several professors along the way
(notably…Dr. Maddox, Dr. Ott, Dr. Cash, Dr. Canny, and Dr. Lynch) have been outstanding and
taught me a great deal not only about the topic at hand, but also how to support, challenge and
inspire students in the academic realm.
I also want to acknowledge my dissertation committee, Dr. Yates, Dr. Sparangis, and Dr.
Andres. Thank you for your valuable feedback and guidance on my work, and your time to
serve on my committee. Especially, my chair Dr. Yates! Dr. Yates, you were outstanding, and I
could not have asked for a more supportive guide during this process. You worked tirelessly to
attend to each of your students, made sure I had what I needed, and tolerated early morning
meetings and my never-ending questions. You were an absolute ASSET (KMO joke)!
I want to acknowledge Cohort X. I am so proud to have shared this adventure with you!
Some of you will be my friends for life and I wish so many great things for each of you.
Finally, I want to acknowledge my support system outside of USC. Thank you to my
husband Dawson for his enduring support of my academic pursuits. Thank you for
understanding how important this was to me. Dr. Trisha Saul, this experience would not have
been as rewarding without you. So thrilled to have gone through this journey side by side.
Thank you to Colleen Wilcoxen. An inspirational nursing leader and my first supervisor as I
stepped into the leader role. Thank you for believing in me. Thank you to my friends far and
wide, especially Dr. Julie Rawls White for encouraging me and keeping me humble. Lastly, I
am grateful to God for all blessings bestowed upon me.

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TABLE OF CONTENTS
Dedication ....................................................................................................................................... ii
Acknowledgements ........................................................................................................................ iii
Table of Contents ........................................................................................................................... iv
List of Tables ...................................................................................................................................x
List of Figures ................................................................................................................................ xi
Abstract ......................................................................................................................................... xii
Chapter 1: INTRODUCTION..........................................................................................................1
Introduction to the Problem of Practice ...............................................................................1
Organizational Context and Mission ...................................................................................3
Organizational Performance Status and Need .....................................................................5
Related Literature.................................................................................................................6
Importance of the Organizational Innovation ......................................................................7
Organizational Performance Goal ........................................................................................8
Description of Stakeholder Groups ......................................................................................8
Stakeholders’ Group Performance Goals.............................................................................9
Stakeholder Group for the Study .......................................................................................10
Purpose of the Project and Questions ................................................................................11
Methodological Framework ...............................................................................................11
Definitions..........................................................................................................................11
Organization of the Study ..................................................................................................12

Chapter 2: REVIEW OF THE LITERATURE ..............................................................................13
Overview of Work-Life Balance .......................................................................................13
Current Construct of Work-Life Balance ..............................................................15
Current Construct of Work-Life Balance in Nursing ................................16
Influences for Work-Life Balance for the Nurse Leader .......................................18
Workload....................................................................................................20
Exempt Status ............................................................................................22
Role of Technology....................................................................................23
The Construct of Burnout ..................................................................................................26
The Clark and Estes Gap Analysis Conceptual Framework ..............................................29
Stakeholder Knowledge, Motivation, and Organizational Influences ...............................31
Knowledge and Skills ............................................................................................32
Exempt Nurse Leaders Need to Define Work-Life Balance .....................32
Exempt Nurse Leaders Need to Understand the Concepts of Work-Life
Balance ...........................................................................................33
Exempt Nurse Leaders Need Knowledge of the Steps to Work-Life
Balance ...........................................................................................34

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Exempt Nurse Leaders Need Knowledge of How Work-Life Balance
Applies to Self................................................................................34
Motivation ..............................................................................................................37
Expectancy Value Motivational .................................................................38
Self-Efficacy ..............................................................................................39
Goal Orientation.........................................................................................40
Organization ...........................................................................................................42
Stakeholder Specific Factors......................................................................42
Cultural Setting: Resources to Meet Demands .............................43
Cultural Setting: Culture of Communication ................................44
Cultural Setting: ENL Expectations ..............................................46
Cultural Model: Focus on Meaningful Work................................47
Cultural Model: Culture of Psychological Safety .........................48
Cultural Model: Positive Work Environment ...............................49
Conceptual Framework: Interaction of Knowledge, Motivation, Organization ....52
Conclusion .............................................................................................................56

Chapter 3: METHODOLOGY .......................................................................................................58
Introduction to the Methodology .......................................................................................58
Participating Stakeholders .................................................................................................58
Sampling Criteria and Rationale ............................................................................59
Criterion 1. Permanent Employment .........................................................59
Criterion 2. Official Titles..........................................................................59
Criterion 3. Tenure .....................................................................................60
Interview Sampling (Recruitment) Strategy and Rationale ...................................60
Observation Sampling (Access) Strategy and Rationale .......................................60
Document Criteria and Rationale...........................................................................61
Criterion 1. Approved by Organization .....................................................61
Criterion 2. Current Documents .................................................................61
Qualitative Data Collection and Instrumentation ..............................................................62
Interviews ...............................................................................................................63
Observations ..........................................................................................................65
Documents .............................................................................................................66
Alignment of the KMO Influences and Data Collection ...................................................67
Data Analysis .....................................................................................................................72
Trustworthiness and Credibility .........................................................................................73
Trustworthiness ......................................................................................................73
Biases .........................................................................................................73
Reflexivity..................................................................................................74
Credibility ..............................................................................................................74
Triangulation ..............................................................................................74
Including Divergent Data ...........................................................................75
Ethics..................................................................................................................................75

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Chapter 4: RESULTS AND FINDINGS .......................................................................................79
Participating Stakeholders .................................................................................................79
Determination of Assets and Needs ...................................................................................80
Results and Findings for Knowledge Causes.....................................................................81
Factual Knowledge ................................................................................................81
Conceptual Knowledge ..........................................................................................82
Procedural Knowledge ...........................................................................................84
Metacognitive Knowledge .....................................................................................86
Results and Findings for Motivational Causes ..................................................................87
Expectancy Value ..................................................................................................87
Self-Efficacy ..........................................................................................................89
Goal Orientation – Mastery ...................................................................................92
Results and Findings for Organizational Causes ...............................................................95
Cultural Settings.....................................................................................................95
Cultural Models ...................................................................................................103
Results and Findings for Influences Not Previously Categorized ...................................112
Guilt .....................................................................................................................112
Competition..........................................................................................................112
Summary of Validated Influences ...................................................................................113
Conclusion .......................................................................................................................115

Chapter 5: DISCUSSION AND RECOMMENDATIONS .........................................................117
Organizational Context and Mission ...............................................................................117
Organizational Performance Goal ....................................................................................118
Stakeholder Group for the Study .....................................................................................118
Purpose of the Project and Research Questions ...............................................................119
Recommendations to Address KMO Influences ..............................................................120
Knowledge Recommendations ............................................................................120
Motivation Recommendations .............................................................................128
Organization Recommendations ..........................................................................133
Integrated Implementation and Evaluation Plan ..............................................................143
Implementation and Evaluation Framework ........................................................143
Organizational Purpose, Need, and Expectations ................................................143
Level Four: Results and Leading Indicators ........................................................145
Level Three: Critical Behaviors ..........................................................................146
Required Drivers ......................................................................................147
Organizational Support ............................................................................149
Level Two: Learning Goals .................................................................................149
Guided Experience ...................................................................................150
Evaluation of the Components of Learning .............................................151
Level One: Reaction ............................................................................................153
Evaluation Tools ..................................................................................................154
During and immediately following the program implementation ...........154
Delayed for a period after the program implementation ..........................154
Data Analysis and Reporting ...............................................................................154
Chapter Summary ............................................................................................................155

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Strengths and Weaknesses of the Approach ....................................................................157
Limitations and Delimitations ..........................................................................................157
Future Research ...............................................................................................................158
Conclusion .......................................................................................................................160
References ........................................................................................................................162
Appendices .......................................................................................................................178
Appendix A Recruitment Letter ............................................................................178
Appendix B Interview Questions ..........................................................................179
Appendix C Observation and Document Checklist ..............................................184
Appendix D Immediate Post-Workshop Evaluation.............................................188
Appendix E Blended (Delayed) Evaluation for Work-Life Balance Guided
Experience....................................................................................................190

x

LIST OF TABLES
Table 1 Organizational Goal and Stakeholder Performance Goals ................................................9
Table 2 Assumed Knowledge Influences, Knowledge Type, and Knowledge Assessment .........36
Table 3 Assumed Motivation Influences and Motivational Assessment ......................................41
Table 4 Assumed Organization Influences and Organizational Assessment................................51
Table 5 Alignment of the KMO Influences and Methods of Data Collection ..............................67
Table 6 Number of Direct Reports per ENL Participant ..............................................................95
Table 7 Assumed Knowledge Assets or Needs as Determined by the Data ...............................112
Table 8 Assumed Motivation Assets or Needs as Determined by the Data ...............................113
Table 9 Assumed Organization Assets or Needs as Determined by the Data ............................113
Table 10 Additional Influences Assets or Needs as Determined by the Data ............................114
Table 11 Summary of Assumed Knowledge Influences and Recommendations .......................120
Table 12 Summary of Assumed Motivation Influences and Recommendations ........................127
Table 13 Summary of Assumed Organization Influences and Recommendations .....................134
Table 14 Outcomes, Metrics, and Methods for External and Internal Outcomes .......................146
Table 15 Critical Behaviors, Metrics, Methods, and Timing for Evaluation .............................147
Table 16 Required Drivers to Support Critical Behaviors ..........................................................148
Table 17 Evaluation of the Components of Learning for the Program .......................................153
Table 18 Components to Measure Reactions to the Program .....................................................154

xi

LIST OF FIGURES
Figure 1 Interaction of Stakeholder Knowledge and Motivation within Organizational Culture
Models and Settings ...........................................................................................................54
Figure 2 ENL Selection of Work-Life Balance Influences ..........................................................82
Figure 3 Self-Efficacy and Work-Life Balance Influencers .........................................................90
Figure 4 Level 4 Internal Outcomes Over Time .........................................................................156

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ABSTRACT
This study applies a combination of learning, motivational, and organizational theories
with the application of the Clark and Estes (2008) gap analysis framework to understand exempt
nurse leader (ENL) work-life balance. The purpose of this project was to identify the
knowledge, motivation, and organizational assets and needs influencing the ENL ability to
maintain work-life balance considering the workload and design of the position. With a
qualitative design, this study included a vast literature review, and triangulated data from 10
interviews, 74 observations, and 32 organizational documents. The literature review identified
15 knowledge, motivation, and organizational influences pertinent to work-life balance.
Analysis of the data revealed that 12 influences emerged as needs, and subsequently illuminated
the necessity for individuals and organizations to work together to positively influence this
problem of practice. Key points from the data analysis recognized the need for procedural and
metacognitive development, self-efficacy, resource management, meaningful work, compatible
expectations, and psychological safety. Based on the findings, and in conjunction with the
literature, this project recommends the creation of, and on-going support for, a comprehensive
work-life balance guided experience to provide individual and organizational support for ENLs
to navigate and thrive in the dynamic terrain of nursing leadership. The Kirkpatrick and
Kirkpatrick New World Model (2016) was utilized in the development of recommendations and
evaluation mechanisms. This study helps to inform how individuals, who work in health care,
and other critical services, especially in leadership positions, can move toward a balance of their
work and personal life.
Keywords: work-life balance, nurse leader, burnout, psychological safety, meaningful work

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CHAPTER 1: INTRODUCTION
Introduction of the Problem of Practice
Hospitals are under tremendous pressure to deliver safe patient care and reduce costs, all
while attracting and retaining the best talent from all caregiver groups. One such group, the
exempt nurse leaders (ENL), has been identified as one of the most influential and pivotal
positions within the hospital organizational chart (Buchanan, Parry, Gascoigne, & Moore, 2013;
Shirey, McDaniel, Ebright, Fisher, & Doebbeling, 2010; Warshawsky & Havens, 2014). These
ENLs supervise front-line caregivers, manage clinical care areas 24 hours a day, and serve the
larger hospital through committees, projects, and the all-inclusive, other duties as assigned
(Loveridge, 2017; Nelson, 2017). The vast literature agrees that the overburden of
responsibilities, including the accountability for the health of the work environment is leading to
disengagement, stress, burnout, and attrition for the ENL (Buchanan et al., 2013; Heeb &
Haberey-Knuessi, 2014; Judkins, Massey, & Huff, 2006; Shirey, 2006; Udod, Cummings, Care,
& Jenkins, 2017). While this problem has been recognized, little has been done to correct it as
evidence highlights hospitals are not responding to the guiding principles set forth by the
American Organization of Nurse Executives (AONE) (2018), to nourish retention, balance job
demands and resources, promote job enjoyment, and foster the work-life balance of the nurse
leader (Buchanan et al., 2013; Heeb & Haberey-Knuessi, 2014; Loveridge, 2017; Middaugh, &
Willis, 2018; Nelson, 2017; Steege, Pinekenstein, Knudsen, & Rainbow, 2017).
Previous studies have shown that situations at work such as work-life imbalance, role
conflict, and work overload lead to stress (Bakker & Costa, 2014; Buchanan et al., 2013; Frone,
2003; Kravits, McAllister-Black, Grant, & Kirk, 2010). It has also been shown that chronic
stress is a contributor to burnout (Bakker & Costa, 2014; Kath, Stichler, Ehrhart, & Sievers,

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2013; Maslach, Schaufeli, & Leiter, 2001). The problem of practice examined by this study is
the struggle for ENLs to achieve work-life balance considering their workload and the design of
their position.
The healthcare culture supports over-functioning to accomplish unrealistic expectations,
which leads to ENLs working more than 14 hours a day in addition to having after-hours
responsibility for their area (Rudan, 2002). The ENLs, sandwiched between their clinical direct
reports and the operational executive leadership team of the hospital, are expected to meet the
demands of their supervisors during the day, while nights and weekends are spent meeting
demands of their clinical team. The literature identifies three main variables affecting work-life
balance for the nurse leader: work overload, exempt status, and use of technology (Kath et al.,
2013; Sullivan, 2014). If this problem of practice is not addressed consequences will continue.
Turnover in the ENL role is higher than any other hospital senior leader and is expected
to increase (Loveridge, 2017). Furthermore, the cost of replacing an ENL is high and worse, the
damage done to a clinical unit, and hospital overall, if ENLs continue to model work-life
imbalance is extensive. Burnout is contagious, and the nurses currently working under an
overwhelmed nurse leader are not interested in the stress and work-life imbalance that comes
with the leader position (Chullin, 2014; Shirey, Ebright, & McDaniel, 2008; Shirey et al., 2010;
Spence Laschinger, Purdy, Cho, & Almost, 2006). It is challenging to succession plan when
staff nurses, our millennial future, are less interested in leadership positions due to the work-life
imbalance inherent in the position (Hewko, Brown, Fraser, Wong, & Cummings, 2015; Spence
Laschinger, Wong, Macdonald-Rencz, Burkoski, Cummings, D’amour, & Grau, 2013; Wong,
Spence Laschinger, Macdonald-Rencz, Burkoski, Cummings, D’amour, & Grau, 2013). These

3

variables, as well as the history of work-life balance and burnout, and the consequences of
allowing this problem of practice to fester will be explored in Chapter 2.
Organizational Context and Mission
Pacific Healthcare (a pseudonym; PH) is a national, ministry inspired, not-for-profit
healthcare system. In addition to more than 50 traditional hospitals, PH also operates long-term
care facilities, home health care, hospice services, physician offices, urgent care centers, as well
as a high school and a full-service university (Pacific Healthcare, 2018). The mission and values
of PH is central to the work. The mission, ‘using God as our guide and through the ministry of
Jesus, we will persevere to serve all people in need, regardless of situation’, inspires our
caregivers to actualize the sentiment and give it meaning (Pacific Healthcare, 2018). Caregivers
within PH look for creative ways and participate in community events to make sure all
community members have access to affordable healthcare. A central part of the mission is
‘giving back’ and therefore, in 2017, PH gave back nearly $200 million dollars to fund free
clinics, outreach programs, and pro bono work to the communities they serve (Pacific
Healthcare, 2018). In addition to the mission, PH is committed to core values that underscore all
caregiving activities. The values guide daily behavior and serve as a prescription for how to treat
others and valuable resources. Humanity, honor, equity, quality, and honesty are lived out each
day through the actions of the caregivers (Pacific Healthcare, 2018). These values not only help
to best serve patients and community members, but also help to recruit and retain talented
caregivers. Truly a place of healing, caregivers speak to what they do, how they do it, and why.
Caregivers within PH proclaim they provide healthcare to patients in need, with the core values
in mind, because healthcare is a human right.

4

Southern

and Western Hospitals (a pseudonym; SWH), is the setting for this study. SWH
are sister hospitals within PH. SWH are in the western half of the United States, set in the
suburbs of a major urban city, and are accessible by several highways and public transportation.
Southern Hospital was founded in the early 1900s and has served its community without
interruption for almost 100 years (Southern Hospital, 2018). Southern Hospital (2018)

is a mid-
sized, community hospital with more than 350 beds, and employs more than 1150 caregivers.
All employees at this hospital are considered caregivers in that all who work here are serving the
patient in some capacity. These caregivers come from the surrounding areas which are urban
and suburban. Southern Hospital is in a community of nearly 100,000 people with the median
age in the mid-30s, 68% are married, and 33% are college educated (United States Census
Bureau, 2018). The surrounding community is working class with an average household yearly
income of $60,000. Unfortunately, this community has a relatively high poverty level at 21%
(United States Census Bureau, 2018). The community this hospital serves is rich in history and
traditions and is considered highly ethnically diverse with large populations of Italian, Latino,
Croatian, and Norwegian inhabitants.
Western Hospital, founded in the mid-1900’s, is also a mid-sized community hospital.
This hospital offers many specialized functions and routinely wins awards for service. The
hospital employs more than 2000 caregivers to care for patients in more than 400 beds (Western
Hospital, 2018). The community surrounding Western Hospital has more than 150,000 people,
with the median age in the mid-40’s (United States Census Bureau, 2018). This community is
predominantly White and Asian, and most households do not have children (United States
Census Bureau, 2018). The surrounding community is working class, with roughly 50% having
a 4-year college degree and 50% owning their own home (United States Census Bureau, 2018).

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Organizational Performance Status and Need
SWH currently does not measure work-life balance for the exempt nurse leaders (ENL).
Instead, every two years, they administer a survey tool from an internationally recognized
advisory firm which collects data on engagement, burnout, and empowerment from all
caregivers. They also actively monitor turnover of caregiver staff, focusing on those who leave
within the first year of employment. Action plans are created to address engagement, burnout,
and risk of attrition for the general population of registered nurses (RNs). However, no
specialized plan is in place to assist the ENLs with their engagement, burnout, risk of turnover,
or work-life imbalance. SWH is missing an opportunity to care for the caregivers in the most
influential and pivotal positions in the hospital. Failure to care for the ENLs will result in
attrition, or worse, lingering burnout.
Work-life balance was chosen for this study for three main reasons, the prevalence of the
work-life balance topic in the current literature, the link between work-life imbalance, stress, and
burnout, and finally, the informal data ascertained within the organizational culture that ENLs
are struggling with work-life imbalance. Chapter 2 of this dissertation will discuss the current
literature of work-life balance in the general context, and more specifically in the nursing
leadership population. This study aims to turn the informal data ascertained within the
organizational culture that ENLs are struggling with work-life balance into sound research data
which will illuminate this study.
As mentioned earlier, SWH does not currently have a work-life balance program, so this
innovative dissertation project hopes to fill the gap and achieve the goal of a work-life balance
program in place and operational by May of 2021. Furthermore, this study will address another
need that exists within the nursing leadership population. Most often, studies are conducted with

6

the general nursing population, or specific factions of nursing, such as emergency department
nurses, or critical care nurses. Missing from the conversation are rigorous studies about the
nursing leadership population. This study hopes to fill a bit of that literature gap and offer a look
into the world of ENLs and their experience with work-life balance.
Related Literature
While popular in scholarly literature for the past several decades, the construct of work-
life balance has been discussed since Kellogg adjusted working hours in the 1930’s to increase
morale (Arenofsky, 2017; Casper, Vaziri, Wayne, DeHauw, & Greenhaus, 2018; Clark, 2000;
Frone, 2003; Greenhaus, Collins, & Shaw, 2003; Parris, Vickers, & Wilkes, 2008; Sullivan,
2014). Since that time we have seen the women’s liberation movement, organizational
implementation of family benefits, and the evolution of work ethic influence the construct of
work-life balance (Arenofsky, 2017). In more recent exploration, work-life balance has been
examined using a variety of theories, such as Polarity Management (Johnson, 1998), Job
Demands-Resources Model (Demerouti, Bakker, Nachreiner, & Schaufeli, 2001), Boundary
Theory (Bulger, Matthews, & Hoffman, 2007), and Congruence Theory (Frone, 2003; Schultz &
Higbee, 2010).
Work-life balance remains an important topic today as organizations, especially
healthcare, are restructuring and thinning leadership roles (Parris et al., 2008). Exempt nurse
leaders are struggling to accomplish all that is expected within a reasonable workday. This
structural realignment has given ENLs additional areas of oversight, increased numbers of direct
reports, and limited supportive resources (Loveridge, 2017; Nelson, 2017; Shirey et al., 2010).
Nelson (2017) maintains the more direct reports a nurse leader has the more likely they are to
vacate the position due to poor job satisfaction and stress. Furthermore, Loveridge (2017)

7

acknowledges the nurse leaders in her study experienced stress and fatigue from the continued
onslaught of new initiatives. This overall increase in workload is cited in the literature as a
prominent reason ENLs are suffering from work-life imbalance which leads to stress, and
ultimately burnout (Parris et al., 2008). Other contributing factors to work-life balance in the
literature are exempt status and increasing use of technology (Parris et al., 2008; Sullivan, 2014).
Chapter 2 will go into greater detail on these factors as well as trends seen with the work-life
balance construct and challenges that remain to solving the problem.
Importance of the Organizational Innovation
It is important for SWH to solve this problem of practice for a variety of reasons. Current
literature highlights three main reasons organizations should partner with the ENLs to establish
work-life balance programs. First, when nurse leaders are burnt out due to work-life imbalance
the healthcare environment is negatively affected (Warshawsky & Havens, 2014). The stress the
ENL feels from their work-life imbalance will transfer to their staffs and lead to increased stress
for the nursing staff, increased nursing turnover, and ultimately negatively affect patient care
(Janet, 2014). Second, the transfer of stress to the staff nurse makes it harder to succession plan
for the leadership position. The current charge nurses, often millennials and often who we look
to advance, are not interested in long hours, interrupted personal time, or inflexible schedules
(Hewko et al., 2015; Spence Laschinger et al., 2013; Stichler, 2008; Wong, Laschinger,
Macdonald-Rencz, Burkoski, Cummings, D’amour, Grinspun, Gurnham, Huckstep, Leiter,
Perkin, MacPhee, Matthews, O’Brien-Pallas, Ritchie, Ruffolo, Vincent, Wilk, Almost, Purdy,
Daniels, & Grau, 2013). Finally, when ENLs leave the position due to stress and burnout
stemming from work-life imbalance, it is very costly for the hospital. Not only does knowledge

8

and experience leave with them, but it costs roughly 125% of the nurse leader salary to onboard a
replacement (Loveridge, 2017).
Organizational Performance Goal
By May of 2021, SWH will have in place and operational an innovative work-life
balance program geared toward retaining current and attracting future ENLs. This goal is
directly related to the mission and values in several ways. Serving the community is central to
the hospital mission and therefore serving the nurse leaders within, whom are also community
members, is mirrored in the mission. Each of the hospital values also speaks to overall health of
caregivers, including nurse leaders. Nurturing all aspects of each person, recognizing the worth
of each person, removing obstacles in the path of healing, improving the quality of life, and the
importance of always doing the right thing for the right reason; these sentiments are highlighted
in the values of SWH and are directly applicable for the ENLs struggling to maintain their own
health when work and life are out of balance.
Description of Stakeholder Groups
For the purposes of supporting the stanchion of growth and motivation of internal
caregivers, key stakeholders must be identified. Three key stakeholder groups have been
identified as holding interest in the achievement of the organizational goal created for this study.
Stakeholder group one is the current ENLs within the two hospitals. These leaders are Directors
(D), Nurse Managers (NM), Assistant Nurse Managers (ANM), and Clinical Supervisors (CS).
This group of roughly 45 professionals, is directly responsible for the day to day operations of
their patient care area and directly supervises front-line caregivers. Their positions are designed
with exempt status meaning they have no set work hours and are ultimately responsible for their
assigned areas 24-hours a day, seven days a week.

9

Stakeholder group two is current and future Charge Nurses at the two hospitals. The
Charge Nurse is a peer leader among the RNs and serves to help manage the daily clinical
activities of the unit alongside the ENLs. The Charge Nurses were chosen as the logical group
targeted for succession planning into the ENL role.
The third stakeholder group is the executive team within the two hospitals. This group
has a vested interest in the achievement of the goal as it may help to retain current ENLs. This
retention is desirable due to the important role ENLs play in the overall productivity of the
hospital as well as the cost involved in replacing ENLs should they be lost to work-life
imbalance and burnout. Table 1 shows stakeholder group goals related to the larger
organizational goal.
Stakeholder Groups Performance Goals
Table 1
Organizational Goal and Stakeholder Performance Goals
Organizational Goal
By May of 2021, Southern and Western Hospitals will have in place and operational an innovative
work-life balance program geared toward retaining current and attracting future ENLs.
Stakeholder Goals
ENL Charge Nurses Executive Team
By May of 2021, 50% of
stakeholder ENLs will
actualize this organizational
goal by enrolling into and
utilizing the innovative work-
life balance program.
By December of 2021, 25% of
Charge Nurses will be priority
candidates to succession plan
into the exempt nurse leader
role.
By December of 2020, 100%
of the Executive Team will
support the organizational goal
of creating an innovative work-
life balance program through
verbal and fiscal support.

10

Stakeholder Group for the Study
This research study has chosen to focus on only one stakeholder group for three reasons:
to narrow the focus, to give the goal the best chance for success, and to give back to the
community of ENLs. This study is specifically about work-life balance for the exempt nurse
leader, therefore the current ENLs are the stakeholder group of focus. While some research
projects attempt to gather data from several stakeholder groups, the author presumed that
strategy would dilute the data in this work. Work-life balance is a concept salient for most
people, and the other stakeholder groups, the executive team and charge nurses, will have their
own experiences with the concept. This study aims to narrow the focus and examine only the
ENL perspective.
The current ENLs are in the best position to actualize the goal of establishing a work-life
balance program. This group is best equipped to give detailed descriptions of knowledge,
motivational, and organizational influences affecting, and needs required, for the work-life
balance of the ENL. Once the ENL needs are known and addressed within the innovative work-
life balance program, the current ENLs will be vital to the success of the program through their
actualization of and demand for its continuance.
Finally, this stakeholder group was chosen to bring light to an otherwise overlooked
position and an often-diminished concern. ENLs, the middle children in the hospital
organizational chart, sandwiched between the executives and the front-line staff, do not often get
the positive recognition they deserve for the myriad of responsibilities they assume (Heeb &
Haberey-Knuessi, 2014). Additionally, the concern of work-life imbalance for this group is
pervasive, yet often minimized. Work-life imbalance for the ENL can be devastating not only to
the individual leader, but also to the entirety of the hospital.

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Purpose of the Project and Questions
The purpose of this research study is to facilitate a needs’ assessment in the areas of
knowledge and skill, motivation, and organizational resources required to reach the
organizational performance goal. The assessment will begin by creating a list of possible needs
and will then move to examining these systematically to focus on actual or validated needs. The
research questions that will guide this needs assessment are:
1. What are the knowledge, motivation, and organizational needs necessary for exempt
nurse leaders to achieve an innovative work-life balance program by May 2021?
2. What is the interaction between organizational culture and the exempt nurse leaders
knowledge and motivation to achieve an innovative work-life balance program?
3. What are the recommended knowledge, motivation, and organizational solutions to
those needs?
Methodological Framework
Employing Clark and Estes (2008) gap analysis framework will allow for a systematic
approach to help explain organizational performance goals and highlight any gap that exists
between actual and desired performance. Based upon related literature and intimate knowledge,
assumed knowledge, motivation, and organizational (KMO) needs will be identified. These
needs will then be authenticated using an extensive literature review, interviews, and subsequent
content analysis. Evidence-based solutions will be recommended, and comprehensive strategies
offered for both formative and summative evaluation.
Definitions
Front-line Caregiver: This employee provides direct patient care within their clinical area. This
employee may be an RN or may be a technician, aide, or therapy professional.

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Direct Report: This employee is supervised by the ENL.
Charge Nurse: The Charge Nurse is a peer leader among the RNs and serves to help manage the
daily clinical activities of the unit alongside the ENLs.
Work-life Balance: While acknowledging many definitions exist for this concept, for this study,
work-life balance is ‘regardless of marital or parental status, a satisfying balance of energy and
time is afforded to both professional and personal activities.’ This phrase will be used when
discussing the overall concept, and as a qualifier of work-life balance and work-life imbalance.
Burnout: A state of physical and/or mental exhaustion caused by overwork or stress.
Millennial: A demographic cohort born in the years 1981 through 2001. This cohort has strong
views on work and life balance, and therefore are of specific interest as the future of healthcare
leadership.
Organization of the Study
This study is organized into five chapters. Chapter 1 provides an overview of key
concepts and terminology related to work-life balance. Additionally, the first chapter covers
mission, goals, and stakeholders within the organization. Chapter 2 reviews current and relevant
literature and introduces the gap analysis framework utilized in the study. Chapter 3 explains the
methodology for the study and espouses on study participants, data collection, ethics, and
analysis. Furthermore, the chapter outlines the needs of the stakeholders and organization to
achieve the organizational goal. Chapter 4 analyzes the data and offers a robust discussion of the
findings. Chapter 5 considers the data alongside the literature and provides evidence-based
solutions for closing the performance gap. This chapter also offers recommendations for
formative and summative evaluation strategies of the innovative program.

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CHAPTER 2: REVIEW OF THE LITERATURE
This literature review will broadly explore the concept of work-life balance and then
narrow to focus on the concept within the nursing culture. A deep discussion on challenges to
achieving work-life balance for the exempt nurse leader (ENL) with specific analysis of pertinent
influences will be offered. This literature review will conclude with a synopsis of a potential
negative consequence of work-life imbalance: burnout. Following the literature review, a
summary of the Clark and Estes Gap Analysis Conceptual Framework (2008) is presented. This
literature section will conclude with knowledge, motivation, and organizational influences
affecting work-life balance of the ENL.
Overview of Work-Life Balance
The balance of work and life has emerged as an antecedent for health and wellness, and
conversely, burnout (Avgar, Givan, & Lui, 2011; Dyrbye, Shanafelt, Sinsky, Cipriano, Bhatt,
West, & Meyers, 2017; Greenblatt, 2002; Leiter, Day, Harvie, & Schaughnessy, 2007; Maslach
& Goldberg, 1998; Maslach & Schaufeli, 1993; Mullen, 2015; Peiro, Gonzales-Roma, Tordena,
& Manas, 2001; Rubino, Luksyte, Perry, & Volpone, 2009; Sanchez-Hernandez, Gonzales-
Lopez, Buenadicha-Mateos, & Tato-Jimenez, 2019). The story of work-life balance begins in
350 BCE with Aristotle writing in Nicomachean Ethics and Politics, that business and leisure are
the components of life (Arenofsky, 2017; Munn, 2013). In more recent history, several
developments have shaped employment, such as, the industrial revolution, the great depression,
the influx of women entering the workplace due to the world wars, and the myriad of laws, acts,
and bills developed to support and protect employee pay, schedules, and employment overall
(Arenofsky, 2017; Mellner, Aronsson, & Kecklund, 2014; Munn, 2013; Parris et al., 2008; Tariq,
Aslam, Siddique, & Tanveer, 2012). Specifically related to work-life balance we see the notion

14

of work ethic born in the early 1900’s, the Kellogg company first created alternate work shifts to
increase morale in the late 1930’s, and the term ”work-life balance” was first developed in
London, England in 1979 (Arenofsky, 2017; Munn; 2013). While an appreciation and
understanding for the historical significance of work-life balance is important, this review will
focus mainly on the growth of the concept within the past 50 years.
Since the concept was officially coined it has incorporated many variations on the theme.
Throughout the last 50 years, balance, integration, interface, alignment, conflict, harmony, well-
being, and work-life fitness have all been used to describe the process of managing the different
responsibilities inherent in our lives (Braun & Peus, 2018; Chang, McDonald, & Burton, 2010;
Greenhaus et al., 2003; Munn, 2013; Oates, 2018; Parkes, & Langford, 2008; Parris et al., 2008).
For the purposes of this study, the definition of work-life balance, cobbled from the wide work-
life balance literature, is, regardless of marital or parental status, a satisfying balance of energy
and time is afforded to both professional and personal activities. Even though the literature
acknowledges the concept of life incorporates work, when whatever we describe as work takes
the bulk of our time and energy so that there is very little left for the rest of life’s activities is
when we experience imbalance (Delecta, 2011; Greenhaus et al., 2003; Tariq et al., 2012). The
literature also acknowledges the growth of work-life balance research over the past several
decades (Chang et al., 2010; Mellner et al., 2014; Munn, 2013; Parkes & Langford, 2008; Tariq
et al., 2012). While methods, study participants, and industry all vary, the overwhelming
majority conclude that a balance between work and the rest of life is necessary for health and
well-being of individuals and families, as well as prosperity for organizations (Greenblatt, 2002;
Parkes & Langford, 2008; Sanchez-Hernandez et al., 2019; Tariq et al., 2012).

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Current Construct of Work-life Balance
The domain of work life balance has experienced an explosion in the literature and in
popular culture due to fundamental shifts in how we define, perform, and navigate our lives. The
advances in our work due to technology, portability, and market trends, plus the changes to the
family structures and responsibilities have shaped this conversation around balancing work and
life (Chang et al., 2010; Munn, 2013; Parkes & Langford, 2008; Tariq et al., 2012; Ueda, 2012).
Most organizations today find themselves doing more with less and this has greatly impacted the
workforce. Longer days, increased expectations, leaner budgets, and tighter timelines have
fueled the discourse on work-life balance (Bakhamis, Paul, Smith, & Coustasse, 2019; Holdren,
Paul, & Coustasse, 2015; Judkins et al., 2006; Mellner et al., 2014; Parkes & Langford, 2008;
Parris et al., 2008). In their research study, Parkes and Langford (2008) revealed that working
hours was the greatest influence on the delicate balance between work and life. In their two-part
qualitative study with middle managers, Parris et al., (2008) investigated the nomenclature of
work-life balance. Exploring the preference for work-life separation or work-life integration fell
to the background when it was revealed that 100% of the study participants expressed concern
for work intruding on other areas of life no matter how it is defined (Parris et al., 2008). This is
but one study in a database of hundreds in the past quarter century illustrating the concerning
development of work-life imbalance. Organizations are detrimentally affected as well, as job
satisfaction decreases, engagement wanes, productivity slumps, and turnover increases with
rising work-life imbalance (Buchanan et al, 2013; Greenhaus et al., 2003; Mullen, 2015; Parkes
& Langford, 2008; Tariq et al., 2012). Peeters, Montgomery, Bakker, and Schaufeli, (2005)
revealed that employees are three times more likely to contemplate quitting and mistakes at work
increase roughly 11% when work and life are out of balance.

16

While work-life balance was gaining traction in the second half of the 21
st
century it was
thought to be an individual encumbrance, however, now enlightened organizations are realizing
work-life balance is an occupation hazard and therefore a shared responsibility between
individual and organization (Olson, Crain, Bodner, King, Hammer, Klein, & Buxton, 2015;
Parkes & Langford, 2008; Ueda, 2012). While research shows work-life imbalance is tolerable
in the short-term, and often dismissed due to the excitement of the work, the fortitude to sustain
wanes over time and it is likely that negative consequences will be experienced by the individual
as well as the organization (Buchanan et al, 2013; Greenhaus et al., 2003; Mullen, 2015; Parkes
& Langford, 2008; Tariq et al., 2012). To negate these negative consequences and furthermore,
to stay competitive, exemplar organizations are developing programs and allocating supportive
resources to meet the work-life balance needs of the diverse workforce.
Current Construct of Work-life Balance in Nursing
The literature on work-life balance in the nursing profession highlights the struggles of
current nurses to balance all the responsibilities in their lives with a very demanding career in
nursing. Not entirely dissimilar to the work environments in the preceding section, nursing does
present some unique challenges to the work-life balance concept. Given that hospitals and many
medical establishments are open 24 hours a day/seven days a week, working hours tend to be
nontraditional. Many nurses work 12-hour shifts and may be scheduled to work nights,
weekends, or holidays. Therefore, this non-traditional schedule has the potential to contribute to
work-life imbalance as routine “life” activities such as soccer games, birthday parties, book club
sessions, and holiday dinners with loved ones usually occur on nights, weekends, or holidays.
That stated, nurses strive for balance by maximizing their non-workdays (Linzer, Levine,
Meltzer, Poplau, Warde, & West, 2014). However, imbalance tips the scales when nurses are

17

forced to work overtime, cover a shift, miss mandatory lunch or rest breaks, or work multiple
holidays in succession (Bakhamis et al., 2019; Buchanan et al., 2013; Gaskin, Ockerby, Smith,
Russell, & O'Connell, B, 2012; Holdren et al., 2015; Linzer et al., 2014; Parkes & Langford,
2008; Rudan, 2002; Shirey, 2006; Shirey et al, 2008).
While organizational factors such as workdays and work hours influence work-life
balance, nurse behavior is a contributing factor as well. Research as shown that nurses often
struggle with self-care and may be impeding their own work-life balance efforts (Andrews,
Tierney, & Seers, 2019; Kravits et al, 2010; Ross, Bevans, Brooks, Gibbons, & Wallen, 2017;
Shirey et al., 2008). While organizations attempt to influence nurse’s health and personal well-
being with human resource programs and work benefits, Oates (2018) discovered in her study
that nurses like clear boundaries between work and their personal lives. Therefore any well
intended strategies, from work meant to influence the personal, may backfire (Oates, 2018). To
be successful with work-life balance, nurses must navigate carefully the porous membrane
separating their demanding career from the rest of their life.
Present in the literature are also studies examining the detrimental effect work-life
imbalance has on succession planning and recruitment for the nurse leader role. In a research
study with registered nurses, Wong et al. (2013), revealed that front-line nurses are dissuaded
from leader positions primarily by the lack of work life balance they see exhibited from their
own nurse leaders. Lack of job security, increased span of control, and heavy workload were
cited as the primary impediments for managers achieving work life balance, and therefore
discourage nurses from following in their footsteps (Buchanan et al, 2013; Hewko et al., 2015;
Rudan, 2002; Spence Laschinger et al., 2013; Wong et al., 2013). While nurses often struggle to

18

maintain a healthy work-life balance, the literature indicates the challenge becomes even more
difficult as nurses rise in the ranks.
Influences for Work-Life Balance for the Nurse Leader
Due to the all-encompassing nature of the nurse leader position, it is a delicate balancing
act for the nurse leaders to harmonize work and life domains. The nurse leader position is
arguably one of the most significant in the hospital setting (Gaskin et al., 2012; Udod et al.,
2017). Effective nurse leaders have a pulse on not only their own unit, but the hospital overall.
Often supervising 50 or more direct reports, the nurse leader is involved in quality initiatives,
risk management investigations, human resource situations, project management, committee
work, and other duties as assigned (Gaskin et al., 2012; Kath et al., 2013; Udod & Care, 2011;
Udod et al., 2017). In their research study on extreme jobs, Buchanan et al. (2013) argue that
nurse leader jobs are, in fact, extreme. Nurse leader positions fit the criteria of extreme as they
encompass eight of ten extreme job qualifiers: long hours, unpredictable work, rapid pace with
tight deadlines, increased span of control, around the clock availability, large number of direct
reports, accountable to productivity budget, and responsible for mentoring and coaching
(Buchanan et al., 2013). The only two qualifiers not in the scope of the nurse leader are
international travel and attendance at after-hours work events, although this last one is debatable
as well due to the nursing celebrations, staff development activities, and hospital functions the
nurse leader either helps to organize or attends.
Further complicating the struggle for work-life balance is the fact that despite
overwhelming job responsibilities, several studies report nurse managers love their jobs, at least
initially (Shirey et al., 2008; Shirey et al., 2010; Warshawsky & Havens, 2014). Buchanan et al.,
(2013) concur and add, that love comes at a cost. While nurse leader positions are well paid,

19

yield promising career trajectories, and offer certain benefits such as greater paid time off banks,
and cell phone stipend, the health costs may be too excessive. Buchanan et al. (2013) discovered
jobs classified as extreme are fraught with extreme stress, poor emotional health, and eventual
decline in productivity.
Just as it is difficult for nurses to participate in self-care, so it is for nurse leaders. As the
nurse leader develops an identity incorporating the nurse leader role, the personal and
professional investment makes it difficult for the leader to become and remain aware of the strain
and effects of work-life imbalance (Andrews et al, 2019; Buchanan et al., 2013; Heeb &
Haberey-Knuessi, 2014; Mellner et al., 2014; Oates, 2018). Keys’ (2014) and Shirey’s et al.,
(2008) research revealed that nurse leaders felt a dichotomy between role of parent and role of
professional; wanting to be successful in both roles but feeling as though one had to suffer while
one thrives. This teeter-tottering may continue for some time before the negative effects of
work-life imbalance become overwhelming.
Despite nurse leaders best efforts, once work and life are out of balance, significant
physical and emotional disturbances emerge (Shirey et al., 2008). In their study with nurse
managers, Shirey et al. (2008) learned that stress and work-life imbalance manifested with signs
such as sleep disruption, physical pains, absenteeism, lack of enthusiasm, and frequent illness.
Many research articles (Lee & Cummings, 2008; Shirey et al., 2008; Shirey et al., 2010;
Udod & Care, 2011; Udod et al., 2017) call for a complete redesign of the nurse leader job
description. This is an important consideration as work-life balance is often near the top when
leaders list what is or will influence them to stay. In their study with nurse managers, Hewko et
al. (2015) revealed that the determining factor for ‘intent to stay’ most reported was work-life
balance.

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The literature shows that nurse leaders are pulled in many directions on the job and are
struggling to maintain clear boundaries between work and life. Considering the vast nature of
the nurse leader role, it is important to narrow the focus to better pinpoint negative influences on
work-life balance. Workload, exempt status, and use of technology are three variables
highlighted in the literature that deserve a closer look as they greatly influence work-life balance
for the nurse leader.
Workload
As organizations flatten their management structure and resources become scarce, nurse
leaders are finding they are asked to do more with less (Brown, Fraser, Wong, Muise, &
Cummings, 2013; Buchanan et al., 2013; Kath et al., 2013; Middaugh & Willis, 2018; Parris et
al., 2008; Warshawsky, Lake, & Brandford, 2013). Nurse leaders often manage several patient
care units, serve on several hospital committees, supervise large numbers of staff, and thus are
overextended (Lee & Cummings, 2008; Warshawsky et al., 2013; Wong et al., 2013). In their
study with nurse managers, Warshawsky et al. (2013) revealed that 100% of participants were
dissatisfied with their workload and argued the absurdity of expectations that nurse leaders
directly supervise 100 caregivers. In a four-year study with healthcare managers, Hewko et al.,
(2015) revealed intense job demands at the top of the list of factors affecting their work-life
balance and intent to stay in the position. Peeters et al. (2005) concur and add that work
overload involves disturbances in time, emotional effort, and mental effort; rather, not only is
there not enough time in the day, but the work is emotionally exhausting and mentally
challenging. Maslach and Goldberg (1998) argue the stress one feels from excessive job
demands is easy to explain as a ‘mismatch’. When the human capacity cannot keep up with job
demands there is an eventual decline in efficiency, productivity, and balance (Bakker &

21

Demerouti, 2007; Schaufeli, Leiter, & Maslach, 2009). Hospitals are dynamic environments
and change is initiated rapidly so the nurse leaders have little time for rest or revitalization before
the next onslaught of responsibilities (Bakhamis et al., 2019; Buchanan et al., 2013; Kinser,
Braun, Deeb, Carrico, & Dow, 2016; Shirey et al., 2010). Equally concerning is the fact that
many nurse leaders feel much of the work they do is either not their job, or meaningless. Shirey
et al. (2008) reported from her study with nurse leaders that up to 75% of their daily work may
not technically be in their job description, however, still occupies the top of the to do list if
requested by a supervisor or if unable to delegate due to lack of personnel resources.
Furthermore, Shirey et al. (2008) and Parris et al. (2008) agree that in addition to meaningless
work, their supervisors and other leaders often thwart best laid plans for the day with last minute
requests and additional expectations.
Work overload is described as a weight upon the nurse leaders shoulders (Buchanan et
al., 2013; Greenblatt, 2002; Keys, 2014; Middaugh & Willis, 2018; Shirey et al., 2008). To
lessen the weight, some leaders choose to work long hours at the hospital, while others take work
home and extend their workday (Bakhamis et al., 2019; Brown et al., 2013; Buchanan et al.,
2013; Gaskin et al., 2012; Holdren et al., 2015; Parris et al., 2008). While both scenarios may
serve to accomplish a few more tasks, it also interrupts rest and interferes with reflection and
disconnection from work that is so badly needed to balance the work-life scale (Buchanan et al.,
2013; Schaufeli et al., 2009; Shirey et al., 2008). Kath et al. (2013) cautions a careful calibration
is needed to balance the workload with each nurse leader. While nurse leaders are finding the
sheer volume of work far surpasses the resources available, it is also important to assess other
contributors to work-life imbalance. The expectation to stay until the work is done is emerging
as a factor and tipping the balance of work and life.

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Exempt Status
While the previous discussion centered on work overload, the exempt status adds to the
problem by eliminating any organizational imposed boundaries to delineate the workday from
personal time (Shirey et al., 2008; Udod & Care, 2011). Just as taking work home at the end of
the day does not allow for a disconnect from work, neither does around-the-clock responsibility.
Exempt status is an important distinction as the nurse leader position is often salaried and
defined as having 24/7 responsibility for their patient care area. Inability to let go, unable to set
the guard down, and forever dealing with a restless mind are some of the paraphrased sentiments
found in the literature as well as the current study, regarding the exempt nature of the role
(Shirey et al., 2008; Warshawsky et al., 2013). The possibility of being called into work at any
time produces significant unrest for nurse leaders, and several studies caution the cumulative
negative effects of this anticipatory anxiety (Greenhaus et al., 2003; Keys, 2014; Mellner et al.,
2014; Mullen, 2015; Raso, 2018; Sarker, Sarker, Xiao, & Ahuja, 2012; Son & Chen, 2018; Tariq
et al., 2012; Warshawsky et al., 2013). Nurses in a study conducted by Warshawsky et al. (2013)
lament that while they often get multiple work calls throughout the night, they are still expected
to function at a high level at work the next day.
In addition to the expectation of responding to emergencies at the hospital, ENLs are
routinely asked to attend after-hours commitments in addition to the more traditional hours they
keep at the hospital (Buchanan et al., 2013; Udod & Care, 2011). Nursing recognition
celebrations, team barbeques, and community outreach events, requiring the ENL in attendance
usually occur outside traditional working hours of 0700 to 1700. ENLs often sacrifice personal
time to show support for such activities (Shirey et al., 2010; Udod & Care, 2011; Udod et al.,
2017).

23

Even when trying to schedule formal rest and rejuvenation time, ENLs are often asked to
remain available. As reported by Bonneville and Grosjean (2016), Keys (2014), and Nelson
(2017), and revealed in the research study completed by Warshawsky et al. (2013), even on
approved days off, weekends, or holidays, nurse managers were asked to remain accessible or
secure impromptu coverage for their areas. While Raso’s (2018) research revealed that 80% of
nurse managers were taking yearly vacations, it also revealed that only 18% of them
disconnected from work while away. The other 72% continued to log on, participate remotely,
and answer phone calls and texts (Raso, 2018). The expectation to remain ever available
negatively affects not only the ENL, but also family members and social relationships (Buchanan
et al. 2013; Loveridge, 2018; Parris et al., 2008).
Exhaustion becomes the norm when leaders sacrifice personal time by not only working
during the week, but also taking calls overnight and participating in hospital sponsored activities
on the weekends (Shirey et al., 2008; Warshawsky et al., 2013). This pattern may prove to be
detrimental as it does not allow for rejuvenation nor work-life balance. Fatigue, brought on by
around the clock responsibility for their patient care units, was a common theme in the literature
with nurse leader stress and challenges to work-life balance (Middaugh & Willis, 2018). The 24-
hour nature of the exempt nurse leader position makes it very difficult to step away from the job
to reflect and recharge. Furthermore, the prolific use of technology, such as cell phones and
email, encourages the accessibility of the nurse leader to a dangerous level.
Role of Technology
In the same way work overload and exempt status influence work-life balance, so does
the prolific use of technology. Cell phones, laptops, email, and even smart TVs, watches, and
cars contribute to the overall struggle for work-life balance (Bonneville & Grosjean, 2016;

24

Controlling Smart-Phone Abuse, 2010; Loveridge, 2017; Middaugh & Willis, 2018; Olson et al.,
2015; Parris et al., 2008; Sarker et al., 2012). As the culture morphs and becomes more reliant
on technology for communication, the expectation and pressure to be instantly accessible
prevails (Bonneville & Grosjean, 2016; Middaugh & Willis, 2018). This use of technology may
negatively affect the nurse leader work life balance in three ways: volume, timing, and
portability.
As discussed earlier, the sheer volume of work in the nurse leader job description is
without question. Research reveals leaders are hesitant to go on vacation as they will return to an
overflowing inbox which negates any stress reduction achieved from time away. Many leaders
admit that they check email while on vacation simply to prevent their email from piling up
(Bonneville & Grosjean, 2016; Loveridge, 2017; Nelson, 2017; Parris et al., 2008; Sarker et al.,
2012). Corresponding by email, rather than phone or text, has become the communication of
choice in many situations due to ease of use, and the fact that it provides a paper trail (Bonneville
& Grosjean, 2016; Parris et al., 2008). However, this method of communication has a downside
as well. In addition to time spent on emails, some predict up to three hours a day, checking
email throughout the day can be addictive, distracting, and even hurt professional relationships
(Bonneville & Grosjean, 2016; Parris et al., 2008; Son & Chen, 2018).
The timing of technology may also affect work-life balance. Emails with emergent
information sent on Sunday afternoon will produce anxiety and stress for the respondents
(Bonneville & Grosjean, 2016; Loveridge, 2017; Sarker et al., 2012), while non-emergent texts
from the nursing staff on weeknights do not allow for rest or rejuvenation for the exhausted
leader (Shirey et al., 2008; Middaugh & Willis, 2018). Years ago, one may have thought twice
before calling the ‘house phone’ in the evening or early hours for fear of waking someone. Now

25

the personal cell phone of the nurse leader rings at all hours of the day and night, often with no
regard for rest days away from the hospital or even paid time off (Loveridge, 2017; Middaugh &
Willis, 2018; Son & Chen, 2018).
The portability factor is a blessing and a curse for the nurse leader striving to balance
their work and life. The laptop enables the leader to work nearly anywhere, and the cell phone
increases work flexibility, yet both further blur the lines between work and life (Middaugh &
Willis, 2018; Olson et al., 2015; Parris et al., 2008). ENLs report they are repeatedly interrupted
by their technology while in meetings, classes, or supporting patient care. It is not uncommon to
look around the room and see ENLs on their phones or laptops, rather than participating in the
situation at hand. This multitasking has been shown to decrease productivity and inhibit learning
(Bonneville & Grosjean, 2016).
Even though the use of technology is cited in many research studies as negatively
affecting work-life balance, there does not seem to be the motivation to change technology use
behavior (Bonneville & Grosjean, 2016; Controlling Smart-Phone Abuse, 2010; Parris et al,
2008; Son & Chen, 2018). Nurse leaders feel a dichotomous pull between wanting to be
informed at all times and wanting to have uninterrupted time with family or for rest (Middaugh
& Willis, 2018). The advancement of technology has both pros and cons, and it is up to each
individual to determine what role technology will play in their lives.
Work overload, exempt status, and use of technology influence the work-life balance of
nurse leaders, and to better understand these factors a deeper dive into the culture that supports
these influences is necessary and forthcoming. Many other work-life balance influences found in
the literature such as last-minute requests, control over workday tasks, other nurse leader
behaviors, and personality traits will also be addressed. In sum, even though work-life balance is

26

elusive and challenging to maintain, it is necessary if individuals and organizations want to
achieve peak performance in both life and work domains.
The Construct of Burnout
While not the primary focus of this study, it is important to briefly discuss literature
around the eventual outcome if work-life imbalance continues….burnout. Merriam-Webster
Dictionary (2020) defines burnout as “to cause to fail, wear out, or become exhausted especially
from overwork or overuse”. Herbert J. Freudenberger (1974) coined the term burnout in 1974,
with many other researchers helping to develop and refine the construct over the next several
decades. Freudenberger (1974) offers that when the mature thought process and rational
behaviors of engagement and commitment is transformed to an almost obsessive degree, burnout
is inevitable (Patel, Bowler, Bowler, & Methe, 2012). Christina Maslach, a prolific burnout
researcher and noted for the Maslach Burnout Inventory survey, maintains there are three
components to burnout: emotional exhaustion, depersonalization, and reduced efficiency (Kinser
et al., 2016; Leiter & Maslach, 2017; Maslach & Goldberg, 1998; Maslach, Jackson, Leiter,
Schaufeli, & Schwab, 1986; Peeters et al, 2005; Schaufeli et al., 2009). Maslach and Goldberg
(1998) explain that work overload is a primary cause of emotional exhaustion due to being
overextended and drained of all coping resources. Depersonalization is characterized by a
reduced concern for others and a failure to thrive on human connections (Leiter & Maslach,
2017; Maslach & Goldberg, 1998; Schaufeli et al., 2009). Finally, reduced efficiency refers to a
loss of productivity triggered by overall feelings of inadequacy or incompetence (Goldberg &
Maslach, 1998; Schaufeli et al., 2009). Overall, burnout is not the result of a single trying event,
or a short duration of hardship, rather it is a progressive condition characterized by prolonged
exposure to triggers and stress (Kinser et al., 2016; Maslach & Goldberg, 1998; Pines & Keinan,

27

2005; Schaufeli et al., 2009). For those that diagnose burnout early and gain control over the
negative influences or remove themselves from the situation, the prognosis to overcome the
detrimental effects of burnout is good. However, for those that allow burnout to fester, the
condition will continue to deteriorate and spread to other co-workers, thereby negatively
impacting the entire work culture (Schaufeli et al., 2009).
It is compelling that work-life imbalance shares many of the same triggers with burnout
such as work overload, reduced self-efficacy, and failure to thrive (Avgar et al., 2011; Dyrbye et
al., 2017; Greenblatt, 2002; Leiter et al., 2007; Maslach & Goldberg, 1998; Maslach et al., 2001;
Rubino et al., 2009). Peeters et al. (2005) contend that research has shown that work-life
imbalance is a preceding condition to burnout. Other burnout and work-life imbalance
connections are tedium, attitudinal exhaustion, and work that is not meaningful, as reported by
Karger (1981) and Pines and Keinan (2005). Job security, market trends, automation,
technology advances, and human resource innovations affect the psychological contract
employees have with their work (Parris et al., 2008). The uncertainty of these changes
contributes to the stress, workload, work-life imbalance, and ultimately burnout (Parris et al.,
2008).
Just as work-life imbalance, burnout tends to be ignored, dismissed, stigmatized, and
often thought to be an individual failure (Hewko et al., 2015; Maslach & Goldberg, 1998;
Schaufeli et al., 2009). Due to this, many ignore the signs and symptoms, and rather than seek
help they choose to forge ahead which makes the situation worse (Kath et al., 2013). Even more
troubling is that work-life imbalance and by extension, burnout, is often worn as a badge of
honor or a sign of how loyal and committed one is to the work (Maslach & Goldberg, 1998;
Parkes & Langford, 2008; Patel et al., 2012). Long hours at work and giving more than 100% is

28

often rewarded by colleagues as well as supervisors, thereby making it even more difficult to
counteract the negative consequences.
While burnout is a widespread condition that does not discriminate, nurses may be
particularly susceptible due to contact with the public, the nature of life and death work, and
workplace issues (Buchanan et al., 2013; Heeb & Haberey-Knuessi, 2014). Mullen (2008), Lee
and Cummings (2008), Kinser et al. (2016), Kath et al. (2013), the Occupational Safety and
Health Administration (2020), and Spence Laschinger & Finegan (2008) report that nurses
endure more stressful situations than the general public due to the extreme nature of work, staff
shortages, personal safety issues, constant changes, and new technology. As a result, workloads
expand, workdays lengthen, and work-life imbalance and burnout continue (Buchanan et al.,
2013; Hewko et al., 2015; Howse, 2006; Labrague, McEnroe-Petitte, Leocadio, Van Bogaert,
and Cummings, 2018; Lee & Cummings, 2008; Matlakala, Bezuidenhout, & Botha, 2014).
Labrague et al. (2018), Middaugh and Willis (2018), and Spence Laschinger & Finegan (2008)
echo the threat of burnout to quality patient care, and caregiver well-being. In a study with nurse
managers, 62% indicate a desire to leave their position within the next five years due to stress
and burnout (Labrague et al., 2018; Middaugh & Willis, 2018). Hewko et al. (2015) report that
only 56% of nurse leaders surveyed in their study intend to stay in the job another two years, and
the determining factor was satisfaction with work-life balance. Losing the nurse leaders to work-
life imbalance and subsequent burnout is disastrous as they are pivotal to hospital success
(Buchanan et al., 2013; Heeb & Haberey-Knuessi, 2014; Hewison, 2006; Spence Laschinger &
Finegan, 2008).
Schaufeli et al. (2009) revisited 35 years of burnout research and concluded that burnout
was prolific in the work realm and it was more than an inconvenience, rather burnout was a

29

destructive experience threatening professional identity. Advances in the study of burnout has
led to the discovery of engagement as the antithesis to burnout (Leiter & Maslach, 2017;
Maslach & Goldberg, 1998). Engagement, on the opposite end of the spectrum, includes energy,
involvement, and self-efficacy. These components are in direct contrast to burnout
characteristics and if tackled jointly, by individuals and organizations, they can become
embedded within the culture (Maslach & Goldberg, 1998).
Organizations have an opportunity to slow the incidence and spread of burnout by
addressing issues related to work-life imbalance and stress for the nurse leaders (Lee &
Cummings, 2008). While there are many contributors to burnout for the nurse leader, the
imbalance of work and life is emerging in the literature as a frontrunner. Therefore, to counter
the effects of burnout before they manifest themselves, it is important to have in place a work-
life balance program to encourage and maintain professional and personal health of the
individual and protect the overall health of the organization. This is further examined in the
sections that follow using the Clark and Estes gap analysis framework.
The Clark and Estes Gap Analysis Conceptual Framework
Much like a nurse assesses the whole patient for factors that may be influencing illness,
so should a researcher assess the total situation when exploring a problem of practice,
performance issue, or phenomenon. Using a framework helps to guide the inquiry and allows
the researcher freedom to explore both breadth and depth of a topic within pliable boundaries.
For this study, the Clark and Estes (2008) gap analysis framework within the Turning Research
into Results Process Model was chosen. It offers a structured, yet flexible framework that
identifies knowledge, motivation, and organizational influences that affect a problem of practice.
This framework serves to identify if such influences are promoting or obstructing the goal, while

30

also highlights the gap between desired and actual performance. Once the differential gap is
identified, this framework examines in detail how knowledge, motivation, and organizational
influences impact the performance gaps (Clark & Estes, 2008).
Beginning with knowledge, Krathwohl (2002) identifies four distinct types: factual,
conceptual, procedural, and metacognitive. These knowledge types are used to assess
stakeholder aptitude and understanding of the construct studied, as well as the desired goal.
Motivational influences are explored to ascertain stakeholder perceptions of value and the
perseverance required to accomplish the goal (Clark & Estes, 2008; Rueda, 2011). Principles
such as value, self-efficacy, and goal orientation are explored when uncovering the motivational
influences (Rueda, 2011). Finally, organizational influences such as culture, processes, and
resources are investigated to determine impact on the problem of practice (Clark & Estes, 2008).
For this study, the three components of Clark and Estes’ (2008) gap analysis were
discussed further in terms of nurse leader knowledge, motivation, and organizational influences
to meet the goal of implementing a work-life balance program by May of 2021. The first
segment included an exploration of nurse leader knowledge, including how training, education,
and information influenced the performance goal. Next, an exploration of motivational
influences within the stakeholder group toward the performance goal was investigated. Since
motivation is a psychological process, variables such as active choice, persistence, and mental
effort toward the performance goal were assessed along with three motivational theories (Clark
& Estes, 2008). Finally, organizational influences on achievement of the stakeholder goal were
analyzed. It was important to discover nurse leader perceptions of the potential organizational
barriers they face in relation to the performance goal. Stakeholder knowledge, motivation, and

31

organizational influences on performance was then investigated through the methodology
discussed in Chapter 3.
Stakeholder Knowledge, Motivation, and Organizational Influences
The literature shows the important role nurse leaders play in a hospital by establishing
healthy work environments for the caregivers they supervise (Andrews & Dziegielewski, 2005;
Kath et al., 2013; Oates, 2018). These healthy work environments are positively correlated to
engaged caregivers, with high retention and low burnout (Andrews & Dziegielewski, 2005;
Oates, 2018). However, when nurse leaders experience stress and burnout themselves, not only
does their own work suffer, so does the work of their caregivers as burnout is contagious
(Maslach et al., 2001). Work-life imbalance, a main contributor to burnout, is becoming more
problematic as the work responsibilities are changing and increasing for nurse leaders (Mullen,
2015). This study focused specifically on the work-life balance, or imbalance, of the exempt
nurse leader (ENL). The exempt status was an important distinction as literature shows exempt
leaders are prone to burnout due to the 24/7 nature of the job (Sliwiriski, 2004). Currently there
is no established global or intermediate goal directly focused on the well-being of nurse leaders.
Therefore, the goal of this study is by May 2021 an innovative work-life balance program will be
in place and operational for exempt nurse leaders at the stakeholder hospitals.
This analysis of scholarly literature targets main elements needed to realize the goal of
increased work-life balance for ENLs. The knowledge and motivation of key players, as well as
the organizational influences overall were important to consider as they can have a strong
influence on the success of the desired outcome.

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Knowledge and Skills
It is important for exempt nurse leaders to develop knowledge about work-life balance.
If current knowledge exists, it should be assessed, calibrated, and determined to be correct.
Sharpening the knowledge and skills for how work and life interact is critical to actualizing the
goal to improve the balance between them.
Clark and Estes (2008) maintain knowledge gaps contribute to poor performance. ENLs
may have knowledge deficits surrounding competing responsibilities and how they may
contribute to work life imbalance. Additionally, ENLs may fail to see how the choices they
make to organize their day influences the balance between work and life. To address these
potential gaps, one must explore and master the four types of knowledge (Krathwohl, 2002).
Krathwohl (2002), revising Bloom’s taxonomy, proposes the knowledge types are factual,
conceptual, procedural, and metacognition. This study proposes that to close any knowledge
gaps present stakeholders must demonstrate competence in the following four constructs.
Exempt Nurse Leaders Need to Define Work-Life Balance
Factual knowledge is basic knowledge about a subject, covers principal characteristics,
and answers the question of what (Krathwohl, 2002). Understanding terminology and making
accurate, declarative statements about work-life balance is a demonstration of factual knowledge
(Krathwohl, 2002). To meet the stakeholder goal, ENLs must be able to define work-life balance
and explain the elements within. Parris et al. (2008) and Mullen (2015) admit it is difficult to
define work-life balance and tease out the sound alike terms in the current literature. Work-life
balance, work-life integration, work-life boundary management, and others all speak to how one
navigates the responsibilities of both work and life.

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It is important that ENLs develop this knowledge as literature shows more organizations
are flattening structures and overloading middle managers across all industries (Shirey et al.,
2010; Sliwiriski, 2004). Furthermore, many ENLs assume these middle management roles with
little or no training. Managers often do not fully understand the scope of the role nor the
impending workload (Kath et al., 2013). Rather than blindly accept over-functioning as part of
the leader position, these ENLs must gain knowledge of the elements of work-life balance and
how to operationalize the concept within this role. Failure to gain this knowledge will result in
attrition or worse, stressed and burnt out leaders infecting their staff with the same infliction.
Exempt Nurse Leaders Need to Understand the Concept of Work-Life Balance
While important to define work-life balance, it is equally imperative to elucidate the
larger concept. Conceptual knowledge applies to the general understanding of a notion or an
approach to solving a problem (Krathwohl, 2002). For ENLs, clinical concepts are mainstream
and easy to understand, however work-life balance falls within the social sciences and is more
abstract and ambiguous (Leiter et al., 2007). ENLs should be aware of the numerous variables
that contribute to work-life imbalance, such as time, energy, commitments, and environment
(Dembo & Eaton, 2000; Schraw & McCrudden, 2009; Tuckman, 2006).
ENLs also need knowledge of the concept of risk within work-life balance (Maslach &
Goldberg, 1998). It is important to ascertain knowledge pertaining to the devastating effects of
work-life imbalance and the potential for burnout (Maslach & Goldberg, 1998). Furthermore,
ENLs need knowledge in how seemingly single events of imbalance can accumulate into a life of
imbalance. Similar to how a nurse may experience unknown microtears along her spine while
repositioning one patient a day. A year later this same nurse hurts her back bending over to
retrieve a tissue from the floor. While it was not the weight of the tissue that caused her injury,

34

rather it was the 300 plus single events over the course of the previous year. For ENLs a single
event of imbalance may not have negative consequences, yet ENLs need knowledge of how
single events of work-life imbalance will accumulate over time and lead to burnout (Maslach &
Goldberg, 1998).
Exempt Nurse Leaders Need Knowledge of the Steps to Balance Work and Life
Procedural knowledge addresses the steps required for success or the formula for moving
through a process (Krathwohl, 2002). Kravits et al. (2010), in their study on self-care for nurses,
offer strategies for coping with stress that are learned and adaptable. They found, for example,
that just as nurses can learn to cope poorly with drugs, alcohol, and food, so can they learn to use
positive strategies such as exercise, meditation, and time with a hobby to manage stress and
feelings of burnout (Kravits et al., 2010).
While ENLs must learn to implement the steps for gaining balance over work and life,
quite often they have cognitive awareness of the steps, yet fail to actualize them for themselves
(Ross et al., 2017).
Exempt Nurse Leaders Need Knowledge of How Work-Life Balance Applies to Self
Nurses, in general, are skilled at taking care of others, however, often fall short when
taking care of themselves. The literature on knowledge transfer to self indicates that barriers to
metacognition may be to blame (Chiejina & Ebenebe, 2013). Metacognition, a higher order of
thinking, involves a critical awareness of self, and control over one’s own thinking and learning
process (Krathwohl, 2002).
Ross et al. (2017) reports knowledge does not always transfer to a situation with self, and
Mullen (2015) contends nurses often ignore their own necessities. Looking inward, nurse
leaders often fail to see what puts them at risk or makes them vulnerable to imbalance, stress,

35

and burnout (Maslach & Goldberg, 1998). Work-life imbalance and burnout often have
accompanying symptoms that unfortunately are often ignored. Shirey et al. (2008) found that
ENLs either dismissed or misunderstood physical symptoms of imbalance and stress.
Furthermore, while ENLs could articulate symptoms such as restlessness, sleep disturbances,
impatience, emotional exhaustion, and irritability as related to work-life imbalance and burnout,
ENLs did not reflect on self nor identify those symptoms as negatively affecting their own health
(Shirey et al., 2008). Functionally, the ENLs in this study reported that their daily effectiveness
was not negatively affected by these symptoms. This finding highlights the need for
metacognitive knowledge of long-term effects of imbalance and stress on effectiveness and
overall health (Shirey et al., 2008).
Table 2 shows an overview of organizational mission, goal statements, and breakdown of
assumed knowledge needed to attain the stakeholder goal. Knowledge influences, corresponding
knowledge types, and an assessment to determine if knowledge is present, is also shared.

36

Table 2
Assumed Knowledge Influences, Knowledge Type, and Knowledge Assessment
Organizational Mission
Using God as our guide and through the ministry of Jesus, we will persevere to serve all people
in need, regardless of situation (Pacific Healthcare, 2018).
Organizational Global Goal
One of five stanchions focus on the growth and motivation of internal caregivers. Pacific
Healthcare (2018) designed a global goal of improving engagement and retaining staff to support
their growth and motivation.
Stakeholder Goal
By May of 2021, SWH will have in place and operational an innovative work-life balance
program geared toward retaining current and attracting future ENLs.
Assumed Knowledge
Influence
Knowledge Type Knowledge Influence
Assessment
Exempt nurse leaders need to
define work-life balance

Factual Interview to assess knowledge
of definitions, terms, and basic
understanding of work-life
balance.
Exempt nurse leaders need to
understand the concept of
work-life balance
Conceptual Interview to assess knowledge
of categories, principles, and
themes of work-life balance.

Assess observations and
documents to determine
stakeholder non-verbal
communication and
conceptual understanding of
work-life balance.
Exempt nurse leaders need
knowledge of the steps to
balance work and life
Procedural Interview to assess knowledge
of steps, plans, and strategies
for balancing work and life.

Assess documents to
determine organizational
support for work-life balance.
Exempt nurse leaders need
knowledge of how work-life
balance applies to self
Metacognitive Interview to assess knowledge
of how to reflect on thought
processes and self-
management techniques
related to work-life balance.

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Assessing the nurse leaders and their knowledge of work-life balance is a good first step
to establish a baseline of understanding. Once people are armed with knowledge, understanding
what motivates them to act is the next step.
Motivation
It is ill advised to assume that once nurse leaders have knowledge about work-life
balance that the problem of imbalance will resolve. Rather, another important construct must be
explored, motivation. Once ENLs have the knowledge and skills needed to improve work-life
balance, they must be motivated to do so. Motivation, at its simplest, is the decision to act, the
persistence to keep going, and the discernment for how much effort is necessary (Clark & Estes,
2008). These three elements, active choice, persistence, and mental effort are present in each
undertaking and must be catalyzed for success (Clark & Estes, 2008). If there is a deficit in any
area, the task and the overall goal, suffers. To address deficiencies in any of these areas it is
important to determine the motivational influences affecting ENLs.
The notion of taking care of one’s self, inherent in work-life balance, so one can take care
of others is fundamental in the world of nursing, yet not always easy to actualize. Scholarly
studies on work-life balance report that nurses, ENLs included, often have the knowledge to
improve their work-life balance yet lack the motivation to act (Ross et al., 2017). Glen, (as cited
in Moody and Pesut, 2006, p. 27) suggests that “nurses need to examine and become more
consciously aware of their emotional and motivational states in order to support competence and
caring in nursing work”. Maslach and Goldberg (1998) agree, and advocate for uncovering the
reason nurses continue to engage in risky behavior.
There are several theories of motivation that apply to ENLs and work-life balance. In the
sections that follow we will explore how Expectancy Value Motivational Theory (Eccles, 2006),

38

Self-Efficacy Theory (Pajares, 2006), and Goal Orientation Theory (Yough & Anderman, 2006)
can navigate the inquiry of work-life balance in ENLs.
Expectancy Value Motivational Theory
The perceived importance of a task is central to the Expectancy Value Motivational
Theory (Eccles, 2006; Wigfield & Cambria, 2010). ENLs are first asked, “Can I do the task?”
Slightly different from self-efficacy, ability in the Expectancy Value Motivational Theory
(Eccles, 2006) is compared to others’ performance and to previous situations. This question is
asked first to ascertain knowledge and skill level. Once knowledge is acquired, motivation to do
the task is then queried by asking “Do I want to do the task?” The value construct of this
question can be broken down into four sections: intrinsic interest, attainment value, utility value,
and perceived cost (Eccles, 2006; Rueda, 2011; Wigfield & Cambria, 2010).
To increase expectancies for success and value, ENLs can tap into intrinsic motivation by
finding joy in the tasks of balancing work and life. While the outcome of a balanced life may
also be motivating, intrinsic motivation will be stimulated if ENLs experience satisfaction and
delight in recognizing contributing factors and implementing the steps to balance work and life.
For attainment value, identity plays a central role (Wigfield & Cambria, 2010). To increase
motivation, ENLs should think about how they currently see themselves compared to how they
expect or want to see themselves. If the vision they have for who they want to be does not fit
with who they are, often a desire to improve ensues (Eccles, 2006). Utility value is the perceived
advantage of the accomplishment. If ENLs proclaim that a healthy work-life balance would
allow them to pursue a degree, participate in a hobby, or spend time with family, this awareness
will help ENLs to persevere (Eccles, 2006; Pintrich, 2003). Finally, cost is an important
consideration. ENLs should consider the cost of attaining the goal, as well as the cost of failure.

39

To improve work-life balance, ENLs may pay the price of time and energy spent on organizing
their day differently or acquiring delegation skills. Furthermore, if work-life balance means
leaving work at a set time each day, one cost may be certain tasks are left undone or ENLs may
fall out of favor with colleagues they leave behind in the workplace at the end of the day. To
remain motivated to improve work-life balance, the costs should be less than the reward of
achieving the goal (Eccles, 2006). ENLs should also consider the costs for continuing with a
work-life imbalance. A famous quote by Henry David Thoreau (1854; 1971), “the cost of a
thing is the amount of what I will call life, which is required to be exchanged for it, immediately
or in the long run” offers a painful truth. Work-life imbalance contributes to stress, emotional
exhaustion, burnout, and eventual attrition (Kravits et al., 2010; Parkes & Langford; 2008;
Rubino et al., 2009). The cost of continuing with work-life imbalance may one day be too steep
to pay.
Self-Efficacy Theory
The theory of self-efficacy, developed by Albert Bandura, encompasses the thoughts and
beliefs one holds regarding ones’ ability to accomplish a task (Pajares, 2006). These beliefs can
be positive in nature which supports accomplishments, or they may be negative which hampers
achievement (Pajares, 2006). In addition to beliefs, triumphs raise efficacy while defeat will
lower it. Self-efficacy beliefs color life choices as people tend to gravitate toward things they do
well, and retreat from things with which they struggle (Pajares, 2006). The same is true for
ENLs, and to increase self-efficacy it is important to promote their competence and capabilities
of improving their work-life balance. If ENLs feel they have no influence over their situation
they will be less likely to act or persevere when facing obstacles. However, Mullen (2015)
maintains nurses have it within themselves to improve their situation. They need not wait for

40

administration to fix the system or for direct reports to self-manage, ENLs need to realize their
skills, and spur the motivation to make the improvements for themselves. Self-Efficacy Theory
(Pajares, 2006) uses role models to set examples for ENLs to follow. These role models should
provide a stratified program for ENLs to emulate, and with targeted feedback and weaning
support, ENLs will discover small successes that will lead to their personal pathway of work-life
balance (Borgogni, Russo, & Latham, 2011; Pajares, 2006). Another strategy to help foster self-
efficacy is to encourage ENLs to band together. Collective efficacy is powerful and together the
team may elevate the self-efficacy of individuals as well as the entire group.
Goal Orientation Theory
Goal Orientation Theory (Yough & Anderman, 2006), is another relevant motivation
theory that may help ENLs actualize the goal of increased work-life balance. Focusing on
achievement, this theory presents performance goals and mastery goals (Yough & Anderman,
2006). Performance goals are primarily concerned with how things “look” to the outside.
Performance goals are not necessarily concerned with understanding, but rather performing
better than others is the goal (Yough & Anderman, 2006). While often encouraging unhealthy
competition, performance goals for ENLs might be helpful if overall well intended. For
example, ENLs may choose to compare themselves against other managers and motivation may
be spurred due to the perception they are handling their work-life balance more effectively than
others. A likely better option are mastery goals as they are not concerned with appearances but
rather the desire for true understanding and proficiency (Yough & Anderman, 2006). ENLs
motivated by mastery goals will want to handle their responsibilities proficiently. Furthermore,
ENLs will want to control the work rather than allowing the work to control them (Parris et al.,
2008). To increase the goal orientation, it is important ENLs succeed with smaller goals to allow

41

time for full comprehension and to show improvement toward the larger goal of increasing work-
life balance (Bonneville & Grosjean, 2016).
Table 3 shows an overview of organizational mission, goal statements, and breakdown of
assumed motivational influences that will impact the success of the stakeholder goal. An
assessment to determine motivation assets or needs is also shared.
Table 3
Assumed Motivation Influences and Motivational Assessment
Organizational Mission
Using God as our guide and through the ministry of Jesus, we will persevere to serve all people
in need, regardless of situation (Pacific Healthcare, 2018).
Organizational Global Goal
One of five stanchions focus on the growth and motivation of internal caregivers. Pacific
Healthcare (2018) designed a global goal of improving engagement and retaining staff to
support their growth and motivation.
Stakeholder Goal
By May of 2021, SWH will have in place and operational an innovative work-life balance
program geared toward retaining current and attracting future ENLs.
Assumed Motivation Influences Motivational Influence Assessment

Expectancy Value Motivational Theory –

Exempt nurse leaders need to see value in
having a healthy work-life balance.
Interview and observations to assess
stakeholder perceptions of the value of work-
life balance.
Self-Efficacy –

Exempt nurse leaders must believe they are
capable to have a healthy work-life balance.
Interview to assess stakeholder perceptions of
self-efficacy to control work-life balance
influences.

Observations to determine stakeholder
practice related to self-efficacy.
Goal Orientation, Mastery Approach –
Exempt nurse leaders should work toward
balancing work and life.
Interview to assess stakeholder perceptions of
mastery goal orientation toward work-life
balance.

Observations to determine stakeholder non-
verbal communication regarding mastery
approach to persevering with work-life
balance.

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Understanding the nuances of motivation and focusing on the positive outcomes will ease
the way and help individuals remain committed to the arduous task of balancing one’s work and
life. Individual efforts to understand work-life balance and persevere in the face of obstacles set
the stage for analysis of the role that structure and environment play in the construct. While the
balance of work and life is often thought to be the responsibility of the individual, the structure
of the environment the individual operates within plays a large role in the success of such efforts.
Organizations, through their policies, procedures, and environment, influence how work-life
balance is supported or negated for nurse leaders. The culture of an organization plays a leading
role in the operationalization of a construct such as work-life balance.
Organization
Clark and Estes (2008) and Rueda (2011) maintain that even if stakeholders have the
knowledge and motivation to perform, there are often factors within the organization that prevent
them from accomplishing goals. Organizational barriers to performance can be as simple as
lacking equipment or poorly designed procedures that complicate rather than expedite.
However, quite often the organizational barriers are more complex and involve the deeply rooted
culture of an organization. For purposes of this study and to better understand organizational
influences affecting the work-life balance of the ENL, cultural settings and cultural models will
be explored.
Stakeholder Specific Factors
The culture of an organization is usually thought to be invisible, however, palpable
through daily work and customs. The broad definition of culture of an organization includes
mission statements, core values, symbols, and professional identity (Clark & Estes, 2008).
Culture also includes shared norms, and systems of behavior that become rote and pervasive

43

throughout the organization (Schein & Schein, 2017). Culture is a fog that infiltrates all
individual performances and operations within an organization, and it is important that all things
touched by this fog, or culture, are aligned. If the culture does not align with the individuals
performance, gaps will present (Clark & Estes, 2008).
Organizational influences on the problem of practice are presented as cultural settings
and models. Cultural settings are places, words, and actions that are seen, heard, and interpreted
as organizational culture (Rueda, 2011). Cultural settings are the actualization of culture.
Alternatively, cultural models within an organization may be felt yet not seen. These models are
a way of doing business that is ingrained into the day to day process and routinely accepted as
the norm (Rueda, 2011).
While the balance of work and life is often thought to be the responsibility of the
individual cultivated through knowledge and motivation, the culture of the environment the
individual operates within plays a large role in the success of such efforts (Kath et al., 2013).
This study brings forth three cultural settings and three cultural models that are prevalent within
the literature on work-life balance.
Cultural Setting: Resources to Meet Demands.
The organization needs to ensure resources are available to meet demands. Job resources
refers to supportive structures or systems put in place to offset increased workload, psychological
demands, or role conflict within a position (Salanova, Del Líbano, Llorens, & Schaufeli, 2014).
Where lack of resources can lead to disengagement, job strain, and stress, the converse is also
true (Bakker & Demerouti, 2007). Appropriate resources to meet the demand can inspire
motivation, increased engagement, and commitment (Bakker & Demerouti, 2007). It is
important the resources meet demands when organizations implement a change. Clark and Estes

44

(2008), and Fernandez and Rainey (2006) argue that additional resources should be available and
existing non-essential work be reduced anytime change is introduced. Unfortunately, the
opposite is often true as resources are often eliminated due to budget cuts and reorganization.
Every time a change is made without additional resources available, productivity falls and the
change implementation is less likely to be successful (Sirkin, Keenan, & Jackson, 2005).
For ENLs, balancing resources with demands is necessary as hospitals restructure and
thin management roles, leaving remaining managers to deal with continual change, increased
areas of oversight, and more direct reports (Parris et al., 2008). Administrative responsibilities
for ENLs have expanded in the last 20 years creating role conflict as nurse leaders prioritize
clinical duties which leads to an eventual mountain of managerial tasks with looming deadlines
(Gaskin et al., 2012; Heeb & Haberey-Knuessi, 2014). A culture that supports resources meeting
demands would also balance supervisory responsibilities. Most ENLs will agree that mentoring,
teaching, and otherwise supporting their caregivers is a positive part of the job, however when
duties expand and ENLs supervise increasing numbers of caregivers, the job feels meaningless as
the task is insurmountable (Kravits et al., 2010; Mullen, 2015). In a quantitative analysis
completed by Hewko et al. (2015), evidence suggests the more direct reports a nurse leader has
the more likely they are to vacate the position due to poor job satisfaction and stress.
Cultural Setting: Culture of Communication that Supports Work-Life Balance.
The organization needs to foster a culture of communication that supports work-life
balance. Therefore, three communication themes should be examined: device management,
timing, and expectations.
Advances in technology further blur the line between work and personal time as
communication devices are prolific, yet overwhelming (Bonneville & Grosjean, 2016; Sarker et

45

al., 2012; Sullivan, 2014). An ENL manages not only a personal cell phone, but also a desktop
computer, a portable laptop, and a work phone. Furthermore, the cell phone alone has the
communication technology for email, phone calls, texts, facetime, team chats, and video
conferencing. Studies report the ENL is inundated with technology and expected to keep track
of communication coming in from all devices (Bonneville & Grosjean, 2016; Buchanan et al.,
2013; Loveridge, 2017). While managing all the various communication portals is cumbersome
during the workday, it is not supportive of work-life balance if it continues after hours. ENLs
acknowledge their need to be available by phone after hours for emergencies, however they also
admit they regularly interact with multiple devices and platforms as necessitated by the content
of the after-hours encounter. Literature encourages that organizations should design a standard
of work for device management, indicating the device of choice and how each should be utilized
(Parris et al., 2008; Sarker et al., 2014; Son & Chen, 2018). Not only should proper use of
devices and technology be considered, but so should timing, availability, and expectations be
carefully thought-through and designed with work-life balance in mind.
Last minute requests, sensitive emails at the end of the day, and non-urgent phone calls
and texts on the weekends and overnights cause stress for the ENL who requires quality
downtime to rest and rejuvenate (Delecta, 2011; Greenblatt, 2002; Parris et al., 2008). While
many ENLs are compelled to be available to their teams 24 hours a day for emergencies, these
low level disturbances continue to deplete the leader who then may find she has nothing left to
give should a true emergency arise (Bonneville & Grosjean, 2016; Parris et al., 2008; Sarker et
al., 2014; Sullivan, 2014). A culture with no regard for work-life balance does not consider how
communication choices affect leaders on the other end. Whereas a supportive culture strives to
avoid last minute requests, sends sensitive emails early in the workday to allow for clarifications

46

and responses, and creates a communication system for caregivers to utilize rather than
overwhelm a weary ENL overnight.
Finally, expectations regarding communication practice should keep work-life balance in
mind. Valcour (2016) advocates for uninterrupted time to be able to focus. Whereas Sarker et
al. (2014) advocate for known boundaries or else the expectations to be available may spiral out
of control. Even though the salaried position is designed, in theory, to allow greater freedom to
the individual and organization, it may morph into the expectation to remain ‘connected’ 24
hours a day (Loveridge, 2017; Sullivan, 2014; Sarker et al., 2014). Research shows the
expectation of constant accessibility emerges as a top contributor for work-life imbalance.
Requiring ENLs to answer calls, texts, and emails at all hours of the day and night contributes to
depletion of valuable human resources and may lead to burnout (Bonneville & Grosjean, 2016;
Loveridge, 2017; Shirey, 2006).
Cultural Setting: ENL Expectations Compatible with Work-Life Balance.
The organization needs to ensure ENL expectations are compatible with work-life
balance. Using the cultural settings discussed earlier, resources and communication, when
negotiating performance expectations, reality should prevail. The notion that everything is
important, and everything is a priority, is prevalent in most organizations today (Catmull &
Wallace, 2014). However, this is not a sustainable premise and to operate in that manner will
create confusion, tax employees, and produce poor outcomes. Rather, expectations should be
reasonable, clearly defined, and outline clear priorities for the employee to thrive.
To achieve the goal of a work-life balance program, expectations for ENLs must be
developed with balance in mind. The broad healthcare culture currently supports over-
functioning to accomplish unrealistic expectations, which leads to nurse managers working more

47

than 14 hours a day in addition to having after-hours responsibility for their area (Rudan, 2002).
Top leaders need to adjust their expectations for ENLs to be constantly available despite their
exempt status. Other cultural settings that should change to show support are limited late
afternoon meetings, reduced after hours work events, shared emergency coverage to allow for
uninterrupted time away from work, and alternate work schedules to allow for workdays at home
(Buchanan et al., 2013). Literature shows that current ENLs feel they must demonstrate their
loyalty to the organization if away from the office for any length of time (Parris et al., 2008).
Top leaders should develop expectations that support time away thus satisfying two goals,
recovery time for ENLs and active support for a culture of reasonable expectations.
Communication and support for reasonable expectations would also help when other leaders step
in and demand time or other resources from the ENL. This situation can be frustrating for ENLs
whom have been trying to manage their own workload to achieve work-life balance (Parris et al.,
2008). Clear expectations will allow shared understanding and mutual acceptance of work
responsibilities, including expectations for availability.
Cultural Model: Focus on Meaningful Work.
The organization needs to support a culture of meaningful work. The concept of
meaningful work has blossomed in the past several decades and has contributed to the literature
on organizational culture. The cultural model of meaningful work is described as a subjective
experience, a feeling that ones’ work is making a difference and has value (Lips-Wiersma &
Morris, 2009). This embodiment of meaningful work cannot be prescribed or mandated, rather it
is an alignment that is felt between the work one does and the overall mission or values one
carries within their own internal compass (Veltman, 2016).

48

Literature shows that continual changes and a bleak forecast for the healthcare industry is
causing ENLs to feel emotionally exhausted and inadequate, while ultimately questioning their
work (Heeb & Haberey-Knuessi, 2014). ENLs who are on the verge of burnout due to work-life
imbalance feel that their work has lost meaning and they are no longer thriving. The human
flourishing paradigm within the meaningful work culture is needed to help renew the sense of
purpose for the ENL (Lips-Wiersma & Morris, 2009; Veltman, 2016). Resetting priorities,
allowing time for professional enrichment, and reconnecting the work to the mission and values
are action items that will help this culture to develop (Nelson, 2017; Shirey et al., 2010).
Cultural Model: Culture of Psychological Safety.
The organization needs to support a culture of psychological safety. Often coupled with
trust, psychological safety goes beyond the understanding that one will not hurt, but rather
encompasses the belief that one will support and encourage (Schein & Schein, 2017). In this
study, a culture of psychological safety is crucial for ENLs to feel comfortable voicing concerns
about workload, stress, and their own satisfaction and engagement. For ENLs to continue
striving for work-life balance they must trust the organization has their best interests at heart.
Current literature highlights that often ENLs feel if they do not work 16 hours a day or
immediately respond to each impromptu demand they will not advance in their career and will
fall out of favor with the boss (Parkes & Langford, 2008). Rather, ENLs will thrive in an
environment where top leaders show support and trust by reinforcing ENL decisions, allowing
the ENL to work through unit issues without getting prematurely involved, and ultimately
trusting the ENL work ethic and need for balance (Loveridge, 2017).
Since top leaders ultimately set the trend for psychological safety in an organization, it is
necessary that participation and even dissent be valued, and openly encouraged (Berger, 2014).

49

Clark and Estes (2008) maintain that openly communicating about struggles and or problems of
practice within the organization demonstrates concern and facilitates trust (Krosgaard, Brodt, &
Whitener, 2002; Schein & Schein, 2017). Research continues to show that employee
performance is enhanced due to interplay and communication with others in the organization
(Berger, 2014). Furthermore, a culture of open and honest communication would help to combat
situations when silence is interpreted as consent (Morrison & Milliken, 2000).
Support for psychological safety, specifically related to work-life balance, is an important
cultural model to consider for this initiative. When employees are given the chance to express
their thoughts and opinions, they feel as though they have more control over their environment
which is crucial for the ENL who may be struggling with work overload and imbalance
(Morrison & Milliken, 2000). In considering organizational silence, Maslach and Goldberg
(1998) maintain there could be significant organizational social pressures regarding work and
effort that are influencing leader performance. Top leaders in the organization should directly
refute, with active strategies, the notion that imbalance and burnout is just part of the job. Nurse
leaders from one study said they had to regularly demonstrate their commitment to the
organization and felt their alternate work schedule was frowned upon by peers (Parris et al.,
2008). Top leaders must support a culture of psychological safety for the ENLs and continue to
develop novel approaches to ensure the caregivers feel supported, cared for, heard, and trusted.
Furthermore, the executive leaders must support widely the work-life balance paradigm and how
they will bolster the process, with alternate work schedules for example, for the culture of
psychological safety and stakeholder goal to be actualized.
Cultural Model: Positive Work Environment that Fosters Work-Life Balance.
The organization needs to support a positive work environment that fosters work-life

50

balance. Erez and Gati (2004) maintain shared understanding is imperative as individuals only
share culture once they share meaning. Organizations have a responsibility to work with
employees to define and create a positive work environment. Furthermore, the culture that
fosters a positive work environment will serve all employees of the organization. This is
important, as often the group highlighting a problem, in this case the ENLs, may be viewed as an
instigator group or special interest group, and the weight of the message may be diminished
(Agocs, 1997). However, if there is a shared understanding, shared support, and communication
from top leaders, the culture that supports a positive work environment will prevail.
This positive work culture should also include support for work-life balance for all,
especially ENLs through policies, processes, and environment. Exempt nurse leaders have a job
classified as extreme as indicated by research conducted by Buchanan et al. (2013). With
unpredictable workflow, 24-hour availability, increasing numbers of direct reports, large spans of
control, and responsibility for creating a positive work environment on their units, the ENL job is
extreme and thus maintaining work-life balance is arduous. Work-life imbalance contributes to
stress, burnout, and eventual attrition (Kravits et al., 2010; Parkes & Langford; 2008; Rubino et
al., 2009). Top leaders should no longer claim ignorance about stress, burnout, and work-life
imbalance plaguing their ENLs. This veiled ignorance is dangerous as others in the organization
will mimic the behavior and the positive work environment that supports work-life balance will
be even harder to achieve (Agocs, 1997). Finally, the National Academy of Sciences (2020),
formerly known as the Institute of Medicine, has recently added a fourth pillar to their initiatives
for health. Care team wellbeing now joins lower cost, better outcomes, and improved patient
experience to create the quadruple aim (Batcheller, Zimmermann, Pappas, & Adams, 2017).
Within this new aim is the recognition that leaders such as ENLs are responsible for creating

51

positive work environments within their units, and they can only be successful if the overall
culture of the organization supports them, as well as their efforts (Udod et al., 2017). Table 4
offers the assumed organization influences on this performance issue and assessment strategies
to determine assets and needs is also shared.
Table 4
Assumed Organization Influences and Organizational Assessment
Organizational Mission
Using God as our guide and through the ministry of Jesus, we will persevere to serve all
people in need, regardless of situation (Pacific Healthcare, 2018).
Organizational Global Goal
One of five stanchions focus on the growth and motivation of internal caregivers. Pacific
Healthcare (2018) designed a global goal of improving engagement and retaining staff to
support their growth and motivation.
Stakeholder Goal
By May of 2021, SWH will have in place and operational an innovative work-life balance
program geared toward retaining current and attracting future ENLs.
Assumed Organization Influences Organizational Influence Assessment
Cultural Setting Influence 1: The organization
needs to ensure resources meet demands.

Interview to assess stakeholder perceptions of
resource management.

Assess observations and documents to
determine stakeholder practice and
organizational messaging related to resource
management.
Cultural Setting Influence 2: The organization
needs to support a culture of communication
that supports work-life balance.
Interview to assess stakeholder perceptions of
culture of communication.

Assess observations and documents to
determine stakeholder practice and
organizational messaging related to
communication.
Cultural Setting Influence 3: The organization
needs to ensure ENL expectations are
compatible with work-life balance.
Interview to assess stakeholder perceptions of
expectations.

Assess documents to determine organizational
messaging related to stakeholder expectations.

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Cultural Model Influence 1: The organization
needs to support a culture of meaningful
work.
Interview to assess stakeholder perceptions of
meaningful work.
Cultural Model Influence 2: The organization
needs to support a culture of psychological
safety.
Interview to assess stakeholder perceptions of
culture of psychological safety.

Assess observations and documents to
determine stakeholder practice and
organizational messaging related to
psychological safety.
Cultural Model Influence 3: The organization
needs to support a positive work environment
that fosters work-life balance.
Interview to assess stakeholder perceptions of
a positive work environment.

Assess documents to determine organizational
messaging, policies, procedures, and practices
related to a positive work environment.

The organizational needs presented are in direct alignment with knowledge and
motivational needs also present. For ENLs to increase their knowledge of and motivation for
work-life balance, the organization must develop a culture that not only supports work-life
balance directly, but also indirectly through resources, multi-directional communication,
reasonable expectations, meaningful work, psychological safety, and support for positive work
environments.
Conceptual Framework: Interaction of Knowledge, Motivation, and Organization
Offering an easy to understand map that guides the reader through the various elements
of a study is imperative (Maxwell, 2013). Conceptual frameworks weave four pieces of
information together to shape a picture of the study. Experiential knowledge, theoretical
literature, empirical research, and thought experiments come together and help build the concept
and produce a visual framework for the study. Theoretical literature and empirical research pull
from the large body of existing work to add depth and validity. Whereas experiential knowledge
and thought experiments fuel hunches about relationships and influences.

53

This constructed theory helps to drive the study by highlighting possible sampling
strategies, determining the most fitting approach to investigate the research questions, and
offering guide rails to keep the project from straying too far from the original concept (Maxwell,
2013). The conceptual framework also unites the associated influences and offers novel
information to the current body of literature (Merriam & Tisdell, 2016).
This conceptual model, addressing the problem of work-life imbalance for ENLs, utilizes
the Clark and Estes (2008) gap analysis framework within the Turning Research into Results
Process Model. The ENLs were chosen as the stakeholder group being, they provide oversight
for one or more areas in the hospital, have a position depicted as “24/7”, and are overworked,
stressed, and burned out (Shirey et al., 2010; Sliwiriski, 2004; Udod et al., 2017).
This conceptual framework shows how organizational cultural models and settings relate
to and influence knowledge and motivation in supporting the overall goal (Clark & Estes, 2008;
Maxwell, 2013). The goal for this study is that by May of 2021, an innovative work-life balance
program will be in place and operational for ENLs at the stakeholder hospitals.
A constructivism worldview helps to shape this study. Constructivism seasons the study
by recognizing multiple approaches and influences on this problem of practice (Creswell &
Creswell, 2018). Appreciating that many perspectives of a single experience are possible and
remaining open to the journey of exploration are crucial to this study. Also, constructivism
supports the qualitative approach for this study by seeking meaning of individual experiences,
using open-ended questions, and interacting with the stakeholder setting (Creswell & Creswell,
2018; Merriam & Tisdell, 2016). Figure 1 illustrates this conceptual framework.

54

Figure 1
Interaction of Stakeholder Knowledge and Motivation within Organizational Cultural Models
and Settings

This framework illustrates a progression of how once organizational cultural models and
settings are aligned with knowledge needs and motivational influences the problem of practice,

55

work-life imbalance for the exempt nurse leader, is likely to be addressed. The large blue circle
represents the organization, and for this study it is the stakeholder environments of Southern and
Western Hospitals (2018). Organizational influences, presented as cultural models and settings,
are indicated prominently at the top of the circle as they are crucial to the success of the
stakeholder goal. This conceptual framework highlights three cultural models and three cultural
settings. These cultural influences include a culture where resources meet demands (Hewko et
al., 2015), communication is structured to support work-life balance (Clark & Estes, 2008;
Schein & Schein, 2017), expectations are compatible with work-life balance (Nelson, 2017;
Rudan, 2002; Rueda, 2011), meaningful work (Gaskin et al., 2012; Lips-Wiersma & Morris,
2009; Mullen, 2015), a culture of psychological safety (Schein & Schein, 2017), and a positive
work environment that supports work-life balance (Buchanan et al., 2013).
The green circle represents the global goal of the organization which focuses on the
growth and motivation of internal caregivers to improve engagement and retention. Within this
global goal are the knowledge and motivation influences for the stakeholders, represented by the
orange and red squares respectively. The knowledge influences include comprehension of basic
terminology of work-life balance as factual knowledge, while understanding the overall
paradigm of work-life balance and the ability to identify it in action as conceptual knowledge
(Krathwohl, 2002). Procedural knowledge and metacognition, also important, involves
understanding the steps necessary to achieve work-life balance and the awareness to apply work-
life balance to self, respectively (Krathwohl, 2002). The motivational influences are crucial to
include as they drive the knowledge acquired into necessary behaviors to change the ENL
experience and accomplish the stakeholder goal of a work-life balance program. These
influences are that ENLs must value work-life balance and desire to have it for themselves as in

56

Expectancy Value Motivational Theory (Eccles, 2006), believe in their own abilities to achieve
balance in their own lives as evidenced by Self-Efficacy Theory (Pajares, 2006; Rueda, 2011)
and strive for mastery of work-life balance rather than performance as in Goal Orientation
Theory (Pintrich, 2003; Yough, & Anderman, 2006).
In this study, once the knowledge and motivation needs are met within the larger
supportive culture, this in turn will support the ENL experience of satisfaction, engagement, and
retention as illustrated by the interaction arrows leading to the blue square (Rueda, 2001; Schein
& Schein, 2017; Shirey et al., 2010; Udod et al., 2017). It is important to highlight the
organization global goal, green circle, lies within the organization as represented by the blue
circle. The influences of knowledge, motivation, and organization interact and are addressed
simultaneously to promote a synergy effect to fuel the ENL experience of satisfaction,
engagement, and retention which then leads to the stakeholder goal, represented the purple
rectangle, that by May of 2021, an innovative work-life balance program will be in place and
operational for ENLs at the stakeholder hospitals.
Conclusion
The purpose of this study seeks to understand the gaps in performance related to
knowledge, motivation, and organizational influences on the work-life balance of exempt nurse
leaders (ENL). To inform this study, the literature review explored the broad concept of work-
life balance, then narrowed the investigation to include work-life balance for nursing and nurse
leaders, and finally explored briefly, the outcome of allowing work-life balance to spiral down to
stress, burnout, and eventual attrition. Knowledge influences consist of the factual, conceptual,
procedural, and metacognitive knowledge required to achieve work-life balance. Motivation
influences discussed were Expectancy Value Motivational Theory (Eccles, 2006), Self-Efficacy

57

Theory (Pajares, 2006), Goal Attainment Theory (Yough & Anderman, 2006). Organizational
influences explored the cultural settings and models that shape the professional environment
regarding work-life balance. All these influences were then applied to the Clark and Estes
(2008) gap analysis framework within the Turning Research into Results Process Model to create
the conceptual framework for this study. Chapter 3 describes the methodological approach,
including the sampling and data collection strategies.

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CHAPTER 3: METHODOLOGY

Introduction to the Methodology
This innovation case study intended to pinpoint knowledge, motivation, and
organizational influences affecting ENL achievement of a work-life balance program by May of
2021. Employing Clark and Estes (2008) gap analysis framework, this case study collected data
qualitatively, which allowed for the capture of meanings, concepts, experiences, and personal
perspective (Creswell & Creswell, 2018). This chapter outlines the following components of the
study: stakeholder sampling and recruitment, data collection, validation, and data analysis. The
research questions guiding this study include:
1. What are the knowledge, motivation, and organizational needs necessary for exempt
nurse leaders to achieve an innovative work-life balance program by May 2021?
2. What is the interaction between organizational culture and the exempt nurse leaders
knowledge and motivation to achieve an innovative work-life balance program?
3. What are the recommended knowledge, motivation, and organizational solutions to
those needs?
Participating Stakeholders
The stakeholder population of focus for this study was ENLs within Southern

and
Western Hospitals (a pseudonym; SWH). According to the hospital’s organizational charts there
are roughly 45 leaders within the hospitals that fit a broad description of ENL. The intention of
this study was to gather data and lay forth a plan for an innovative work-life balance program
designed primarily for front-line leaders. Therefore, nurse executives and other nurse leaders far
removed from the bedside were not the target audience. Even so, while not the stakeholder
group of focus, these executives were important to the overall success of the goal. They will be

59

called upon to exercise their authority and power to support the overall goal and communicate
the importance of work-life balance for the ENLs (Bogue & Carter, 2019). For the purposes of
this study, participating stakeholders were ENLs that directly supervise front-line nurses.
Furthermore, their positions are designed with exempt status, meaning they have no set work
hours, are not eligible for overtime pay, and are ultimately responsible for their patient care areas
24-hours a day, seven days a week.
Sampling Criteria and Rationale
The sampling strategy for this study was purposeful and therefore certain criteria for
participation was met to gather the best data possible. Identifying appropriate participants is one
of the most important aspects of a qualitative study. The sample size is usually small, and it is
crucial the participants be able to inform the research questions and offer rich detail of the
problem of practice. The following was the criteria for participation in this study.
Criterion 1. Permanent Employment
ENLs sampled included only permanent employees with the organization. Persons hired
from outside agencies to temporarily fill leadership positions were excluded from this study as
they did not receive the same detailed orientation and training content, nor have the same level of
commitment expected from permanent employees.
Criterion 2. Official Titles
ENLs sampled included only those with official titles of Director, Nurse Manager,
Assistant Nurse Manager, or Clinical Supervisor. Permanent employees asked to cover duties of
vacated leadership positions were excluded as they were not officially in the position and were
only asked to cover for a short duration.

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Criterion 3. Tenure
ENLs sampled must have been with the organization for at least one year prior to the data
collection. ENLs new to the organization or new to the position were excluded from this study
as they were still in orientation and had not yet assumed full responsibility for their area.
Interview Sampling (Recruitment) Strategy and Rationale
The intention for this study was to gain as much data and insight regarding the
knowledge, motivation, and organizational influences affecting the ENL to achieve work-life
balance. Therefore, the recruitment strategy needed to yield the most amount of purposeful data
feasible within the time allowed. Since qualitative research has a unique approach to scholarly
inquiry and randomization is not necessarily the goal, the researcher used purposeful sampling.
After creating a database of all ENLs fitting the above criteria at each hospital, volunteers were
sought from the ENLs at SWH (See Appendix A for Recruitment Letter). This process of
seeking voluntary participants continued until five ENLs from each location had been
interviewed. The intent of this study was to produce internal generalizability so understanding
variation in the smaller sample (of ENLs) studied was crucial when analyzing the data collected
(Maxwell, 2013).
Observation Sampling (Access) Strategy and Rationale
Unique to qualitative research, nearly anything that happens during the course of a study
may become data, therefore it was exceptionally important to be observant from inception
(Maxwell, 2013). More specifically, observation is often included in qualitative research to add
depth to interviews and document analysis (Merriam & Tisdell, 2016). The technique of
observing for research is not an easy task and requires focus (Patton, 2002). For this study, the
researcher used observations to explore knowledge and motivation needs, and to a lesser degree

61

organizational influence albeit from the stakeholder perspective. As the conceptual framework
indicates, the way knowledge and motivational needs interact within the culture of the
organization is rich with information. Observations on behavior, process, and skill, often offer
insight to the congruence of other data collected (Johnson & Christensen, 2015). The
observations occurred in two major settings: the interview and the overall process of data
collection.
Document Criteria and Rationale
Documents are another form of data that adds depth to a qualitative research study.
While some documents may inform research questions, provide background and context, and
verify other findings, others may serve no purpose in the study (Creswell & Creswell, 2018). It
was important to set criteria for document use to ensure credible content analysis. The following
were the criteria for document collection in this study.
Criterion 1. Approved by Organization
To bolster credibility, documents collected for this study were either authored by the
organization or sanctioned by the organization if authored by an outside party. Often
organizations use outside services to provide resources to employees. The documents from these
resources were approved for distribution through the organization and therefore, considered for
analysis in this study if applicable in content.
Criterion 2. Current Documents
Documents used for this study were current (within three years) and recently acquired for
analysis. This helped to ensure the content was timely.

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Qualitative Data Collection and Instrumentation
This innovation case study intended to pinpoint knowledge, motivation, and
organizational influences affecting ENL achievement of a work-life balance (WLB) program by
May of 2021. Based on the purpose of this project and the exploratory nature of the research,
this case study utilized a qualitative approach. Collecting data qualitatively allowed for the
capture of meanings, concepts, experiences, and personal perspective (Creswell & Creswell,
2018). Researchers using a qualitative approach strive to offer exquisite portrayal of what is
happening as understood and experienced by each stakeholder (McEwan & McEwan, 2003).
Wolcott (1990) echoes this sentiment and maintains that the search for understanding, rather than
truth, is the objective in qualitative research.
In this case, a constructivism worldview was forefront and supported the qualitative
approach for this study by seeking meaning of individual experiences, using open-ended
questions, and interacting with the stakeholder setting (Creswell & Creswell, 2018; Merriam &
Tisdell, 2016). A constructivist worldview maintains many perspectives of a single experience is
possible and the context of the situation makes the meaning for each individual (Creswell &
Creswell, 2018). For this study, how each nurse leader interprets and makes sense of a shared
concept was the focus.
Three qualitative data collection methods were utilized in this study: interviews,
observations, and document analysis. Interviews and observations explored knowledge,
motivation, and organizational influences through the verbalized experiences of the ENLs and
the observation skills of the researcher. While document analysis investigated the organizational
influence of the problem of practice. More information on each collection method follows.

63

Interviews
Interviews, arguably the principal method used in this research to obtain data, allowed for
an interpersonal exchange between researcher and ENL and within this exchange, rapport and
trust was built to encourage rich discourse and unabated participation (Patton, 2002, 2014).
The interviews were semi-structured to allow the researcher to keep the interview on
track with predetermined topics yet was flexible enough to allow the ENL the freedom to
meander within the broad topic (Johnson & Christensen, 2015). Using this approach to
interviewing was intentional, as the work-life balance concept may be deeply personal, it
allowed the ENL the freedom to describe what was meaningful for them. Maxwell (2013)
cautions that the questions should not be too general or stiff, but rather interesting, to allow for an
expressive response. The researcher in this study asked open-ended questions to allow the ENL
the freedom to share personal insights and meaningful experiences.
The interview questions were also connected to the conceptual framework for this study.
Knowledge and motivational needs, just as organizational influences, were important to consider
in addressing this problem of practice (See Appendix B for list of interview questions). The
conceptual framework highlights several knowledge needs such as, comprehension of basic
terminology of work-life balance, understanding the overall paradigm of work-life balance and
the steps necessary to achieve it, and the awareness to apply work-life balance to self
(Krathwohl, 2002). Interview questions directly addressed these knowledge needs with
questions about current knowledge and past experiences with WLB, and how WLB applies to
self. The motivational needs were also crucial to include as they drive the knowledge acquired
into necessary behaviors for change (Moody & Pesut, 2006). Interview questions mirrored the
framework and included queries surrounding how the ENL values WLB as in Value Expectancy

64

Theory (Eccles, 2006; Wigfield & Cambria, 2010), if they believe in their own abilities to
achieve balance in their own lives as evidenced by Self-Efficacy Theory (Pajares, 2006; Rueda,
2011), and how they work toward balance for their own lives as in Goal Orientation Theory
(Pintrich, 2003; Yough, & Anderman, 2006).
There were 36 ENLs that met the criteria for inclusion, and this study interviewed 10, or
28%. In qualitative interviewing there is no set number to aim for, rather saturation of the data
was the goal (Merriam & Tisdell, 2016; Patton, 2002, 2014).
The individual interviews were between 56 and 109 minutes, conducted in English and in
person at the ENL’s office in the hospital. As current literature will attest, the ENL has very
little free time throughout their day so it was important to allow them to choose the time for the
interview that would work best with their schedule (Shirey et al., 2010; Sliwiriski, 2004; Udod et
al., 2017). Interviews were audio recorded, with consent, to allow for ease of thematic coding.
In addition, the researcher took notes on a printed copy of the research questions for each
participant to keep data organized. These journal notes, along with the recorder and audio file
were kept in a locked box at the home of the researcher during the study and will be destroyed
once this study is complete.
These interviews were professional in nature yet informal enough to allow for a relaxed
interview atmosphere. While interviewing in the ENL’s office was intentional due to
observation opportunities, the researcher was prepared to be flexible should the ENL desire a
different location. Overall it took approximately 14 hours to interview ten ENL stakeholders for
this research study.

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Observations
For this study, the interview process and actual interview were the focus for the
observations. The researcher role was known and functioned as a participant observer. As the
researcher was the collection instrument, this observer stance afforded the researcher the
opportunity to ask questions about the observation if warranted (See Appendix C for the
Observation and Document Analysis Checklist).
The researcher explored the ENL office for evidence of items related to WLB such as
family photos, children’s artwork, photos of pets or vacations, and other items depicting time
outside of work. Observations were also utilized as the ENL proceeded through the interview
questions. Body language, verbal as well as non-verbal reactions to questions, and responses to
the interview activities were observed. Furthermore, observations also captured content the
interviewee may not have intended to share, such as eye rolling, fidgeting, and exhaling loudly
(Maxwell, 2013). Finally, the researcher intently observed the overall process of data collection,
for example, the process of scheduling and conducting the interview and the climate in the ENL
office (i.e. interruptions, noise, etc.).
While audio recording captured verbal content throughout the interview, the researcher
was free to capture observations. The researcher documented in as much detail and as
objectively as possible as the data was triangulated later with the verbal content from the
interview and document analysis. The researcher spent approximately 15 hours observing within
the interview setting and approximately two additional hours observing the overall process of
data collection.

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Documents
While the topic of work-life balance is often a personal, subjective experience, objective
documents do exist to shed light on the organization’s role within the topic. For this study,
several documents, such as ENL job descriptions, talent acquisition recruiting materials, nursing
annual reports, and human resources benefits information were analyzed. These documents are
public domain therefore no permission to use was necessary.
These documents, written from the organization perspective, were analyzed to see if the
broad topic of work-life balance was contained within, and furthermore to ascertain if the various
messages were congruent not only with one another but also with other data collected (See
Appendix C for the Observation and Document Analysis Checklist).
Collection of these materials was in line with the conceptual framework for this study.
The framework illustrates how organizational cultural models and settings relate to and influence
knowledge and motivation in supporting the overall goal (Clark & Estes, 2008; Maxwell, 2013).
The framework also shows a progression of how once cultural models and settings are aligned
with knowledge needs and motivational influences, the problem of practice, poor WLB, is likely
to be addressed. The conceptual framework highlights three cultural models, meaningful work
(Gaskin et al., 2012; Lips-Wiersma & Morris, 2009; Mullen, 2015), a culture of psychological
safety (Schein & Schein, 2017), a positive work environment that supports work-life balance
(Buchanan et al., 2013), and three cultural settings, a culture where resources meet demands
(Hewko et al., 2015), communication is structured to support work-life balance (Clark & Estes,
2008; Schein & Schein, 2017), and expectations are compatible with work-life balance (Nelson,
2017; Rudan, 2002; Rueda, 2011). The documents were analyzed for language and content
congruent with the organizational settings and models necessary to support WLB.

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Alignment of the KMO Influences and Data Collection
Table 5 shows each KMO influence and the method and measure of the influence. By
examining the rows, the alignment of the influences and methods is demonstrated.
Table 5
Alignment of the KMO Influences and Methods of Data Collection
Knowledge
Influence
Interview Question Observation Document Analysis
Factual - Exempt
nurse leaders need to
define work-life
balance
What is your
definition of work-
life balance (WLB)?

Conceptual - Exempt
nurse leaders need to
understand the
concept of work-life
balance
Literature indicates
there are many
factors that influence
WLB. What are the
top 5 items that
influence YOUR
WLB?
❏ Working hours
❏ Work schedule
❏ Control workday
tasks
❏ Control over
personal time
❏ Bringing work
home
❏ Bringing life to
work
❏ Last minute
requests
❏ Other ENLs work
habits
❏ Calls/emails/texts
from personal life
at work
How easy or difficult
is it for them to rank
the list?

Watch for body
language,
commentary,
emotions, etc.
Activity form

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❏ Calls/emails/texts
from work during
personal time
❏ My personality
❏ Exempt status of
position
❏ Use of technology
❏ Other:
Procedural - Exempt
nurse leaders need
knowledge of the
steps to balance work
and life
What strategies are
you aware of that
could help you with
your WLB?

If you were told
tomorrow that you
must have a balance
of your work and life,
what would you do
first?
Organization blog on
health benefits:
Notice of expansion
of virtual mental
health and wellness
concierge services
Metacognitive -
Exempt nurse leaders
need knowledge of
how work-life
balance applies to
self.
What things do YOU
currently do that
influences your work-
life balance either
positively or
negatively?

Expectancy Value
Motivational Theory
(Eccles, 2006) –

Exempt nurse leaders
need to see value in
having a healthy
work-life balance.

What do you think
you may gain by
having a healthy
WLB?

What do you think
you might you lose?

Observe the
workspace for family
photos, vacation
memories, or other
life represented.

Observe the ease of
recruitment,
scheduling, and
completion of the
interview.

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Self-Efficacy
(Pajares, 2006) –

Exempt nurse leaders
must believe they are
capable to have a
healthy work-life
balance.
Using the scale
below...
0 = not confident at
all
10
20
30
40
50 = moderately
confident
60
70
80
90
100 = highly
confident

Please rate how
confident you are that
you are capable to do
the following right
now...
___ control working
hours
___control work
schedule
___control workday
tasks
___control over
personal time
___not bring work
home
___not bring life to
work
___control last
minute requests
___ignore ENLs
work habits
___avoid
calls/emails/texts
from personal life at
work
___avoid
calls/emails/texts
from work during
personal time
Behavior during
activity.
Activity form.

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___alter personality
___change exempt
status of the ENL
position
___limit use of
technology
Goal Orientation –
Mastery (Yough &
Anderman, 2006)

Exempt nurse leaders
should work toward
balancing work and
life.

Are you happy with
where your work-life
balance is right now?

What are you doing
to actively improve
your work-life
balance?

How important is it to
you to be proficient at
balancing your work
and life?

How do other ENLs
work habits influence
your WLB?
Behavior during the
interview.

Organizational
Setting -
The organization
needs to ensure
resources meet
demands.
How many direct
reports do you have?

Do you have the
necessary resources
to handle the
workload of your
position?

What resources are
available at work to
help you improve
your work-life
balance?
Observe the ease of
scheduling the
interview based on
availability of the
ENL to fit this time
into their schedule.

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Organizational
Setting -
The organization
needs to support a
culture of
communication that
supports work-life
balance.
How does
organizational
communication
influence your WLB?

What is
communicated about
work-life balance?
Observe the climate
of the workspace and
if the interview is
interrupted by
caregivers.
Outgoing email
message during time
away.
Organizational setting
-
The organization
needs to ensure ENL
expectations are
compatible with
work-life balance.
What do you believe
are your supervisor’s
expectations about
your availability?

How do these
expectations
influence your WLB?
Organization website,
career opportunities:
Job Description of
Nurse Manager.

Outgoing email
during time away.
Organizational model
-
The organization
needs to support a
culture of meaningful
work.
How much of your
job is meaningful
work?

How does that
influence your WLB?

Organizational model
-
The organization
needs to support a
culture of
psychological safety.

How comfortable do
you feel to speak up
at work when you
have a question or
safety concern?

How safe do you feel
in the organization’s
social climate to
discuss issues around
work-life balance?
Observe the climate
of the workspace and
the physical
positioning of
participant and
researcher during the
interview.

Display of emotions.
New Employee
Orientation, High
Reliability
Organization hand-
out related to
“Speaking Up for
Safety”

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Organizational model
-
The organization
needs to support a
positive work
environment that
fosters work-life
balance.
How is WLB
perceived within this
organization?

How does the overall
work environment
influence your work-
life balance?

Human resources
benefits:
● PTO benefits
● Caregiver
Assistance
Program

Spiritual Care
Services

Organization website,
career opportunities:
● Job Description
of Nurse Manager
● Wellness Program

Nursing Annual
Report 2018:
● Strategic Plan

Data Analysis
Data analysis allows for the transformation of individual data points into themes,
patterns, and salient information to support hunches and inform conclusions. For qualitative
research, and specifically interviews, observations, and documents, analysis begins during data
collection. Interviews were audio recorded, transcribed, and coded within one week of the
interview. Researcher notes were also used for triangulation of the data.
During the first stage of analysis, using the conceptual framework, empirical codes
generated from the interviews were cataloged. Next, the data was filtered using a priori codes
created ahead of time from the literature review and general knowledge of the topic. The
researcher then explored the data using open coding, looking to identify pattern codes and
themes that emerged in relation to the conceptual framework, but which fell outside the study
questions. Finally, the researcher analyzed observations and documents for evidence that aligns
with the concepts in the conceptual framework.

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Trustworthiness and Credibility
Researchers have an ethical responsibility to incorporate rigor and high standards into
their study to produce information that is judicious. This is especially important in studies that
affect vulnerable populations or contain sensitive material (Merriam & Tisdell, 2016). Two
terms that are most associated with qualitative research, although contested in the literature, are
trustworthiness and credibility (Creswell & Creswell, 2018; Merriam & Tisdell, 2016).
Trustworthiness
In qualitative research, trustworthiness often refers to the character of the researcher
(Horsburgh, 2003). This is especially critical as the researcher is the primary instrument in
qualitative studies and recognizing the gravity of this responsibility is important to instill
confidence. There are several things researchers can do to improve their trustworthiness in the
eyes of the reader. This study employed two strategies, identify and address biases and
reflexivity.
Biases
While unable to eliminate biases completely, the researcher has a responsibility to be
self-aware and employ strategies to limit how they may interfere with the research (Maxwell,
2013). The researcher in this study had personal feelings about the stakeholder group and the
topic in general, but to enhance trustworthiness the researcher allowed the study to unfold
naturally. Furthermore, the researcher did not hand pick complementary data to satisfy personal
objectives. One of the most beautiful aspects of qualitative research is how connected the
researcher is to the study. Appropriately managing this connection however was key to
producing quality work.

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Reflexivity
Reflexivity, different from bias, is the influence of the researcher on participants, study
environment, or analysis of the data (Maxwell, 2013). The researcher of this study employed
several tactics to reduce this influence. The researcher was careful to not interject their own
experiences with WLB during the interviews, so the content was representative of the
interviewee. Furthermore, while the researcher may have had hunches as to how interviewees
may respond to questions and how they may feel toward the organization, the researcher did not
let those hunches inappropriately steer the interview, did not ask leading questions, nor tilt the
data analysis. Furthermore, the researcher was aware how their qualifications, experiences,
history, and even socioeconomic status had the potential to shape and flavor the study (Creswell
& Creswell, 2018). Finally, the researcher disclosed to the IRB and all interviewees their
previous employment position of ENL within the study organization. This acknowledgment
served to increase trustworthiness by establishing the researcher’s connection to the study, while
also facilitating credibility in that it made known how well informed the researcher is on the
environment of the study.
Credibility
Where trustworthiness is representative of the character of the researcher, credibility is
related to the study design and analysis of the data collected (Creswell & Creswell, 2018).
Efforts to enhance rigor and tenability should be employed in all qualitative research. This study
applied two strategies: triangulation and the inclusion of divergent data.
Triangulation
One popular strategy to increase credibility is to use triangulation (Maxwell, 2013).
Including subjects from different settings and a variety of data collection methods will not only

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help to test alignment of the data, but will also allow for greater profundity (Maxwell, 2013).
This study interviewed ENLs from two hospitals serving a variety of hospital departments.
Furthermore, as discussed in the previous section, three data collection methods were used for
this study: interviews, observations, and document analysis. Finally, triangulation allows for a
broader look at a central concept (Maxwell, 2013). Using interviews and observations gains
insight into individual perspective and experiences, and document analysis leads to greater
understanding of the organizational perspective.
Inclusion of Divergent Data
Another strategy to increase credibility of the research is to include data that does not
support the researchers hunches nor the expected conclusion (Creswell & Creswell, 2018;
Maxwell, 2013). While most data supported the theme, there was also dissenting data included
which adds to the depth of the study. Merriam and Tisdell (2016) support that including
discrepant evidence is in alignment with the constructivist worldview that there are multiple
viewpoints resulting in multiple realities, so to include those that are contrasting add to the
credibility of the research.
Ethics
Ensuring research is conducted ethically is of greatest concern to the primary investigator
(PI), or researcher of each study. To produce ethically sound research, the researcher should
consider, in advance, possible ethical concerns and have a plan in place to handle such situations
(Merriam & Tisdell, 2016). Furthermore, the researcher must ensure certain safeguards, so no
participant is harmed throughout the course of the investigation (Glesne, 2011). This section will
discuss necessary considerations such as, Institutional Review Board (IRB) approval, informed
consent, confidentiality, and the role of the researcher.

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The purpose of this study was to understand ENLs experience with work-life balance.
This study involved human subjects and was therefore mandated to follow a certain code of
ethics (Glesne, 2011). To satisfy certain mandates, this study was submitted to both the
University of Southern California IRB, as well as Pacific Healthcare IRB for approval. Once the
study received approval from both IRBs, it followed all inherent rules and regulations for an
ethically sound research study.
Ethical integrity is especially salient as in-person interviews were employed as the
primary data collection method. With interviews, there is always the potential to discuss
sensitive material, therefore, stakeholders were fully informed of the purpose of the study and
asked to provide informed consent at the first interview meeting. The written informed consent
included several elements related to their participation in the study. The informed consent
clarified that participation is voluntary, and participants were free to leave the study at any time
and for any reason.
To establish credibility and confidence, participants were informed that their identities
and interviews would be kept confidential, and raw data protected both in a locked drawer and
on a password protected computer (Creswell & Creswell, 2014). The researcher emphasized that
no raw data would be shared with the leadership of the organization. A separate verbal
permission was sought from each participant to audio record the interview. These audio files
were kept on a password protected computer and pseudonyms were given to participants when
interviews were transcribed into the dissertation. The researcher explained that every reasonable
measure would be taken to reduce the possibility of connecting content in the dissertation back to
individual stakeholders.

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It is appropriate to disclose the researcher relationship with the organization included in
the study. At the time of data collection, the researcher was employed at the same organization,
yet within a different department than any of the ENL participants. During the time of the study,
the researcher was considered a peer, maintained professional working relationships with study
participants, and, in no way had any supervisory responsibilities over any ENLs interviewed for
the study. The researcher approached the interviews with respect and realized the significance of
stakeholders sharing details of their professional and personal lives. Maxwell (2013) cautions to
hold these relationships sacred, especially while participating in the research.
The researcher did have intimate knowledge of the stakeholder role since holding an ENL
position at the study location prior to 2018. This experience served to inform the study but in no
way interfered or proved detrimental to the research. While the researcher had a vested interest
in the research topic and wanted the goal of the study to be actualized, it was the responsibility of
the researcher to be aware of the potential bias and work to minimize assumptions (Glesne,
2011). The researcher’s former role was disclosed to the IRBs, the dissertation committee, and
each ENL who participated in this study. The researcher also made very clear the desire was to
hear participants experiences, rather than taint the discussion with her own. Furthermore, the
researcher emphasized the study was conducted to fulfill the requirements of a doctoral program
and was not related to the researcher’s employment with the organization. The researcher also
made clear the intention of the study was to gather data from current ENLs, explore the related
literature, and offer evidence-based strategies to the leadership of the organization for how to
implement an innovative work-life balance program. There was no monetary incentive offered
to the stakeholders to participate in the study, however the potential professional and personal
benefits to participating such as helping to solve a problem of practice, participating in valuable

78

research, and the opportunity to have their voice be heard on an issue that has a direct impact on
professional work and personal lives was shared. The researcher sent a note of appreciation to
each participant after their interview.

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CHAPTER 4: RESULTS AND FINDINGS

This innovation study seeks to identify stakeholder knowledge and motivation influences,
and organizational resources necessary to achieve the goal that by May of 2021, Southern and
Western Hospitals (a pseudonym) will have in place and operational an innovative work-life
balance program geared toward retaining current and attracting future ENLs. This study has
utilized the gap analysis framework with a qualitative design. This chapter first reviews the
stakeholder participants in the study and then outlines the findings and results from stakeholder
interviews, observations, and organizational documents in relation to the three research
questions:
1. What are the knowledge, motivation, and organizational needs necessary for exempt
nurse leaders to achieve an innovative work-life balance program by May 2021?
2. What is the interaction between organizational culture and the exempt nurse leaders
knowledge and motivation to achieve an innovative work-life balance program?
3. What are the recommended knowledge, motivation, and organizational solutions to
those needs?
To address these research questions, the researcher conducted ten interviews, with
concurrent and subsequent observation, and document analysis. The data collection for this
study took place over a five-week period at Southern and Western Hospitals.
Participating Stakeholders

This qualitative study invited ten female nurse leaders to participate, and all ten accepted
and completed the interview process. All participants had been exempt nurse leaders in the
range of one to five years. Other similarities included marital status with 80% married and 20%
single, and nursing education with 90% educated at a bachelor's degree level, while 10% had a

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Master’s in Nursing. Furthermore, the group consisted of one Director, three Nurse Managers,
and six Assistant Nurse Managers. It was important for the study to ensure a variety of clinical
areas were included, therefore three ENLs were from specialty care areas, one from a procedural
area, four represented critical care areas, and two from general medical/surgical units.
Determination of Assets and Needs

The sources of data for this study consisted of interviews, observations, and document
analysis. By using three methods of data collection, methodological triangulation of data was
possible. Each data collection method was standardized to corroborate what information the data
was offering. Interviewing ten participants was anticipated from the start of this project,
however the researcher was prepared to increase or decrease the number based on saturation and
redundancy of data collected. The interviews conducted were plentiful with information to
determine if influences were a need or an asset, therefore the decision was made to cease after
the initial ten were complete. The researcher determined saturation was reached as no new
information was coming forth upon completing the last several interviews. The same
observation periods were noted for each participant and while documents were plentiful, only
those directly applicable to the topic of work-life balance were analyzed.
This study considered an influence an asset if at least 60% of ENLs interviewed were
able to speak to the influence, verbally respond in such a way that established no doubt of
understanding and critical thinking regarding the question content, and, if necessary, a response
on the positive side of the continuum indicating a support for work-life balance. Observations
and documents helped to either support the content from the interviews or show a disconnect.

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Results and Findings for Knowledge Causes
This section reports on the findings of the interviews, observations, and documents as
they relate to the research questions. Thus, the results and findings are reported through the
specific lenses of KMO influences identified in the conceptual framework and the literature. The
chapter concludes with a discussion of these results and findings as they interact and triangulate
each other.
Factual Knowledge
Influence 1 Exempt nurse leaders need to define work-life balance.
Survey Results. No surveys were conducted for this study.
Interview Findings. Participants were asked to define work balance. Seven out of ten
exempt nurse leaders were able to articulate a definition of work-life balance found in the
literature. Participant 5 defined work-life balance as, “Being able to have time away from work
where, I get to turn off and shut down and spend time on things other than work.” Participant 7
agreed and added that work-life balance for her is “The ability to separate the two [work and
life], to be able to have a fulfilling life stress free life outside of work.” Participant 2 asserted, “It
means trying to make sure that there's enough time for family and friends and doing things that I
just want to do for myself rather than what I need to do for work.” Conversely, three participants
did not include definition elements such as enough energy to attend to all areas of life, a balance
of time between areas of life, nor a mention of attending to something in life other than work.
Participant 6 offered her definition of work-life balance is, “Shut off work, and focus on my
home life.” This definition is missing the element of energy and balance. Participant 1 is
missing the elements of balance while her definition implies that work is the driver, “There is

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always something going on so you kind of have to make the hours and the job and the schedule
work for you and work for the other people in your lives.”
Observation. No observations were conducted for this influence.
Document Analysis. No document analysis was conducted for this influence.
Summary. The assumed influence that exempt nurse leaders need to define work-life
balance was determined to be an asset as 60% of the participants provided a satisfactory
definition.
Conceptual Knowledge
Influence 2 Exempt nurse leaders need to understand the concept of work-life balance.
Survey Results. No surveys were conducted for this study.
Interview Findings. Participants were given a list of 13 influences gathered from the
literature on work-life balance and asked to identify the top five that affect their work-life
balance. While participants were not asked to generate the list of influences, they were asked to
explain and elaborate, thus through this process demonstrate their conceptual knowledge. The
data revealed seven participants indicated last minute requests negatively affected their work life
balance. While the influences of my personality, use of technology, and calls, texts, and emails
from work on my personal time were chosen by six participants. Seven participants felt the
provided list of influences covered their situations, while only three participants provided an
additional influence in the other category. See Figure 2 below for graphic representation of
influences chosen.

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Figure 2
ENL Selection of Work-Life Balance Influences

Note: The table above shows the number of ENLs choosing each influence as one the top five
that affect their work-life balance.

Observation. The observations noted for this influence included participant behavior
during the short activity. It was observed that all participants circled the first three influences
with relative ease and speed. Whereas the final two influences took more time and thought to
render a response. All participants relinquished the activity sheet without hesitation when they
completed the activity.
Document Analysis. The document available for this influence is the actual activity
form from each participant. The document was used to further the conversation regarding what
the participant chose.
0
1
1
1
1
2
3
4
4
4
4
5
6
6
6
7
Bringing Life to Work
Calls, Emails, or Texts From My Personal…
Other: Commute
Other: 2nd Job
Other: Family/Kids
Control Over My Personal Time
Other ENL Work Habits
Work Schedule
Control Over Workday Tasks
Bringing Work Home
Exempt Status of My Position
Working Hours
Calls, Emails, or Texts From My Work…
My Personality
Use of Technology
Last Minute Requests
ENL Selection of Work-Life Balance Influences
N = 10

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Summary. Overall, participants in this study demonstrated an understanding of the
various categories, and larger concepts of work-life balance. They were able to use the cognitive
process to understand, apply, analyze, and evaluate the various influences of work-life balance.
Therefore, conceptual knowledge was determined to be an asset.
Procedural Knowledge
Influence 3 Exempt nurse leaders need knowledge of the steps to balance work and life.
Survey Results. No surveys were conducted for this study.
Interview Findings. Participants were asked two questions regarding procedural
knowledge of work-life balance (a) What strategies are you aware of that could help you with
your work-life balance?; (b) If you were told tomorrow that you must have a balance of your
work and life, what would you do first? For the first question about strategies, only two ENLs
responded with strategies to help their work-life balance. Participants 1 and 2 offered that they
would make changes to their work schedules to better support time away from the work setting.
Three ENLs replied that they did not know of any strategies, and four offered stress relieving
activities. Participant 4 offered a list of activities, “Exercise or yoga or meditation or massage or
the calm app. But I don't think these give me overall satisfaction like I have a good work life
balance.” Additionally, Participant 6 offered,
Outside of work, I think just a regular exercise or routine or hobby, traveling especially
out of the country so you don't have as much access to the technology. I don’t have a
routine. I would have a hard time following one, because of work hours.

While hobbies and activities such as, exercise, walking the dog, and traveling might be suited for
stress reduction they are not considered strategies to help re-shape the experience of work-life
balance.

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For the second question, “If you were told tomorrow that you must have a balance of
your work and life, what would you do first?”, the responses were more in line with literature on
work-life balance. Fifty percent of ENLs responded with structural changes to their jobs, hours
worked, or job tasks. The other 50% of ENLs were unable to verbalize changes they would
make, or offered activities, such as yoga, that would be short-lived and not directly related to
strategies for improving work-life balance.
Observation. No observations were conducted for this influence.
Document Analysis. The document analyzed for this influence is found on the
organizations blog connected to the health benefits program for employees. This document was
a notice of an expansion of a virtual mental health and wellness concierge service for caregivers
to address all facets of burnout. None of the participants in the study referenced this offering.
Summary. These participants lack procedural knowledge defined in the literature for
the steps or process in establishing and maintaining work-life balance. Several participants
spoke of calming activities, yet failed to elucidate on the strategy involved, or steps necessary to
establish a healthy work-life balance. Even more telling was the fact that five out of ten
participants interviewed admitted that although strategies and resources may exist, they have not
explored them. Participant 5 admitted, “There are a lot of things that are available if you choose
to go that path.”, and Participant 3 maintained, “So even if there are a lot of strategies, I am
going to spend time with the kids.” Both statements demonstrated that the participants admit
strategies exist, but also showed an inability to offer specifics and revealed a reluctance to
explore them. Therefore, this influence was determined to be a need.

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Metacognitive Knowledge
Influence 4 Exempt nurse leaders need knowledge of how work-life balance applies to self.
Survey Results. No surveys were conducted for this study.
Interview Findings. Participants were asked; What things do you currently do that
influences your work-life balance either positively or negatively? While all participants were
able to offer isolated actions that influence their work-life balance, only one participant had spent
any time thinking and reflecting on their work-life balance. Participant 9 offered that she did
considerable work on herself this year to cope with the demands of the job. Conversely, the rest
of the participants admitted their actions to increase the positive influences and limit the negative
were haphazard and infrequent. Participant 5 admitted, “A big part of the problem is that I don't
do anything really on a daily or weekly basis. I wait until I’m so overwhelmed and then take a
chunk of time to kind of recuperate.” Participant 10 said she is serious about her one day off per
week, yet she still answers calls, texts, and emails, and therefore does not allow herself to
disconnect from work. Participants 2 and 8 admitted to staying late nearly every day and
verbalized the need for an external commitment that would force them to leave at the end of the
day.
Observation. No observations were conducted for this influence.
Document Analysis. No document analysis was conducted for this influence.
Summary. Ninety percent of the participants interviewed lack metacognitive knowledge
of how work-life balance applies to self. While participants were able to articulate vacations,
yoga, and concerts as activities they participate in, they did not articulate the process of thinking
about work-life balance. Rather, their poor work-life balance is something that is happening to
them, rather than within them. Therefore, this influence was determined to be a need.

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Results and Findings for Motivation Causes
Expectancy Value Theory (Eccles, 2006)
Influence 1 Exempt nurse leaders need to see value in having a healthy work-life balance.
Survey Results. No surveys were conducted for this study.
Interview Findings. Participants were asked two questions regarding this influence (a)
What do you think you may gain by having a healthy work-life balance?; (b) What do you think
you might lose? One hundred percent of participants offered positive statements about what they
would gain. Participants 3 and 4 would have “less guilt from home” and “be more present with
family and friends” respectively. Somewhat surprising was that several participants spoke that
they would gain professionally by improving their work-life balance. Participant 5 felt that she
would enjoy work more. Participant 7 offered that she would be a better leader. Finally,
Participant 9 said she would have, “good relationships at work and home.”
When participants were asked what they might lose by having a healthy work-life
balance, 50% indicated there would be nothing to lose. Whereas the other 50% offered
insightful responses such as “sense of control”, “producing quality work”, and “respect from co-
workers.” Participant 9 offered,
Yes, I feel like I might lose a little bit here, because I don't put in the time that I probably
could to be better at my job. I feel like I'm very dedicated to this place and to this
hospital, and to my job and to my co-workers. But I am not dedicated enough that I'm
going to give up my life for this job.

Observation. Observations conducted for this influence were related to physical
reminders of life outside of work on display in participant offices and ease of recruitment for the
study. Eighty percent of the participants had personal photos, child artwork, vacation pictures, or
greeting cards displayed in their offices. One participant even had a replica of a favorite piece of
exercise equipment on her desk, and when asked she said it was an activity she loved, and it

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reminded her to take care of herself. One interview took place outside the ENL office, so no
observation was conducted. Finally, only one participant had no personal effects in her office.
When asked she said that she usually does, but she just had not had any time to put anything up,
and furthermore, she heard she would be moving offices soon, so she did not want to decorate
only to have to take everything down.
When considering whether participants valued the paradigm of work-life balance, the
ease with which the researcher was able to secure participants and conduct interviews was
considered. One hundred percent of the participants were easy to recruit as all said yes
immediately to participate. Fifty percent of the participants were easy to schedule, and the
interviews were completed on the first attempt with no obstacles. One participant was delayed in
responding to the request to set up a time for the interview, and four participants rescheduled
their interview between one and three times. Reasons for rescheduled interviews were personal
illness, last minute tasks at work, forgot, unit too busy, took PTO at the last minute, and was
called home for a sick child. Based on the observations, this influence is an asset.
Document Analysis. No document analysis was conducted for this influence.
Summary. These participants overall verbalized that they see the value in having a
healthy work-life balance. While some participants spoke of gains to their life, others spoke of
work benefits. However, what is concerning are the responses to the what you might lose
question. Those who answered there would be no losses might be lacking in critical thinking
about the multifaceted concept of work-life balance. Finally, the concern that one might “lose
the respect from her co-workers” was a theme that presented itself multiple times throughout this
study and deserves a deeper dive (See Future Research).

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Observations concur with the interviews and conclude the participant group values
activities outside of work such as family, vacations, and exercise as evidenced by the personal
effects at work. Furthermore their commitment to share their experiences with work-life balance
also show they, as a group, value the concept.
Even though participants verbalized they value work-life balance, and completed the
interview process, they did not demonstrate the visible characteristics of motivation such as
active choice, perseverance, and mental effort. Further examination is needed to determine what
is impeding their actions. However, this influence was determined to be an asset.
Self-Efficacy Theory (Pajares, 2006)
Influence 2 Exempt nurse leaders must believe they are capable of having a healthy work-life
balance.
Survey Results. No surveys were conducted for this study.
Interview Findings. Participants were asked to use the same list of 13 influences from
the conceptual question and indicate how confident they felt that they could control each
influence. Participants were asked to give each influence a score from zero to 100. It was noted
that the influences most often chosen by the participant group that influence their work-life
balance are also those that ranked the lowest in terms of self-efficacy. Last minute requests, my
personality, use of technology, and calls, texts, and emails from work on my personal time were
the influences most chosen and least self-efficacious. See Figure 3 for a graphic representation
of self-efficacy scores for ENLs participants.

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Figure 3
Self-Efficacy and Work-Life Balance Influencers

For last minute requests, Participant 2 offered, “Other people see things as urgent, so I
have to stop what I’m doing to handle it.” Participant 3 reported, “I don’t leave work on time for
family dinners because something always comes up. I can’t say no. I’m scared of how people
will view me.” Participant 4 agreed and offered, “I cannot leave at the end of the day if someone
needs me. I would feel guilty and then worry that I’m not well received by my team.”
Participant 9 stated,
Sometimes last-minute requests come in...we need it in 30 minutes and it’s my day off. I
understand that is part of my job. And that this person needs this data for a meeting that
is happening at noon. It is annoying that they didn't know this yesterday. But I also know
that's my job. Yeah, they’re my boss and if they say jump…. I say how high, right?

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For the calls, emails, or texts from work during personal time, Participant 1 asserted,
“The hospital is open 24/7. I want to turn off my phone and be with my family, but I can’t.”
Participant 4 agrees, “Leaders and caregivers expect an immediate response. Usually if I'm
getting an email from the CE. He wants a response, or he wants me to do something
immediately.”
For the influence of my personality, five participants scored themselves a 20 or below.
Participant 4 maintained, “My type A personality has been good for this job, but bad for me
personally. I don’t know if I can or should change.” Participants 1 and 6 claimed it would be
hard to change because “I think we are who we are.” and “That's kind of the person you are.”,
respectively.
Finally for the influence of use of technology, Participant 3 exclaimed, “The phone is all
consuming.”, while Participant 6 offered, “I feel an obligation to the department to be available
to them all the time.” Participant 10 reported, “Docs, staff, everyone texts me. It’s a failure of
technology….that you are always easily accessible.”
Observation. The observations noted for this influence include participants behavior
during the short activity. It was observed that this activity took longer for participants to
complete as compared to the first activity investigating conceptual knowledge. At one point
during the activity, Participant 2 admitted that she struggles with decision making and was
having a hard time assigning the self-efficacy scores. While discussing the self-assessed scores
for “not bringing work home” and “not bringing life to work”, Participant 1 began to cry. She
offered that she has a situation in her personal life right now that is influencing her work-life
balance. She said that although her time spent at work has increased, she expressed that she was

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worried “…that it's affecting me in other ways that I don't realize, especially in my interactions
with the caregivers.” She composed herself within a couple minutes and the interview resumed.
Document Analysis. The document available for this influence is the actual activity
form from each participant. The document was used to further the conversation regarding
participant self-efficacy scores.
Summary. These participants overall demonstrated a lack of self-efficacy to control the
influences that most negatively affect their work-life balance. While most participants felt
confident in their abilities to control personal life situations affecting their work-life balance,
conversely, they felt less confident in their ability to control work influences. Interviews and
observations were aligned to show lack of self-efficacy. Therefore, this influence of self-
efficacy was determined to be a need.
Goal Orientation – Mastery (Yough & Anderman, 2006)
Influence 3 Exempt nurse leaders should work toward balancing work and life.
Survey Results. No surveys were conducted for this study.
Interview Findings. Participants were asked four questions to investigate their goal
orientation (a) Are you happy with where your work-life balance is right now?; (b) What are you
doing to actively improve your work-life balance?; (c) How important is it to you to be proficient
at balancing your work and life?; (d) How do other exempt nurse leader work habits influence
your work-life balance?
The initial question; Are you happy with where your work-life balance is right now?
yielded nine negative responses. Only one participant interviewed said that she was happy
where her balance was right now and that was only because she had worked on improving it for
the last six months.

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For the question addressing what they were doing right now to improve, seven
participants out of ten were doing nothing, therefore not choosing to act. A myriad of
explanations was offered such as this from Participant 1,
I want to but it's one of those things, like you're constantly thinking about. I'm gonna
pick this day. And then you pick the day and you could say the reason you could say
excuse. But there's always something where it's like, no, it's not happening because of
this.

Participant 3 confessed, “Well, I tell myself ….when I get home. I'm going to put my phone
down for at least two hours and disconnect fully from my phone and be more involved at home.
I just haven't started.” Participant 6 admitted she is not actively working on it. Rather she
contended, “Just trying to get the job done.” When asked “Which job?”, she replied “My work
job.” For the other participants that responded in the affirmative, most attempts were isolated
activities with no real pattern, intention, or schedule. Participant 4 revealed,
It’s a journey, a roller coaster, I do really well for a while, then I’ll have a really bad
week causing me to be here longer. And so I feel like I kind of live in that state all the
time. I don't have consistency. I just haven't gotten to that point. I don't know if I ever
will.

For the question; How important is it for you to be proficient at balancing your work and
life? only two participants offered thoughtful responses incorporating the proficiency piece.
Participant 2 responded, “I've been thinking about that more….I need to. I'm the one that really
needs to be in charge of it”. Participant 4 admitted,
I haven't made it a priority. It's really important for me to feel proficient in my work. It's
really important to me to feel proficient as a mom. But I still … struggle. Yeah, so it's
interesting to me because for as important as, as I say, my family and myself and my time
is, it's weird that I haven't put as much emphasis on it. It's not that it's weird, it's just that
it's sad.

The remaining participants all asserted that it is important to them to have work-life balance but
failed to explain why it was important for them to take control and be proficient.

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For the question investigating the influence other ENL work habits have on their work-
life balance, 100% of the participants indicated they tend to notice others’ work habits such as,
coming in early and staying late, sending emails in the middle of the night, and working on the
weekends. One hundred percent of the participants also acknowledged there were no positive
work-life balance role models in the organization. So any influence those others’ habits may
exert would be negative and serve to perpetuate the culture of work-life imbalance. Also
revealing with this question was the feeling that work-life balance would not be valued,
supported, or revered within the exempt nurse leader group. Participant 1 indicated that leaving
at the end of the day for childcare issues is perceived as valid, but she felt she would be judged if
she left for her personal appointment. Participant 4 admitted how she would feel about an ENL
with healthy work-life balance,
I would resent it. I’m working so hard here……the only way it would work is if the
person was respected in the organization who was getting promoted, who the executive
team spoke highly of…..But that’s not what I’ve seen.

Participant 5 offered,
Others are able to set really good boundaries. But I think that they are not as revered
because they have boundaries. I hear people say ‘good for her’ but then at the end of the
day what you hear behind the scenes is that's not really someone you can count on. A
couple of the leaders who are really good at setting boundaries, I see that they're not part
of their core group either. Rather always on the outskirts of everything.

Observation. The observations noted for this influence included participants' behavior
during the interview question asking, “Are you happy with where your work-life balance is right
now?” and “What are you doing right now to actively improve your work-life balance?” It was
observed that Participants 1, 3, and 5 followed the questioning sequence with a facial cringe, and
subsequent nervous laughter. Participant 2 began to cry while responding to the first question.
She offered “For whatever reason it's a kind of a topic that…..just raw emotions...it's just for

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whatever reason, when I go to talk about it, it's hard.” She continued the interview and
expressed concern over a personal situation and conceded, “So there's a lot. That's like another
full-time job.”
Document Analysis. No document analysis was conducted for this influence.
Summary. Eight out of ten participants admitted they are not actively working to
improve their work-life balance. Furthermore, the two participants that claimed they are actively
working to improve, acknowledged it is a difficult process and admitted they more often try than
do. While 100% of participants indicated that it was important for them to be proficient in
balancing work and life, only two participants captured the mastery intention of the question.
Most responses were related to the value of a balanced work and life, not necessarily the reward
of mastering the mission of work-life balance. Finally, several responses to the question how do
other ENL work habits influence your work-life balance indicated a troublesome culture aspect.
Therefore this influence was determined to be a need.
Results and Findings for Organizational Causes
Cultural Settings
Influence 1 The organization needs to ensure resources meet demands.
Survey Results. No surveys were conducted for this study.
Interview Findings. Participants were asked three questions to ascertain information
regarding this influence (a) How many direct reports do you have?; (b) Do you have the
necessary resources to handle the workload of your position?; (c) What resources are available at
work to help you improve your work-life balance? For the first question, see table 6 for direct
report numbers per ENL.

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Table 6
Number of Direct Reports per ENL Participant
Participant Number of Direct Reports
1 106
2 20
3 68
4 6
5 30
6 74
7 68
8 70
9 61
10 92

For the second question, 80% of the participants indicated that they did not have the
necessary resources to handle the workload of their position. Participant 3 admitted, “I need help
but everyone is busy so there is no one to ask. I feel alone.” Participant 5 agreed and
maintained, “Taking leaders away is burning us out and not helping the caregivers.” Participant
7 concurred, “Me as one person, no. I don't think we have enough resources and I think that
we're shortchanging the staff to be honest.”
For the third question asking to identify resources available to help with work-life
balance, three of ten participants did not verbalize knowledge of any resources, and the
remaining seven spoke of resources available through work such as the caregiver assistance
program, virgin pulse, and life balance for discounted recreational tickets. Participant 4
acknowledged,
But for me personally when you say that…. I'm thinking more of like not the hospital
organization but like what my direct leaders or executive team can offer me. I'm not
aware of anything specifically good. My one up has said you need to take a day, at least
one a month and work from home… I've done it like twice in a year and a half.

This data was revealing that although participants listed general health related resources the

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hospital offered, they did not reveal any resources available at work to specifically help them
improve their work-life balance.
Observation. The observation conducted related to this influence, mentioned earlier,
was the ease of scheduling and interviewing participants. Fifty percent of participants had some
degree of delay in scheduling or the need to reschedule their work-life balance interview. Eighty
percent of those rescheduled appointments were due to work overload as expressed by the ENL.
One ENL indicated she needed to go into staffing because they were short-staffed that day, and
one ENL indicated we needed to reschedule because she needed to give a tour and no one else
was available to help. The ENLs indicated it was these types of demands that affected their
work-life balance because it added to their workload and lengthened their workday.
Document Analysis. The document analyzed for this influence is a job description
posted with a job opportunity on the hospital career opportunity webpage. The responsibilities
reflected an expectation to directly supervise more than 80 caregivers.
Summary. All three data collection methods agreed that job expectations for the ENL
are immense. ENLs are working with limited resources despite growing demands. The
triangulation of data revealed this influence to be a need.
Influence 2 The organization needs to support a culture of communication that supports work-
life balance.
Survey Results. No surveys were conducted for this study.
Interview Findings. Participants were asked two questions regarding culture of
communication within the organization (a) How does organizational communication influence
your work-life balance?; (b) What is communicated about work-life balance?

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Participant 1 suggested communication expectations influenced her work-life balance
significantly, she offered,
I think you are expected to be caught up. You are expected to be caught up on the emails
and caught up on what's occurring. But I think the daily huddles help with that same kind
of information. You know if it's really important they’ll talk about it in the huddle.

Participant 4 stated,
Leaders are supposed to be empowered to take days off, but you have a fire and I need
an answer to this. And, you know, be visible in your department, and all of those things.
It just doesn't make sense, I think, with leader time off, the most I've taken is two weeks
and that was this summer for the first time ever since I became a leader. I think that
sometimes taking time off just means you come back to even more stress. And so
sometimes even in those two weeks that I took time off, I was still answering emails and
cleaning them out.

Participant 5 agreed,
Everybody's so reactionary that if something goes wrong, they want an answer now. So
the expectation is that immediately when something happens, they be called. So then that
kind of flips it on you to that you need to be the one, you need to be on top of it. As soon
as it happens. So as soon as something happens, you need to get on the phone and, you
know, call these people who are at home, and they're supposedly on their family time, but
you are upsetting their family time by telling them all of this that's going on at work. So,
if that's the expectation that you interrupt them. Yeah, then it goes to show, then you
should also welcome that being interrupted in your family time for things that go wrong
in your department or under your watch.

Participant 6 offered,
The emails...it’s constant, like 24/7. On vacation I don’t want to be bombarded when I
come back and there's 300 emails that I gotta get through. That's the same for the
weekends if I don't do it on the weekend, Monday is all day emails.

Participant 7 agreed and admitted that she, “[stays] on top of emails even on my day off or while
on a stateside vacation.” Finally, Participant 8 said, “Late night texts and emails make me feel
that I should be responding, that is what is expected. Short notice emails are stressful and there
is not enough time to do it.”

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Additionally, participants were asked what the organization communicated about work-
life balance. Participant 1 offered,
There is the expectation that you're always going to be available. That you're always
going to be able to, you know, manage, whatever that situation is that you're always
going to be asked and expected to do extra things that maybe aren't really within your
role. Going to the Heart Walk, volunteering your time with this harvest festival that
we're going to have, just volunteering in general.

Participant 2 admitted the message was sincere but gets lost,
The executive team will talk in meetings about taking time for yourself, summer and
holidays. It’s not just about the budget, they mean it to be with families. Focus on being
healthier. But the reality is there’s just more and more focus on stewardship, combining
roles.

Participant 5 agreed,
You know, I think it's like 50/50, I mean they do a good job of talking about work life
balance, putting things out there through the HR portal where they have all these
activities you can do and things like that. So they do offer all of that. I don't think they
tell you what your work life balance should look like. But there's a lot of talk about
work-life balance. Like you should have work-life balance, what does that mean? I'm
sure it means something different to everybody. But it stops there and like I said at the
end of the day the people modeling it are NOT modeling it. So it kind of trickles
down….if you don't see them doing it, you probably shouldn't be doing it either.

Participant 6 agreed, “It's not modeled from above. I feel like we preach it a lot here. And
nobody really follows through with that. It’s preached but not practiced.” Participant 7 offered
more,
That they support it, but I don't really know how they support it. Because they don't give
me anything less to do… they give me more. I don't feel like they practice what they
preach. You see the emails coming at six o'clock on Friday, big files that put me in email
jail, so I have to address them. I think it's a great theory to preach. But when we’re
constantly taking away and not refilling positions. Expecting less people to do more
work than what we did nine years ago, because we are, we're doing more work than we
were nine years ago, there are more requirements for every staff member.

Participant 8 admitted,
I think the sincerity is there 100%. They truly care about it because it's part of the
caregiver engagement survey, but there’s a gap between the goal. There is a really big

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gap between the talk and the walk. Even leaders, and I'm an example of it. That's my
goal but I don't really do it. Mission and mentoring, they sent people there, it really
touched me that they talked about work life balance - you have to care for your soul, care
for your needs. I just got so touched by it. It resonates well with me. I truly believe in
that. But once you get back to the hospital. you forget what you learn because you're
back at it again.

Finally, Participant 9 relayed,
I don't think they do a good job about work-life balance because I feel like at least from a
management point of view, it's the bottom line. It’s all the dollars. So it's about the
bottom line, it's less about work life balance.

Observation. Observations conducted for this influence consisted of interruptions noted
while interviews were in progress. One hundred percent of the interviews were interrupted by
either a physical presence or a phone call. One hundred percent of the time the disturbance was
permitted, with the notable exception of a personal call from a participant’s daughter that she let
go to voicemail. Only one participant indicated with a sign on her door that a meeting was in
progress. For the others, a closed door was not a sufficient signal that a meeting was in progress.
The interruption content consisted of staffing changes, vacation requests, questions regarding a
shared email, and social visits.
Document Analysis. One document was analyzed related to communication and work-
life balance. The email system utilized at this organization gives the user the opportunity to
display an outgoing message, alerting others to important information. Several outgoing
messages from participants in this study were analyzed. Of the four outgoing messages saved
from the data collection period, 100% indicated the caregiver was out of the office on PTO and
could be reached if necessary, at the following cell phone number. Therefore, rather than
information referring them to their leader or designee, these ENLs created the opportunity to be
contacted via cell phone while they were away from the office on PTO.

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Summary. In analyzing interview responses, observations, and a document related to
this cultural setting of communication, it was clear the current culture of communication
supported instant availability even for non-emergent situations. Several of the ENLs mentioned
it was possibly their fault that their staffs interrupt and contact them at all hours of the day and
night. They admitted they have set no boundaries for their staff because they felt the message
has always been to remain available and attend to staff needs 100% of the time. In triangulating
data, it was determined this influence was a need.
Influence 3 The organization needs to ensure ENL expectations are compatible with work-life
balance.
Survey Results. No surveys were conducted for this study.
Interview Findings. Participants were asked two questions to investigate the cultural
setting of expectations (a) What do you believe are your supervisor’s expectations about your
availability?; (b) How do these expectations influence your work-life balance? For the first
question, Participant 1 said,
It’s a mixed message. Do what I ask you to do, but also take time off so you don’t get
burnt out, and why didn’t you tell me you were getting burnt out and why didn’t you do
these 27 things?

Participant 2 disclosed, “I think that he knows that I am available, a lot, and has encouraged me
to make use of the assistance that I have and the managers that I have so that I don't have to
always be available.” Participant 4 agreed,
So I will say to her credit my one up I feel is probably one of the only executives who is
very real and wants that for us. She wants us to check out and I definitely feel supported
by her. Does she check out? No, not that I know of, because even when she’s off and
I'm the one covering her I might have to call her, so I don't think she's good at checking
out either. I mean she'll preach that to us. I preach that to my ANM. We all preach that
to each other, but nobody actually does it. So role modeling is not there.

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Participant 6 asserted her supervisor said, “Be available and work till the work is done. Would it
be said aloud that way…no…but….it feels that way. I feel like she would never say you need to
work more. Never say to work less either.” Participant 8 maintained,
They want you to answer. To get back to them. Even if you're on vacation, she may call
me, but she apologizes. I know you're really off today but… I have been noticing that
my new supervisor replies to email at the end of the day. I totally understand that's the
time she gets to sit and go through her email, but she wants a response and it’s late in the
day.

The second question for this influence was how these expectations influence your work-
life balance. Participant 3 offered,
Some weekends are better than others. Some nights are better than others. We're on call
24/7… but it doesn’t happen every weekend. If I get text messages from caregivers, it's
nonsense, nothing that's urgent. If I'm checking my emails, that's my personal problem.
It's not somebody who's making me do it. However, I see my supervisor checking her
email all the time, but I don’t think she expects that I do…but I see her and then I feel
guilty.

Participant 4 acknowledged that she does not take many vacations, always answers phone calls
and texts, brings work home, and stays late at work. Participant 5 agreed, “They want us to have
work-life balance but also to be available 24/7. Which one trumps? The work. It's kind of a
price of participation, if you want to be part of this club.” Participant 6 maintained the
expectations influenced her a lot,
The staff expects me to be there for them. And be available to either vent or hold others
accountable or just assist them with RQI, or their schedule. And I'm supposed to be the
one to help them. I work 40 hours a week, but they are here 24 hours a day.

Participant 8 asserted, “Emails come in late in the day and I know they are expecting a response
so that makes me stay late or respond from home. The schedule of my leader influences my
own.” Finally, Participant 9 revealed, “It’s expected my areas are always “covered” with no
gaps, so that’s why I’ll check in on my off days. Because I want to keep my current schedule.”
Observation. No observations were conducted for this influence.

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Document Analysis. The documents analyzed for this influence have already been
mentioned in other influence categories: the job description indicating 24-hour responsibility for
multiple nursing areas and the inclusion of a cell phone number on an outgoing message on
email.
Summary. In examining the ENL interviews, observations, and two documents, it was
apparent that there was alignment between the data. Both documents indicate there was very
little rest built into the nurse leader position, which was further exacerbated by the perceived or
real expectation to be available even while on approved PTO. This influence has been
determined to be a need.
Cultural Models
Influence 1 The organization needs to support a culture of meaningful work.
Survey Results. No surveys were conducted for this study.
Interview Findings. Participants were asked two questions to ascertain the culture of
meaningful work (a) How much of your job is meaningful work?; (b) How does that influence
your work-life balance? For the first question, Participant 1 revealed,
I would say probably 85%. I think that 15% is me being, I think maybe you're gonna
love this, is being an adult babysitter. Yes, running after people have you done this?
Have you done this? Have you accomplished this? Let me call you about your TB
testing, to me that's not meaningful, because I'm just following up with you as an adult to
do the minimum requirements for your position.

Participant 3 agreed,
A big portion of it is me being after the caregivers to complete this, complete that, and it's
stuff that I feel is not necessary, I shouldn't be after them. Having to make sure they're
doing things that's like their responsibility. I feel that the caregivers need to take
ownership.

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Participant 5 offered,
I'd say 60% is meaningful. And the other 40% is stuff that just has to get done, you didn't
do your TB, you didn't do your health stream, I mean those kind of parenting type
activities that we have to do, we have to keep on top of it.

Participant 6 estimated,
Fifty percent is meaningful. The other are the meetings, some emails, the constant
changes that just seem to change to change and then they change it back and constantly
chasing people... holding them accountable. Get your flu shot, do safe patient handling
class…constantly nagging, nagging, nagging….. herding chickens.

Participant 7 offered that she struggles when asked how much of her work is meaningful,
Right now, today, not much. Consumed by the staffing and the schedules, the tasky stuff.
Taking me away from looking at what my staff needs. How do I help the staff, learn and
grow? I have so many things that I would rather be doing that's meaningful, but instead I
am chasing compliance …TB tests, flu shots, RQI. It's a nightmare. It's usually the same
people over and over.

Participant 8, however, said that the bulk of her work was meaningful,
I would say 75%. There are those things that you have to do... regulatory requirements,
but it’s not very meaningful or value-added to time or energy, such as UORs, finding lost
dentures (I’m glad we found it, but it was a waste of time), investigating lost belongings.

The second question asked how does the influence of meaningful [or non-meaningful
work] affect work-life balance and Participant 1 offered,
Yeah, okay, because those are the things that you know you have to do, that take a lot of
time that you're not really getting satisfaction about, telling you know, a 40 year old man
like let me show you how to fill this form out, like, to me that's not like a lot of job
satisfaction right there.

Participant 2 admitted the non-meaningful work takes its toll, “It affects my satisfaction. [with
the meaningful work] I feel a sense of accomplishment. Then I can relax and enjoy home life
more. If I don’t feel that, it will drain me more.” Participant 3 has similar struggles, and
offered,
We waste a lot of time doing these kinds of things. We should be doing other things.
Right now I have a list of people that have been texting, emailing you know calling them

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make sure you do this, make sure you do that, you haven't done this. Even after all that
they still don't get it done.

Participant 4 attested, “Lots of meaningless tasks on my plate, I stay longer just to do what’s
been dumped on me from the caregivers. Now I have to figure out how to do these things the
caregiver should have taken care of.” Participant 5 took issue with clerical work, she added, “I
feel like when I do those kinds of things. It's a waste of my time. Honestly, you're paying me so
much money to do this clerical work, really I should be doing something more important with
my time.” Participant 6 agreed, “It's more time consumed and it's the text messaging because I
get the night shift so I'm gonna text them [when it’s] convenient for them. It adds to the after
work, work.” Finally, Participant 8 asserted, “The meaningless things take up so much
time…away from the meaningful things. And when I spend so much time looking for dentures,
for example, I am less efficient and then I don’t leave on time.”
Observation. No observations were conducted for this influence.
Document Analysis. No documents were analyzed for this influence.
Summary. The majority of ENLs report that chasing employees was not meaningful
and added to their workload which eventually negatively affected their ability to balance work
and life. Both questions asked to explore the issue of meaningful work and the effect on work-
life balance supported this influence was a need.
Influence 2 The organization needs to support a culture of psychological safety.
Survey Results. No surveys were conducted for this study.
Interview Findings. For this influence two questions were asked during the interviews
(a) How comfortable do you feel to speak up at work when you have a question or safety
concern?; (b) How safe do you feel in the organization's social climate to discuss issues around
work-life balance? For the first question, 50% of the participants offered affirmative reactions

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to speaking up with a question or for safety. However, it was not as easy for all. Participant 2
revealed,
Overall, I feel pretty comfortable bringing up a concern or question. I hesitate slightly
because I’m wondering if this is just something that's me focused or is it more department
or organization focused. And the timing of the question. And the audience – it might
depend upon the audience.

Participant 5 admitted,
It depends. I usually throw whatever's on my mind on the table. But I think I get
shushed a lot. I mean literally people will say shhh to me and put their hand on me. I
don't know, maybe because I'm more vocal now. I don't know. It's making me feel
insecure.

Participant 9 contended,
I don't know if it's like a safety thing or if it's a personality thing but in the management
realm I'm not outspoken like I am with my department. So I feel safe doing it. But like
not on a forum. I think I'm just embarrassed.

Next, participants were asked how safe they felt discussing issues around work-life
balance. Participant 1 contended,
It would depend on who is in the room. I'm just saying some of those people would see it
as a weakness. Whereas other people would be able to very much relate to that because
that does open yourself up to some vulnerability. And I think other people would use that
vulnerability against you in a way where it's like well obviously that person, they can't do
the job. They can't do it.

Participant 4 divulged,
It's very political and how you approach things and how they like to receive things and
how that then affects how they perceive you as a person, as a leader. What I might say is
I really think we need to do a better job with work life balance. What I want to say is this
is a total like joke like what you're asking of us for work life balance there's no way
you're making that possible for us with how much pressure you're putting on us for a, b
and c, how much leadership and support you're taking away from us. That would not go
well. I would be worried they would say…. they're not going to make it in leadership,
they're probably not the right person for the job…. I feel like my movement up in this
organization would be severely stifled and would probably stop if I came across that
honest about what my real feelings are.

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Participant 5 said, “I don't think I would be comfortable bringing up that I don't feel like I have
work-life balance, or I need more balance…. because of the stigma.” Participant 6 disclosed, “ I
feel like the “aboves” don’t model work-life balance, so I feel like I’m going against the grain.
Safety issues are more important, so I’ll discuss those. Don’t want to be perceived as a slacker.”
Participant 8 offered, “I'm not going to be very comfortable saying in front of the leadership
because they probably would see it as a lack of ability to control yourself or time management.”
Participant 9 admitted,
So I want to say yes because I want to be that person but, but no, but the answer is no,
and only because I never said anything to my leader, about how overwhelmed I was. I
think she could see it. But I always just tried to manage it yeah and then I would go
home and cry or I'd stay here and cry.

Only one ENL responded that she felt comfortable, with no qualifiers, to speak up, however she
admitted she wonders what good it would do. Participant 10 contended, “ I would feel
comfortable telling them (leaders), I have no work life balance I'm drowning. I don't know what
I think I would get out of it. But I have no problem saying it.”
Observation. Observations conducted for this question further explored psychological
safety by examining physical positioning during the interview and flares of emotions. The
interviewer was intentional to allow the participant to determine the seating arrangement for the
interview. Seventy percent of participants faced the interviewer by either turning chairs to face
one another or facing each other across a desk. Three participants did not turn toward the
interviewer during the encounter, preferring to remain facing their computer. One participant
arranged for a side by side orientation and looked straight ahead for most of the interview.
While some office environments did not allow for a variety of seating arrangements, the three
that did not sit face to face would have managed that orientation if the participant would have
wanted it to be so.

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Another observation during the interview process was the outward display of emotions.
Two participants cried during the interview, one participant said, “You are going to make me
cry.”, and two others exhibited relief at the end of the interview for not crying. It is compelling
that 50% of participants either referenced or displayed strong emotions at the topic of work-life
balance. Finally, it is also important to include the fact that executive leaders approved this
study and verbalized their interest to read it when complete. This approval demonstrated a
willingness to uncover and examine a potentially sensitive topic. Three executive leaders
expressed a desire that this study help to improve ENL work-life balance.
Document Analysis. In keeping with the influence of psychological safety, a document
offered in new employee orientation, outlining patient safety and Joint Commission guidelines,
stressed the importance of speaking up for safety. The document encouraged the use of tools
present in a High Reliability Organization, and further explained that speaking up and having a
questioning attitude was expected of all caregivers.
Summary. As noted in the interview responses, participants demonstrated a reluctance
to speak up. Only 50% of the participants would speak up for safety without qualifiers or
hesitation, and only 10% felt comfortable to speak up regarding issues of work-life balance.
Even though several participants shed tears during the interview, a sign of distress and
concurrent show of vulnerability, this may have been due to a relief that they finally were able to
speak with a neutral party about their struggles to balance work and life. Despite documents
calling for caregivers to speak up, the interviews indicated the participants do not feel
psychologically safe to do so. Subsequently, this influence was determined to be a need.

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Influence 3 The organization needs to support a positive work environment that fosters work-
life balance.
Survey Results. No surveys were conducted for this study.
Interview Findings. Participants were asked two questions to analyze this influence (a)
How is work-life balance perceived within this organization?; (b) How does the overall work
environment influence your work-life balance? For the first question, Participant 4 stated,
What's being preached is not being supported, or possible. I’ve seen people who have
checked out a little bit to be perceived as not working hard enough, not present enough,
people who are killing themselves are being promoted, producing results because they are
killing themselves. People say that about me. I am killing myself to get promoted.
Overworking is valued.

Participant 5 offered,
I think that at the end of the day, there is a perception that if you step back and pay more
attention to your work life balance and give more to your life balance… that there is that
kind of perception that you're not the team player.

Participant 8 offered that work-life balance was perceived as very important but not supported,
It’s dear to their heart, because it’s on the caregiver engagement survey, it's the whole
organization….burnout. It’s there every year, we try to work on it, but it’s still there.
Because I don't really see a role model. Even if there was one, they would not be looked
at highly. If someone tries to have boundaries, it’s not perceived very well. It was
thought to be not caring. At the session I went to on leader development they talked
about work-life balance and someone leaned over and said, this isn’t for us….our leaders
need to hear this.

For the second question, participants admitted that although work-life balance was
perceived as important but not necessarily practiced, it did influence their behavior. Participant 6
admitted,
I don’t want to be perceived as a slacker if I promote work-life balance. I'd be envious [if
someone had a healthy work-life balance] but then at the same time like if I thought
seriously, I'd probably wonder if they were doing their job. I might judge a little bit.
Because how can they do it and I can’t.

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Finally, Participant 10 revealed,
To be honest, I think it's talked about, but I don't think it's lived. Oh, it's the holidays,
flex off or whatever but still have the same amount of work. I don't work in a nine to five
office, this is a 24/7 operation, weekends, holidays. no one cares. It's talked about but I
don't know that non-clinical people, like executives, that don't really live it, day to day at
the bedside today understand how it's not really as possible as it seems. Additionally,
because we don’t value work life balance, we cultivate negative influences, such as the
acceptance of last-minute requests but it affects my work-life balance because now I
might leave late doing what’s been asked of me at the last minute.

Observation. No observations were conducted for this influence.
Document Analysis. Several documents were analyzed for this influence. First, on the
organization career opportunity page, available positions were listed with job descriptions
included. A quick search revealed a Nurse Manager position required 24-hour responsibility for
multiple nursing units and supervision of 80+ full time caregivers. Additionally this position
required responsibility for covering the entire hospital on assigned days.
Another document analyzed for alignment was a packet from Human Resources
explaining caregiver benefits. Both an inclusion and an omission are noted within the
explanation of benefits packet. First, the inclusion was a market-competitive PTO program.
Hours awarded and years of service were outlined and how the program worked was explained.
The sheer existence of this program encourages caregivers to use time away from work for
personal activities. ENLs reported in interviews the difficulty in taking time away from work
due to work responsibilities and expectations of 24/7 coverage. Most often they remained in
touch through phone or computer, not entirely disconnecting from work while on PTO.
One program mentioned several times during the interviews, the caregiver assistance
program, was not included in the benefits information. This program was mentioned in
interviews as a resource should one be struggling with a myriad of issues and need guidance.

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The omission of this resource in the benefits review speaks negatively to the value the
organization places on the services offered.
Another omission noted in the information provided to new caregivers was pertaining to
staff use of spiritual care services. The information given to caregivers mentioned that spiritual
care services were available to support staff, yet the instructions on when to call a chaplain
explicitly say, ‘when a patient wants…, when a patient needs…, when a patient is…’, and
neglects to say how to access chaplains for caregiver support. This missing information may
dissuade a caregiver from reaching out for counsel about work-life imbalance.
The organization web page was explored for messaging about work-life balance. Again,
the career opportunity page included information regarding employee benefits such as a wellness
program designed to support all aspects of health and wellness. However, the page appeared
outdated as the blue hyperlinks were broken and static, and it mentioned the sharing of
information through two emails a month to caregivers. However, several ENLs interviewed
were oblivious to the program entirely which would suggest there are no bi-monthly emails
advertising and educating about the program.
Finally, the nursing annual report for 2018 contained a wealth of information highlighting
noteworthy events and accomplishments from the prior year. This report, mailed to nurses,
donors, dignitaries, and select community members, contained several pieces of information
relevant to the discussion about work-life balance. First, the nursing strategic plan contained
calls for an increase in caregiver engagement and a reduction in turnover. This initiative, if
successful, would support the work-life balance pursuit. However, what is not included in the
report was the fact that engagement fell, and burnout increased by 4% from the previous year.
Furthermore, the plan called for leadership mentoring and succession planning, however ENLs

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interviewed reported there was no mentoring for their positions, and they have no plans in place
to succession plan future nurse leaders.
Summary. ENL interviews indicated a misalignment between what the organization
says about work-life balance and what is reflected in policies, procedures, programs, and
practice. The document analysis supports that assertion as, for example, the manager job
description indicated 24-hour responsibility, yet the strategic plan called for increased caregiver
well-being. Due to this and other polarities, this influence was determined to be a need.
Results and Findings for Influence not Previously Categorized
Guilt
The word guilt was referenced a total of 18 times over seven interviews. Seventy percent
of participants interviewed mentioned guilt in some fashion related to work-life balance. The
concept of guilt, a realization of compromising standards, was referenced in both the life domain,
as well as the work setting. It is important to consider this influence as it may affect
psychological safety, as well as motivational influences such as self-efficacy and mastery goal
orientation. Seven ENLs struggling with feelings of guilt demonstrates the importance of this
work and illustrates a need to include this influence. This influence which might be stated as:
“The ENL needs to address feelings of guilt related to work-life balance” should be further
examined in future research.
Competition
Interview findings already presented alluded to a culture of suspicion and resentment
regarding those leaders who try to achieve work-life balance. One observation captured during
the data collection period was with an ENL not participating in the study. This ENL was
referencing her workload, work schedule, and was in the presence of several participating ENLs

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when she said, “If I have to work the weekend, then so does she.” Excerpts from previously
discussed interviews and the statement made from an additional ENL demonstrate a culture not
of support, but rather of collective misery and unhealthy attitudes toward colleagues. While it is
difficult to know exactly the motivation behind the extraneous comment, a culture where this
attitude is supported does not also support work-life balance. Therefore this influence,
demonstrated as a need and should be examined in future research, might be stated as: “The
organization needs to support a culture of support and collegiality.”
Summary of Validated Influences

Tables 7, 8, and 9 show the assumed knowledge, motivation and organization influences
for this study and their determination as an asset or a need. Table 10 represents influences not
previously categorized.
Knowledge

Table 7

Knowledge Assets or Needs as Determined by the Data

Assumed Knowledge Influences Asset or Need
Factual
Exempt nurse leaders need to define work-life balance. Asset
Conceptual
Exempt nurse leaders need to understand the concept of work-life balance. Asset
Procedural
Exempt nurse leaders need knowledge of the steps to balance work and life. Need
Metacognitive
Exempt nurse leaders need knowledge of how work-life balance applies to self. Need

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Motivation

Table 8

Motivation Assets or Needs as Determined by the Data

Assumed Motivation Influences Asset or Need
Expectancy Value Motivational Theory
Exempt nurse leaders need to see value in having a healthy work-life balance. Asset
Self-Efficacy Theory
Exempt nurse leaders must believe they are capable of having a healthy work-
life balance.
Need
Goal Orientation Theory
Exempt nurse leaders should work toward balancing work and life. Need

Organization

Table 9

Organization Assets or Needs as Determined by the Data

Assumed Organizational Influences Asset or Need
Cultural setting
The organization needs to ensure resources meet demands. Need
Cultural setting
The organization needs to support a culture of communication that supports
work-life balance.
Need
Cultural setting
The organization needs to ensure expectations are compatible with work-life
balance
Need
Cultural model
The organization needs to support a culture of meaningful work. Need
Cultural model
The organization needs to support a culture of psychological safety. Need
Cultural model
The organization needs to support a positive work environment that fosters
work-life balance.

Need

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Influences Not Previously Categorized

Table 10

Additional Influences Assets or Needs as Determined by the Data

Additional Assumed Influence Asset or Need
Guilt
The ENL needs to address feelings of guilt related to work-life balance. Need
Competition
The organization needs to support a culture of support and collegiality. Need

Conclusion
This chapter has presented the results of the qualitative interviews, observations, and
related document analysis as they have related to the first two research questions. The
presentation included the assumed influences presented in Chapter 3 as well as the conceptual
framework and the corresponding literature. The findings offer an exceptional opportunity to
examine the possibility for ENLs to achieve work-life balance.
It is not surprising the data revealed that 90% of ENLs are unsatisfied with their work-life
balance. While most participants were able to offer a satisfying definition for the term, and
understood most concepts, their knowledge beyond was lacking. Work-life balance demands
both the individual as well as the organization work together to actualize the concept. If
procedural knowledge and metacognition are absent, the individual is ill-equipped to maintain
motivation for a concept they scarcely understand. It was determined that the organization also
undermines any individual efforts as all six organizational influences emerged as needs,
indicating the culture does not currently actively support the practice of work-life balance.
One unexpected finding in the study was no work-life balance role models were
identified in the organization. Additionally, it was discovered that role models might not be well
received as ENLs spoke of resentment and suspicion suggesting a performance goal orientation,

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rather than a mastery approach, might be pervasive. To enhance knowledge, specifically
procedural and metacognition, and support the mastery goal orientation, exposure to role models
and exemplars is often suggested. However, with no role models for the concept of work-life
balance emerging, it appears this organization may have to learn together and support one
another on this journey.
Additionally compelling is the absence of psychological safety and the
related, collective misery and competitiveness uncovered. These themes are antithesis to the
culture that supports work-life balance.
The data suggests that there is much work to be done both with the individuals, as well as
the organization to actualize the goal of a work-life balance program for ENLs. The organization
must be willing to create, implement, and sustain an intentional framework that supports work-
life balance. Chapter 5 offers a scaffolding of such a framework. The chapter makes
recommendations for the results and findings and illuminates the third research question, “What
are the recommended knowledge, motivation, and organizational solutions to the identified
needs?” The suggested interventions, taken from empirical research, are aligned with the
influences demonstrated as a need.

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CHAPTER 5: RECOMMENDATIONS AND EVALUATION
Chapter 4 presented the results and findings from the interviews, observations, and
document analysis to establish knowledge, motivation, and organization needs influencing
exempt nurse leader work-life balance.
Chapter 5 proposes solutions to the identified and validated needs, within the context of
the organization. The first section reviews the organization context and mission, the
organizational performance goal, the stakeholder group, purpose of the project and research
questions. The second section includes the recommendations to the address the knowledge,
motivation, and organizational influences. The third section address the implementation and
evaluation plan using Kirkpatrick’s New World Evaluation Model (2016). The fourth section
includes strengths and weaknesses, limitation and delimitations, and recommendations for future
research. The chapter ends with final thoughts about the evaluation of this problem of practice
using the gap analysis dimensions of knowledge, motivation, and organization.
Organizational Context and Mission
Pacific Healthcare (a pseudonym; PH) is a national, ministry inspired, not-for-profit
healthcare system. In addition to more than 50 traditional hospitals, PH also operates long-term
care facilities, home health care, hospice services, physician offices, urgent care centers, as well
as a high school and a full-service university (Pacific Healthcare, 2018). The mission and values
of PH are central to the work. More than just a sentiment on paper, the caregivers inspire and
actualize its meaning. Furthermore, the values guide daily behavior and serve as a prescription
for how to treat others and valuable resources. The mission, ‘using God as our guide and
through the ministry of Jesus, we will persevere to serve all people in need, regardless of

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situation’, inspires our caregivers to actualize the sentiment and give it meaning (Pacific
Healthcare, 2018).
Organizational Performance Goal
Southern

and Western Hospitals (a pseudonym; SWH), is the setting for this study. By
May of 2021, SWH will have in place and operational an innovative work-life balance program
geared toward retaining current and attracting future exempt nurse leaders. This goal is directly
related to the mission and values in several ways. Serving the community is central to the
hospital mission and therefore serving the nurse leaders within, who are also community
members, is in alignment. Each of the hospital values also speaks to the overall health of
caregivers, including nurse leaders. Nurturing all aspects of each person, recognizing the worth
of each person, removing obstacles in the path of healing, improving the quality of life, and the
importance of always doing the right thing for the right reason; these sentiments are highlighted
in the values of SWH and are directly applicable for the ENLs struggling to maintain their own
health when work and life are out of balance.
Stakeholder Group for the Study
This research study chose to focus on only one stakeholder group for three reasons: to
narrow the focus, to give the goal the best chance for success, and to give back to the community
of ENLs. This study was specifically about work-life balance for the exempt nurse leader,
therefore the current ENLs were the stakeholder group of focus. While some research projects
attempt to gather data from several stakeholder groups, the author presumed that strategy would
dilute the data in this work. Work-life balance is a concept salient for most people, and the other
stakeholder groups, the executive team and charge nurses, will have their own experiences with
the concept. This study aims to narrow the focus and examine only the ENL perspective.

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The current ENLs are in the best position to actualize the goal of establishing a work-life
balance program. This group is best equipped to give detailed descriptions of knowledge,
motivational, and organizational influences and needs required for the work-life balance of the
ENL. Once the ENL needs are known and addressed within the innovative work-life balance
program, the current ENLs will be vital to the success of the program through their actualization
of and demand for its continuance.
Finally, this stakeholder group was chosen to bring light to an otherwise overlooked
position and an often-diminished concern. ENLs, the middle children in the hospital
organizational chart, sandwiched between the executives and the front-line staff, do not often get
the positive recognition they deserve for the myriad of responsibilities they assume (Heeb &
Haberey-Knuessi, 2014). Additionally, the concern of work-life imbalance for this group is
pervasive, yet often minimized. Work-life imbalance for the ENL can be devastating not only to
the individual leader, but also to the entirety of the hospital.
Purpose of the Project and Research Questions
The purpose of this research study is to facilitate a needs assessment in the areas of
knowledge and skill, motivation, and organizational resources required to reach the
organizational performance goal. The assessment will begin by creating a list of possible needs
and then move to examining these systematically to focus on actual or validated needs. While a
complete needs assessment would focus on all stakeholders, the stakeholder group of focus for
this study is the current ENLs. The research questions that will guide this needs assessment are:
1. What are the knowledge, motivation, and organizational needs necessary for exempt
nurse leaders to achieve an innovative work-life balance program by May 2021?

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2. What is the interaction between organizational culture and the exempt nurse leaders
knowledge and motivation to achieve an innovative work-life balance program?
3. What are the recommended knowledge, motivation, and organizational solutions to
those needs?
Recommendations to Address KMO Influences
As this study is an innovation model, and a work-life balance program was non-existent
in the organization, the goal was that the organization will have in place and operational an
innovative work-life balance program geared toward retaining current and attracting future
exempt nurse leaders by May of 2021. The literature review centered on an overview of work-
life balance, the current construct of work-life balance, then narrowed to explore the concept in
nursing, and then nurse leaders. Three broad themes, workload, exempt status, and role of
technology emerged as largely influential to work-life balance. Finally, the literature explored
the construct of burnout as a likely outcome to unchecked work-life imbalance. These identified
influences were categorized within the Clark and Estes (2008) Knowledge, Motivation, and
Organization (KMO) Framework. Addressing these barriers and others that emerge from the
data increases the likelihood of overcoming obstacles to achieving the organizational goal (Clark
& Estes, 2008). The following sections outline the recommendations for the assumed influences
and needs according to the KMO Framework.
Knowledge Recommendations
Four types of knowledge, factual, conceptual, procedural, and metacognitive (Krathwohl,
2002) were assessed and analyzed during the data collection of this study. Establishing
stakeholder knowledge needs and then appropriately addressing those needs increases the
likelihood of successfully actualizing the stated goal (Krathwohl, 2002). Supported by a relevant

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literature review, procedural knowledge and metacognition have emerged as needs for this study,
while factual and conceptual knowledge, also known as declarative knowledge, have been
validated as assets (Clark & Estes, 2008). Table 11 shows each type of knowledge analyzed and
indicates if it has been validated as a need or an asset. Furthermore, the table prioritizes the needs
first, and offers a relevant theoretical principle and context-specific recommendation for
addressing each validated knowledge need.
Table 11
Summary of Assumed Knowledge Influences and Recommendations
Assumed
Knowledge
Influence

Validated
as an asset
or a need
(A or N)
Priority
Yes, No
(Y, N)
Principle and Citation Context-Specific
Recommendation
Exempt nurse
leaders need
knowledge of the
steps to balance
work and life. (P)
N Y To develop mastery,
individuals must
acquire component
skills, practice
integrating them, and
know when to apply
what they have
learned (Schraw and
McCrudden, 2009).

Continued practice
promotes automaticity
and takes less
capacity in working
memory (Schraw and
McCrudden, 2009).
Provide sufficient
training opportunities
including practice and
scaffolding such as
job aids and feedback
to facilitate learning
and performance, then
gradually withdraw
scaffolds as learning
progresses and
performance
improves.

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Exempt nurse
leaders need
knowledge of how
work-life balance
applies to self. (M)

N Y
The use of
metacognitive
strategies facilitates
learning (Baker,
2006).

Learning is
enhanced when
learners monitor their
performance
and evaluate their
progress towards
achieving enhanced
knowledge (Ambrose,
Bridges, DiPietro,
Lovett, and Norman,
2010; Mayer, 2011).
Through training,
teach learners
strategies to monitor
their learning and
performance by self-
regulating their
thought processes,
enhancing time
management skills,
and controlling their
physical and social
environments.

In training sessions
learners will pair up to
foster reciprocal
learning and explore
the cultural and work
context implications
of work-life balance.
Exempt nurse
leaders need to
define work-life
balance. (D)

A N
Information learned
meaningfully and
connected with prior
knowledge is stored
more quickly and
remembered more
accurately because it
is elaborated with
prior learning
(Schraw and
McCrudden, 2009).
Through education
and information
sharing, connect
learning to individual
interests to encourage
meaningfulness.

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Exempt nurse
leaders need to
understand the
concept of work-
life balance. (D)
N - not a
need at this
time, but
conceptual
knowledge
must be
maintained
N
Managing intrinsic
load by segmenting
complex material into
simpler parts and pre-
training, among other
strategies, enables
learning to be
enhanced (Kirschner,
Kirschner, and Paas,
2006).

Targeting training and
instruction between
the individual’s
independent
performance level and
their level of assisted
performance (zone of
proximal
development)
promotes optimal
learning (Scott and
Palincsar, 2006).
Present information
and educational
sessions in
manageable parts and
encourage learners to
only tackle one aspect
of the larger concept
at a time.

Provide people tasks
that fall within their
zone of proximal
development (ZPD) to
enhance
understanding of the
larger concept and
interconnectedness of
work-life balance.

Exempt Nurse Leaders Need Knowledge of the Steps to Balance Work and Life
The results and findings of this study indicated that 100% of exempt nurse leaders need
enhanced procedural knowledge regarding the steps or process involved in establishing and
maintaining a healthy work-life balance. A recommendation grounded in Information
Processing System Theory (Schraw and McCrudden, 2009) is offered to eliminate the procedural
knowledge gap. Schraw and McCrudden (2009) offer that learners must develop relevant skills,
practice incorporating them into the schema, and develop an awareness of when to utilize the
new knowledge to develop mastery. Furthermore Schraw and McCrudden (2009) highlight the
importance of practice to develop an almost subconscious ability to perform the task. The
recommendation then is to provide sufficient training opportunities including practice and
scaffolding such as job aids and continual feedback to facilitate learning and performance. Once

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learning progresses and performance improves, scaffolding is withdrawn while support measures
such as continued feedback should remain.
Middaugh (2014) and Swearingen (2009) agree that nursing leaders need on-the-job
education and training about the steps of work-life balance. Nurses must also learn how the
context of any given situation may influence the process or procedural steps. Greenblatt (2002)
calls this process sequencing; she contends that in order to be successful in navigating a concept
as vast as work-life balance, learners need a plan and the ability to categorize the steps into a
functional progression. Rubino et al., (2009) echo this sentiment and offer that a person’s
perception of their skills and knowledge may be affected if they do not understand how to
achieve a goal or comprehend the steps for success. Caproni (2004) cautions that appreciation
for the journey and flexibility is the key, although planning and goal setting is important to move
one toward an intended target. Through his many years of immersion in the topic of work-life
balance, he found that trial and error, progressive practice, self-reflection, and feedback to be
ever important for creating a flexible, realistic plan for work-life balance (Caproni, 2004).
Further, Caproni (2004) explains the importance of involving those closest to you in your goal
and asking for reality checks, suggestions, and hard truths along the way. Furthermore, Rubino
et al. (2009) reveal that it may be more advantageous to work on the individual components that
make-up work-life balance rather than tackle the entire paradigm of work-life balance. Their
research revealed even small improvements in certain areas can positively influence the whole.
This reveals the importance of a strategic plan, breaking down the components piece by piece,
step by step to actualize the larger goal of work-life balance.

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Exempt Nurse Leaders Need Knowledge of How Work-Life Balance Applies to Self
The results and findings of this study indicated that 80% of exempt nurse leaders have a
metacognitive knowledge gap and require enhanced understanding of the self with regards to
work-life balance. A recommendation rooted in Sociocultural Theory (Baker, 2006) is offered
to close the ENL metacognitive knowledge gap. Sociocultural Theory (Baker, 2006) focuses on
the role of cultural and social bases of learning, including the role of context and learning with
others (Rueda, 2011). Rueda (2011) further offers that the culture or context often plays a
central role in the process of learning, and to ignore or dismiss its presence would be short-
sighted. Cognition and learning are greatly influenced by culture, traditions, and developing
identities within a context (Rogoff, 2003). Rogoff (2003) maintains that learners must focus on
the development of self-cognition while navigating the contextual history and norms, and the
interpersonal interaction with others Through training, facilitators can teach learners strategies
to self-regulate their thought processes and learning patterns. Additionally, since context is
crucial to consider, learners should receive training on controlling their physical environment,
social environment, and time management skills while continuously monitoring their self-talk
and overall understanding of self. Finally, in training sessions, learners should work in pairs to
foster interpersonal relationships and reciprocal learning. These pairings will help learners
explore their individual metacognitive identities within the cultural and work contexts and
consider the implications of work-life balance.
Buchanan et al., (2013) revealed in their study with nurse managers that due to the
chaotic work environment, nurse managers found little time in their day for reflection. Shirey et
al., (2008, 2010) in their research with nurse leaders, found that self-awareness and subsequent
action is helpful in developing coping mechanisms for work-life balance. Kim and Windsor

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(2015) found in their research with nurses that continuous reflection emerged as a central theme.
When nurses engaged in routine reflection on work-life balance conflict issues, they were more
receptive to professional development and experienced greater transformation (Kim & Windsor,
2015). Additionally, Shirey et al. (2008, 2010) found having a partner with whom to share
work-life balance strategies and exchange ideas enhanced the feelings of support and comradery
during the self-discovery period. Kelly, Lefton, and Fischer (2019) agree, and revealed in their
research the importance of feedback and reflection for taking ownership of your own work-life
balance. In their study with nurse managers they found for those that report a healthy work-life
balance, there was a memorable turning point when they began to see their work-life balance as
theirs to claim. As other researchers agree, once the nurse leader accepts responsibility and
expands their metacognitive knowledge of work-life balance, they begin to see a shift from an
external locus of control, to an internal one (Judkins, Reid, & Furlow, 2006; Kelly et al., 2019;
Kravits et al., 2010).
Exempt Nurse Leaders Need to Define and Understand the Concepts of Work-Life Balance
The results and findings of this study indicated while declarative knowledge is not
currently a need for the exempt nurse leader group, it is crucial to the success of the goal to
maintain existing knowledge. Although a subjective topic, 100% of exempt nurse leaders
interviewed were able to articulate what work-life balance means to them with adequate clarity.
Consequently, although the details of responses differed, a general definition was shared.
Conceptual knowledge of the larger work-life balance notion, including models and principles,
was determined to be a weak asset and should continue to be fostered to sustain knowledge. A
recommendation grounded in Cognitive Load Theory (Kirshner, Kirshner, & Paas, 2006) is
offered to sustain the overall declarative knowledge. Kirshner et al., (2006) maintain that

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cognitive saturation may occur quickly with complex material if not broken down into
manageable segments. Therefore, to enhance learning, the recommendation is to present
education on work-life balance in smaller parts, offer pre-training when possible, and process
check understanding and saturation levels at regular intervals. Encouraging learners to only
tackle one aspect of the larger concept at a time will help to prevent feelings of inundation.
Furthermore, assigning individuals tasks that fall within their zone of proximal development
(ZPD) will encourage the learner to enhance understanding of the larger concept and
interconnectedness of work-life balance (Scott & Palincsar, 2006).
Kravits et al., (2010) proffer that nurses, in general, are unaware of the stresses inherent
in the nursing profession. Nurse leaders, specifically, should educate themselves on the impact
these stressors may have on their emotional and physical health. In their qualitative study with
17 nurse managers, Udod et al., (2017) discovered a need for leaders to intimately understand
coping measures to deal with the stress and intricacies of the manager position. Similar to
findings with the ENLs, Udod et al. (2017) confirms there is a “false consciousness” which is a
dis-service to leaders as they mistakenly believe they are enlightened to tactics for well-being yet
fail to challenge or stretch their knowledge beyond the basics. This corresponds to the zone of
proximal development (ZPD) and ENLs should step beyond the known and comfortable to
enhance their knowledge of work stressors and work-life balance to gain control over their
individual situation. Mellner, Aronson, and Keckland (2014) concur as their quantitative
findings with 808 employees indicate the importance of knowledge around factors within the job
that may affect work-life balance. For example, if managers better understand the time and
effort it takes for a specific task, they can better understand the influence it will have on their

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work-life balance structure and therefore, increase the capacity for managing their boundaries
between work and life.
Motivation Recommendations
Exploring the motivation domain is crucial to understanding behavior and perseverance
required to complete a task. For this research, motivation theories including self-efficacy
(Pajares, 2006), goal orientation (Yough & Anderman, 2006), and expectancy value (Eccles,
2006) are explored and subsequently validated through interviews as either an asset or a need
(Clark & Estes, 2008). Supported by a relevant literature review, all three motivational
influences emerged as needs in this research on work-life balance. Table 12 shows, in order of
priority, the three assumed motivation influences and associated theory utilized in this research
and offers a relevant theoretical principle(s) for each. Furthermore, the table also offers a
context-specific recommendation for addressing each motivation need.
Table 12
Summary of Assumed Motivation Influences and Recommendations
Assumed
Motivation
Influence

Validated
as an asset
or a need
(A or N)
Priority
Yes, No
(Y, N)
Principle and Citation Context-Specific
Recommendation
Self-efficacy
(Pajares, 2006) –
Exempt nurse
leaders must
believe they are
capable of having
a healthy work-life
balance.
N Y High self-efficacy can
positively influence
motivation (Pajares,
2006).

Learning and
motivation
are enhanced when
learners have positive
expectancies for
success (Pajares,
2006).

Provide balanced
feedback, including
strengths and
challenges.

Provide close,
concrete, and
challenging goals that
allow the learner to
experience success at
the task.

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Mastery Goal
Orientation
(Yough &
Anderman, 2006)
– Exempt nurse
leaders should
work toward
balancing work
and life.
N Y Focusing on mastery,
individual
improvement,
learning, and progress
promotes positive
motivation (Yough
and Anderman, 2006).

Designing learning
tasks that are
novel, varied, diverse,
interesting,
and reasonably
challenging promotes
mastery orientation
(Yough and
Anderman, 2006).
Use task, reward, and
evaluation structures,
including SMART
goals that promote
mastery, learning,
effort, progress, and
self-improvement
standards.

Encourage
heterogeneous
cooperative groups to
foster peer interaction;
however, focus on
self-improvement and
use individual work to
convey progress.

Provide experiences
to learn from and
accept own mistakes
as opportunities to
learn.
Expectancy Value
Motivational
Theory (Eccles,
2006) – Exempt
nurse leaders need
to see value in
having a healthy
work-life balance.
A N Rationales that
include a discussion
of the importance
and utility value of
the work or learning
can help learners
develop positive
values (Eccles, 2006;
Pintrich, 2003).

Individuals are more
likely to engage in an
activity when it
provides value to
them (Eccles, 2006).

Activating personal
interest through
opportunities for
choice and control can
increase motivation
(Eccles, 2006).
Provide rationales
about the importance
and utility value of the
task.

Ensure materials and
activities are relevant
and useful to the
learners, connected to
their interests, and
based on real-
world tasks.

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Exempt Nurse Leaders Must Believe They are Capable of Having a Healthy Work-Life
Balance
ENLs were presented with a list of 13 influences taken from the current literature on
work-life balance and asked to indicate the top five that influence their work-life balance. Then
later, ENLs were asked to rate their level of confidence in their ability to affect those influences.
The results of this qualitative study indicate that only one out of ten ENLs feels capable of
having a healthy work-life balance. Pajares (2006) postulates that learning and motivation can
be positively influenced when learners elevate their self-efficacy and expect success. Two
recommendations grounded in Self-Efficacy Theory (Pajares, 2006) are offered to close this
specific motivation gap. First, both positive and constructive feedback should be offered to the
ENL as this may enhance efficaciousness in managing work-life balance (Borgogni et al., 2011).
Second, to build confidence in the learner, set challenging yet attainable goals so that they
experience small successes along the way.
A case study investigated by Ross et al., (2017), demonstrated that self-efficacy, or lack
thereof, directly affects what healthy behaviors nurses choose to execute. In this study, if nurses
found external barriers to health-promoting behaviors, they quickly cited a lack of control over
such barriers as explanation for failing to choose or persist. In another exploratory study
investigating middle managers and work-life balance, similar findings emerged (Parris et al.,
2008). When these middle managers were interrupted with calls from work during personal
time, the managers felt helpless to stop the intrusion, and therefore did nothing. Furthermore, in
two additional studies, nurse managers described a permeating feeling of inadequacy and guilt
for not being able to satisfy everyone all the time (Shirey et al., 2008, 2010). Judkins et al.
(2006) suggests that to close gaps mentioned above, strengthening autonomy, promoting

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responsibility, and developing tenacity will help ENLs to build self-efficacy. Thus, by setting
achievable goals and incorporating a robust feedback loop, nurse leaders would slowly develop
confidence in their ability to tackle barriers to their achieving a healthy work-life balance.
Exempt Nurse Leaders Should Work Toward Balancing Work and Life
As mentioned earlier, only 10% of ENLs in this study are actively working to improve
their work-life balance. In a related interview question, 80% of ENLs indicate that it is
important for them to be proficient at balancing their work and life. This indicates that a mastery
goal orientation is desired. This influence is emerging as a need because even though 80% of the
ENLs say it is important for them to be proficient, only 10% are actively working to improve.
To address this motivation gap, a principle from Goal Orientation Theory (Yough & Anderman,
2006) is suggested. To highlight the mastery rather than performance approach, focus should be
on self-improvement and personal achievement to increase motivation (Yough & Anderman,
2006). A context specific recommendation from Goal Orientation Theory (Yough & Anderman,
2006) is to employ learning strategies and set SMART goals that are personally interesting,
varied, and reasonably challenging so that the ENL will learn for the sake of learning. The
mindset for this style of goal setting is focused on developing proficiency by learning from
mistakes and promoting mastery rather than grandstanding.
In a work-life balance study with athletic trainers, Mazerolle and Goodman (2013) found
success was increased when highly individualized plans for success were utilized. “We must
plan.” is a strategy offered by Chittenden and Ritchie (2011) in their work on work-life balance
for palliative clinicians. In addition to being highly individualized as would support the mastery
approach, the goals should also incorporate cyclical patterns to one’s life and work, considering
busy times, as well as calmer periods. Finally, exciting findings from a study with nurses

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indicates that mastery goal orientation, as compared to a performance approach, helps to advance
learning. Gardner (2006) discovered nurses in the mastery group maintained a positive attitude
when faced with new challenges and persisted when encountering obstacles. Gardner’s study
offers evidence that the mastery approach to goal orientation illuminates the observable
motivation components of persistence and mental effort.
Exempt Nurse Leaders Need to See Value in Having a Healthy Work-Life Balance
The results of this qualitative study indicate that 100% of ENLs agreed that having a
healthy work-life balance was valuable. To maintain this asset, a principle from Expectancy
Value Theory (Eccles, 2006) is offered. Eccles (2006) and Pintrich (2003) suggest that to
cultivate positive values, the significance and worth of the undertaking be explained at every
opportunity. A context specific recommendation then is to ensure that every education and
training session includes intentional content about the importance and utility value of work-life
balance as a whole, as well as each task, learning opportunity, and goal. Even though this
influence is emerging as an asset, assistance is needed to propel the ENLs into action. While it is
beneficial that ENLs indicate they value work-life balance, their behaviors are not congruent
with this assertion. When directly asked if they are presently working to improve their work-life
balance, only one ENL answered in the affirmative. This means 90% of the ENLs are not
actively choosing nor persisting to improve their work-life balance. A principle from the
Expectancy Value Theory Eccles, (2006) helps to transition the initial asset into action. Eccles
(2006) maintains that learners are more apt to participate in an activity if they see a value within.
Furthermore, he asserts that giving learners the opportunity to ‘choose and control’ will foster
personal interest and thereby increase motivation. The context-specific recommendation to
actualize this principle is that training activities should be explicitly relevant and useful to the

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learners, directly address their interests, and be based on actual tasks, such as; establishing
coverage so the ENL can leave on time, delegation and efficiency skills to diminish workload,
and mindfulness activities to allow a disconnect from work while home.
While researching nurses’ self-care and self-compassion, Andrews, Tierney, and Seers
(2019) found that nurses often value the care they give to others over the care they give to
themselves. Nurses in this study acknowledge they know they should be practicing self-care;
however the drive to care for someone else makes them feel valued and that supersedes the value
they have for self-care, such as work-life balance. Buchanan et al., (2013) in their study
investigating the extreme nature of healthcare middle management jobs, discovered that often
middle managers prioritize the job due to the challenge and excitement many feel from the work.
However, they caution that the feelings of excitement are usually short-lived, as the extreme
natures of the nursing management positions and the tendency to over-function lead to stress,
work-life imbalance, and burnout (Buchanan et al., 2013). Rather, attention should be directed
toward highlighting the value of a healthy work-life balance for the vulnerable population of
nurse managers. Promoting a harmony of work and play where both domains are valued is the
optimal scenario.
Organization Recommendations
This study of exempt nurse leaders and work-life balance assessed organizational
influences relevant to this problem of practice. Organizational domains such as culture, policies
and procedures, and structure have profound impact on stakeholders and their ability to actualize
performance goals (Rueda, 2011). Six organizational influences, three cultural settings and three
cultural models, taken from current literature on work-life balance are examined and
recommendations offered. Table 13 shows each assumed organizational influence analyzed and

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indicates if it has been validated as a need or an asset. Furthermore, the table offers a relevant
theoretical principle and context-specific recommendation for addressing each validated
organizational need.
Table 13
Summary of Assumed Organization Influences and Recommendations
Assumed
Organization
Influence

Validated
as an asset
or a need
(A or N)
Priority
Yes, No
(Y, N)
Principle and Citation

Context-Specific
Recommendation
The organization
needs to ensure
resources meet
demands.
(Cultural Setting)
N Y Effective change
efforts ensure that
everyone has the
resources needed to do
their job, and that if
there are resource
shortages, then
resources are aligned
with organizational
priorities (Clark and
Estes, 2008).
Provide opportunities
for ENLs to work with
their leaders and their
teams to establish
priorities, so that when
hard choices must be
made regarding
allocation of
resources, the
guidance is already in
place.
The organization
needs to support a
culture of
communication
that supports
work-life balance.
(Cultural Setting)
N Y Effective leaders have
the skills and
strategies needed to
redesign their
organization for
effective
communication.
Related Research:
(Lewis, 2019;
Denning, 2006.)
Provide opportunities
to learn how various
communication
approaches can
influence
stakeholders.

Think about and
reflect on different
types of
communication
models and work with
stakeholders to decide
which model or
combination of models
would work best in the
organization.

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The organization
needs to ensure
ENL expectations
are compatible
with work-life
balance. (Cultural
Setting)
N Y Accountability is
increased when
individual roles and
expectations are
aligned with
organizational goals
and mission.
Clearly articulate a set
of practical skills
leaders need and
develop strategies to
promote accountability
within their
organization to
improve
organizational
performance.

Develop strategies to
align institutional
goals with individual
practices.
The organization
needs to support a
culture of
meaningful work.
(Cultural Model)
N Y Employee attitudes,
particularly feeling as
though they matter and
their work makes a
difference, are
correlated with
numerous
organizational outputs
(Buckingham and
Coffman, 2014;
Harter, Schmidt,
Asplund, Killham, and
Agrawal, 2010;
Schlossberg, 1989).
Provide clear
communication
regarding the why, not
just the what, of any
decision.

Develop strategies to
align institutional
goals with individual
practices.
The organization
needs to support a
culture of
psychological
safety. (Cultural
Model)
N Y Effective leaders are
aware of biases and
prejudices that occur
in the organization at
the individual and
structural levels.

They
acknowledge their
own biases and
prejudices and protect
the organization from
their negative impact.

Encourage all
information to be
brought forth and
discussed. Encourage
all to react calmly and
appreciatively when
someone brings
negative news/data
forward.

Make it “safe” for
opposing viewpoints
to be heard.

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They also recognize
and address
micro-aggression and
other covert ways of
expressing bias and
prejudice. (Bensimon,
2005; Chavez, Duran,
Baker, Avila, and
Wallerstein, 2008).
Communicate to staff
regularly about the
importance of
diversity and
inclusion.

Utilize reflective
practices to ensure
biases and prejudices
are kept in check.
The organization
needs to support a
positive work
environment that
fosters work-life
balance. (Cultural
Model)
N Y Effective
organizations ensure
that organizational
messages, rewards,
policies and
procedures that govern
the work of the
organization are
aligned with or are
supportive of
organizational goals
and values (Clark and
Estes, 2008).
Conduct an informal
audit of policies,
procedures and
messages to check for
alignment or
interference with
goals.

The Organization Needs to Ensure Resources Meet Demands (Cultural Setting)
The results and findings of this study indicate that this influence is determined to be a
need in supporting work-life balance for the exempt nurse leaders. A principle grounded in
Change Theory is offered to eliminate this organizational gap. Clark and Estes (2008) proclaim
that necessary resources, such as time, personnel, etc., must be available for change efforts to be
successful. This suggests that if exempt nurse leaders have increased time in their workday and
personnel to help alleviate tasks, ENLs will accomplish work responsibilities as well as achieve
work-life balance. The recommendation then is ENLs should work with their leaders and their
teams to establish priorities and a plan to share the work so that when hard choices must be made
regarding resource allocation, the guidance is already in place.

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Kath et al., (2013) quantitatively studied nurse managers and found that organizational
constraints, such a lack of resources, barriers or obstacles to performance, and inadequate
information, was the second most important predictor of stress for nurse managers. When nurse
managers were faced with organizational constraints, it took more time to accomplish tasks, and
therefore negatively affected their work-life balance and job satisfaction. Kath and colleagues
(2013) concluded by recommending that nurse managers be allowed to troubleshoot these
resource limitations to better address demands. Additionally, they called for hospitals to
permanently eliminate these constraints to allow the nurse manager to be as efficient as possible
and thereby support their work-life balance efforts. In 2011, Udod and Care’s qualitative study
with nurse managers revealed similar results. Inadequate human resources were found to be a
major stressor as the managers often needed to function in several different roles due to the lack
of resources. Possibly missing the point, Udod and Care (2011) recommend many stress coping
strategies, such as yoga, in her discussion. While this may be marginally helpful, it does not
address the underlying obstacles and gaps creating the stress. A better proposal is for hospital
leaders and financial officers to realign the budget to allow for necessary resources at the
bedside. Not only does this have the potential to eliminate stress from the nurse leader and
support work-life balance, it also may help to create a positive work environment and support
quality patient care.
The Organization Needs to Support a Culture of Communication That Supports Work-Life
Balance (Cultural Setting)
The results and findings of this study indicate that 100% of the exempt nurse leaders
interviewed indicated that a culture of communication that supports work-life balance is needed.
A principle grounded in Leadership Theory is offered to eliminate this communication gap.

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Lewis (2019) maintains that, in order to redesign the communication culture, leaders must
employ specific skills and strategies to be successful. This suggests that, if hospital leaders
create an intentional plan to redesign how and when leaders communicate, it will foster work-life
balance. The recommendations then are two-fold: be aware of how various types of
communication approaches and dynamics can influence stakeholders, and reflect on different
types of communication models and work with stakeholders to decide which model or
combination of models would work best in this organization.
In addition to work overload, Parris et al. (2008) also investigated the use of technology
and communication. Technology and how the intrusion of such shapes communication culture
emerged as a top impediment to work-life balance. This study echoes the sentiments of exempt
nurse leaders in that advancing technology has made accessibility an expectation and a constant.
Parris et al. (2008) offer that realistic expectations need to be outlined for the use of technology
and manager availability. Furthermore, middle managers and, by extension, exempt nurse
leaders, should learn to use the technology to their advantage by relishing the flexibility it offers
to work outside the office for a day yet remain in touch.
The Organization Needs to Ensure ENL Expectations are Compatible with Work-Life Balance
(Cultural Setting)
The results and findings of this study indicate that 100% of the exempt nurse leaders
interviewed indicated that job expectations should be compatible with work-life balance. A
principle grounded in Accountability Theory (Elmore, 2003) is offered to eliminate the job
expectations gap. Elmore (2003) asserts that when the goals and mission of an organization
reflect alignment with the roles and expectations of employees then accountability is expanded.
This suggests that if ENL job expectations were strategically parallel with organizational goals

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and work-life balance, then leader expectations would be manageable and foster greater
productivity. The recommendation then is to clearly articulate a set of practical skills leaders
need to monitor their workload. Furthermore, they should develop strategies to promote
accountability within their organization and improve organizational performance, which includes
the goal for work-life balance.
In their interpretive phenomenological study exploring impediments to work-life balance,
Parris et al., (2008) interviewed six middle managers and investigated how daily organization
affects work-life balance. Despite best laid plans and time management strategies, managers
cited the sheer volume of work as one of the top three reasons they struggled with work-life
balance. Furthermore the managers reported that others in the organization could add to their
workload with little notice. This additional work was often not satisfying as it tended to take
them away from patient quality projects or unit responsibilities that they enjoyed (Parris et al.,
2008). Kath et al. (2013) also studied nurse managers through the lens of the Role Stress
Theory. Employing a quantitative survey, 480 nurse managers were asked about role ambiguity,
role overload, role conflict, organizational constraints, interpersonal conflict, and job stress. This
study revealed that the number one predictor of stress for nurse managers was role overload.
Extrapolating further, these excessive tasks and increasing demands on time affect the amount of
work a nurse manager can accomplish during work hours, which leads many to working longer
hours or bringing work home, thereby negatively affecting work-life balance. Both studies
called for hospital leaders to thoughtfully redesign the nurse manager job description. While the
overload of work is leading to poor work-life balance for nurse managers, the expectation for
nurse leaders to be constantly accessible also contributes to this problem.

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The Organization Needs to Support a Culture of Meaningful Work (Cultural Model)
The results and findings of this study indicate that, on average, exempt nurse leaders
report approximately 38% of their work is not meaningful. A principle grounded in Leadership
Theory is offered to eliminate the meaningful work gap. Harter et al., (2010) proclaim that
organizational goals and outputs are increased when employees feel that their work is
meaningful and that they, as people, matter. This suggests if exempt nurse leaders were
encouraged to offload tasks that are not meaningful, and instead focus on work that is
meaningful, then attitudes would improve, productivity would increase, and the schedule would
allow for greater work-life balance. The recommendation then is for all leaders to communicate
the why, not just the what, of any decision or initiative, and develop strategies to align
institutional goals with individual practices.
In a study of nurse managers, Udod et al. (2017) investigated the role of stressors and
coping mechanisms. Using qualitative interviews and focus groups, 17 nurse managers echoed
the sentiments of the need for meaningful work. Using a stress and coping theory for
framework, Udod et al. (2017) support a redesign of the nurse manager position to shift focus
back to the units and caregivers and away from organizational initiatives and administrative
work. Shirey et al., (2008) also qualitatively studied nurse managers and found that 60% of
participants referred to “invisible work” defined as busy work or duties that should be delegated
but cannot be due to limited personnel. This study also called for a closer look at the job duties
of nurse managers specifically addressing the meaningless tasks as they have a deleterious effect
on job satisfaction, time management, and, ultimately, work-life balance.

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The Organization Needs to Support a Culture of Psychological Safety (Cultural Model)
The results and findings of this study indicate that only 10% of participants felt
comfortable bringing up issues about work-life balance at work for fear of judgment and
retaliation. A principle grounded in diversity theory is offered to eliminate the psychological
safety gap. Bensimon (2005) asserts that for organizations to evolve and thrive, leaders must be
cognizant of organizational biases as well as personal prejudices. This suggests that if exempt
nurse leaders were to speak up in favor of work life balance, they would be protected from overt
acts of prejudice, as well as covert displays of micro-aggression. The first recommendation then
is to make it “safe” for all information including opposing viewpoints to be put “on the table” by
reacting calmly and appreciatively when someone brings information forward. Second,
executive hospital leaders should communicate to staff the importance of inclusion and
acceptance of differing work-life balance goals. Finally, it is recommended that all staff use
reflective practices to ensure biases and prejudices are tempered.
In their study, Gaskin et al. (2012) interviewed 22 nurse unit managers using Mintzberg’s
(2002) Model of Managerial Work to inform the study. Gaskin et al. (2012) revealed
participants admitted to feeling uncomfortable seeking help or discussing topics when it could
appear, they were ignorant. Andrews et al., (2019) found similar results in their grounded theory
study exploring self-care and self-compassion in 30 nurses. The data showed nurses require
safety and security in themselves and the workplace before they will feel comfortable taking care
of themselves. It was also revealed that many things can threaten these foundational needs, such
as poor job security, a negative work environment, and an ineffective relationship with a superior
(Andrews et al., 2019). This study offered that nurses need to be reminded of the importance of
self-care and self-compassion. Additionally, rather than address the symptoms of lack of self-

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care with forced strategies focused at the individual such as yoga or breathing clinics, hospital
executives need to ensure the practices that threaten the stable base are transformed to better
support nurses well-being.
The Organization Needs to Support a Positive Work Environment That Fosters Work-Life
Balance (Cultural Model)
The results and findings of this study reveal a misalignment between the tenets that make
up a positive work environment and work-life balance for the exempt nurse leaders. Clark and
Estes (2008) maintain that to achieve organizational goals, such as work-life balance,
organizational literature, policies, procedures, and communication should be supportive of such.
This suggests that if messages of work-life balance were heard and actualized, the exempt nurse
leaders would feel supported by policies and procedures designed to foster work-life balance.
The recommendation then is to conduct a formal audit of all policies, procedures, and messages
to check for alignment or interference with the goal of work-life balance.
In their study exploring self-care and self-compassion of nurses, Andrews et al., (2019)
found that nurses required permission to take care of themselves. Nurses offered that if the
policies and procedures better supported the occasional sick day or self-care activity, there would
be less guilt felt by the nurses. Parkes and Langford (2008) acknowledged in their study that
there appears to be widespread dichotomy between what organizations say about work-life
balance and what is reality for those they employ. In their study exploring over 16,000
employees, they found it important for organizations to write supportive policies and procedures
and create goals and values that come alive to actively support work-life balance.

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Integrated Implementation and Evaluation Plan
Implementation and Evaluation Framework
The model that guided this implementation and evaluation plan is the New World
Kirkpatrick Model (Kirkpatrick & Kirkpatrick, 2016), based on the original Kirkpatrick Four
Level Model of Evaluation (Kirkpatrick & Kirkpatrick, 2006). This New World Model flips the
delivery of the original model by starting with the end in mind. Beginning at the end provides an
easier to identify pathway from the internal and external outcomes of the program, then the
behaviors needed to achieve the outcomes, and finally the drivers that influence said behaviors.
By organizing the evaluation strategy in this fashion it ensures the recommended solutions are
directly aligned to the stakeholder and organizational goals. This flipped order of the New
World Kirkpatrick Model allows a presentation of the best scenario. First in Level 4 the
expected results are highlighted. Level 3 is the assessment of behaviors and changes applied to
get to those results. Level 3 should also include how the stakeholder and organization will
support the required behaviors. Level 2 assesses that learning occurred during the
implementation period. Finally, Level 1 assesses that stakeholders are satisfied and that the
organization is engaged and invested in the overall plan. Carefully creating the implementation
activities, and the evaluation plan that follows, is crucial to establish affiliations between the
desired behaviors and the larger goal (Kirkpatrick and Kirkpatrick, 2016).
Organizational Purpose, Need, and Expectations
The mission and values of PH is central to the work. The mission, ‘using God as our
guide and through the ministry of Jesus, we will persevere to serve all people in need, regardless
of situation’, reassures that through God’s work we serve all community members regardless of
status and station. More than just a sentiment on paper, the caregivers inspire and actualize its

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meaning. The resonance with the mission also helps to recruit and retain talented caregivers.
Without our caregivers, the mission would simply be words on paper. While all caregivers are
important, one group stands out as pivotal to the successful operations of the hospital overall:
the exempt nurse leaders. These exempt nurse leaders are responsible for the overall operations
on their patient care unit 24 hours a day. In addition to the management of the care area, these
leaders supervise caregivers, ensure compliance and accountability measures are in place, attend
to risk and safety issues, control productivity and supply budgets, and serve the hospital ministry
on committees, task forces, and work groups. With recent hospital restructuring and market
influences, ENLs are finding their work is exceeding their capacity. While some ENLs are
sacrificing themselves by working longer days, or bringing work home on the weekend, other
ENLS are resigning amid the pressure to keep up. Therefore, the problem of practice examined
by this study is the struggle for ENLs to achieve work-life balance considering their workload
and the design of their position.
The goal of this study was to investigate the knowledge, motivation, and organizational
influences on ENL work-life balance, and subsequently offer an innovative work-life balance
program in place by May 2021 and geared toward retaining current and attracting future ENLs.
This goal is directly related to the mission and values in several ways. Serving the community is
central to the hospital mission and therefore serving the nurse leaders within, who are also
community members, is also reflected within the mission. Each of the hospital values also
speaks to the overall health of caregivers, including nurse leaders. Nurturing all aspects of each
person, recognizing the worth of each person, removing obstacles in the path of healing,
improving the quality of life, and the importance of always doing the right thing for the right

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reason; these sentiments are highlighted in the values of SWH and are directly applicable for the
ENLs struggling to maintain their own health when work and life are out of balance.
It is expected the desired results of the recommendations will result in an increase in the
number of ENLs that self-report satisfaction of work-life balance, a decrease in ENL burnout,
and an increase in ENL psychological safety. By extension we also expect ENL and caregiver
engagement scores and ENL retention will increase.
Level 4: Results and Leading Indicators
Table 14 shows the proposed Level 4: Results and Leading Indicators in the form of
outcomes, metrics, and methods for both external and internal outcomes for the work-life
balance program. If the internal outcomes are met as expected as a result of exempt nurse
leaders actualizing the innovative work-life balance program, then the external outcomes should
also be realized.
Table 14

Outcomes, Metrics, and Methods for External and Internal Outcomes

Outcome Metric(s) Method(s)
External Outcomes
Increased recognition as a
promising practice for work-
life balance
The number of requests for
information regarding our
work-life balance program will
rise
Reports from executive or
Human Resource partners
Awarded top spot on top
employer list
Ranking from agency on
recognition
Indeed 2021 America’s Top 15
Employer for Work-Life
Balance
Increased ENL retention Number of ENL vacancies Regional Human Resources
turnover report
Increased ENL Caregiver
engagement
Number of ENLs who report
higher engagement scores
Regional Yearly Caregiver
engagement survey
Internal Outcomes
Increased ENL satisfaction
with work-life balance
Number of ENLs who report
satisfaction with work-life
balance
ENL work-life balance survey
or focus group

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Decreased ENL burnout Scores on burnout assessment ENL burnout survey (2x/year)
Increased ENL psychological
safety with one another
Number of ENLs who report
psychological safety
Self-report of culture of
psychological safety progress
All ENLs want to participate in
the ENL work-life balance
program
Number of ENLs enrolled Waitlist for program
participation
Increased succession planning
and leadership development for
Charge Nurses and other RNs
Number participating in
succession planning
Reports from ENLs regarding
staff activities

Level 3: Critical Behaviors
The stakeholders of focus are the exempt nurse leaders in the acute care hospital setting.
Therefore, four critical behaviors have been identified for the ENL (a) the ENL will attend and
participate actively in all meetings and discussions about work-life balance to share ideas and
struggles, (b) the ENL will discuss work-life balance with their supervisor weekly, (c) the ENL
will use available tools and strategies to actualize and persevere with a plan for work-life
balance, (d) the ENL will identify on-going personal and professional learning needs regarding
work-life balance and be empowered and self-directed to satisfy those needs. The specific
metrics, methods, and timing for each of these outcome behaviors appears in Table 15.
Table 15

Critical Behaviors, Metrics, Methods, and Timing for Evaluation
Critical Behavior Metric(s)
Method(s)
Timing
1. ENL will attend and participate actively
in all meetings and discussions about
work-life balance to share ideas and
struggles
Number of
meetings ENL
attends
Attendance
records
Weekly
2. ENL will discuss work-life balance with
supervisor weekly where they will:
● reflect on previous week work-life
balance efforts
● plan work-life balance goals for week
ahead
● strategize together to remove obstacles
and support efforts
Number of ENLs
participating in
weekly meetings
Supervisor
records

Weekly
x8 then
monthly
on-
going

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3. ENL will use available tools and
strategies to actualize and persevere with
a plan for work-life balance (i.e., alternate
plan for caregiver communication
redistribute meaningless work, etc.)
Number of tools
and strategies

ENL
Reflection
journal

Weekly,
monthly
4. ENL will identify on-going personal and
professional learning needs regarding
work-life balance and be empowered and
self-directed to satisfy those needs
Number of ENLs
participating in
professional
development
activities

Professional
Development
attendance
rosters

Daily,
weekly

Required Drivers
Exempt nurse leaders require the support of their peer group, direct leaders, and the
organization at large to reinforce the work-life balance program. Rewards should be established
for achievement of performance goals to enhance continued support for the change initiative.
Table 16 shows the recommended drivers to support critical behaviors of exempt nurse leaders.
Table 16
Required Drivers to Support Critical Behaviors
Method(s) Timing
Critical Behaviors
Supported
1, 2, 3 Etc.
Reinforcing
Organization should provide
the opportunities for
ENLs/exec leaders to engage,
discuss, strategize, and
support issues of work-life
balance
Monthly 1, 2, 3, 4
Organization should provide
for communities of practice
with on-going work-life
balance workshops and peer
sessions to collaborate and
learn from peers, tackle
challenges together, and
intentionally work on work-
life balance strategies
Monthly x6, then Quarterly 1, 2, 3, 4

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Executive leaders should
model healthy work-life
balance practice
On-going 1, 2, 3, 4
Encouraging
Organization should provide a
work-life balance expert to be
available for consultations and
teach on-going workshops
Quarterly, Ongoing 1, 2, 3, 4
Organization should make
time available for coaching
sessions with expert or
supervisor to offer corrective
feedback as well as positive
encouragement on the ENLs
ability to achieve work-life
balance
Weekly 1, 2, 3, 4
Rewarding
Organization should
encourage public recognition
in meetings or huddles on
work-life balance efforts
Daily, On-going 1, 2, 3, 4
Organization should
encourage private
acknowledgement by
supervisor on work-life
balance efforts
Daily, On-going 1, 2, 3, 4
Organization should
encourage public recognition
when ENLs present divergent
ideas or speak up in support of
work-life balance (helps
psychological safety)
Daily, On-going 1, 2, 3, 4
Monitoring
ENLs will journal weekly on
their knowledge and
motivation in work-life
efforts; and mentor,
supervisor, or expert will
review and place in
developmental/performance
goals
Weekly, On-going 1, 2, 3, 4
The organization will ensure
policies, procedures, and
practice support a positive
work culture to foster work-
life balance
On-going 1, 2, 3, 4

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Organizational Support
In considering the cultural settings and models needed to achieve success with the work-
life balance goal, there are several ways the organization should support the stakeholders critical
behaviors. Resources, such as personnel and time should be allocated in order to implement the
organizational change plan. Executive leadership, including the exempt nurse leaders, will need
to ensure time is built into weekly and quarterly schedules to allow for the recommended team
and individual meetings to support the establishment of individual goals and for feedback
sessions. Additionally, the culture of organizational communication and policies needs to
adequately prioritize and reinforce the importance of the work-life balance goal tactics.
Additional financial resources may be needed to actualize other recommendations such as
administrative support to handle administrative tasks and other delegated work.
Level 2: Learning Goals
Following completion of the recommended solutions, most notably the work-life balance
program, the stakeholders will be able to:
• Produce a workable definition for work-life balance that fits their situation (D)
• Discern which influences/tasks throughout the day negatively and positively influence
work-life balance (D)
• Determine what strategies to employ to improve work-life balance (D)
• Design an efficient/dynamic plan to improve work-life balance. (P)
• Clarify expectations related to positive work-life balance behaviors (P)
• Monitor self-effectiveness through journaling, peer feedback, and coaching (M)
• Monitor own response to operationalizing work-life balance toolkit and strategies (M)
• Value own work-life balance as well as the work-life balance of other ENLs (Value)

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• Demonstrate self confidence in controlling/enhancing influences on work-life balance
(Self-efficacy)
• Master the psychological and emotional distress (guilt) that may accompany a healthy
work-life balance (Goal Mastery)
Guided Experience
The learning goals listed in the previous section, will be achieved with a guided
experience that imparts knowledge on the work-life balance paradigm including identification,
process, strategies, and application to self. This guided experience is modeled after other
professional development programs such as Lean Leader Development (Shingo Institute, 2020),
nursing leader fellowship programs, and Six Sigma Green Belt (Glower, 2006). The guided
experience proposed is a hybrid design, including both individual education as well as partner
and small group work. The learners, exempt nurse leaders, will study a broad range of topics
pertaining to the tenets of work-life balance, as well as those psychological and motivational
themes that may influence how they feel about the task. Private reflective activities as well as
face-to-face workshops is proposed. Additional meetings with the work-life balance expert or
ENL supervisor are also part of the plan, and hours will be absorbed within regular work.
During the private reflective activities, learners should be provided a job aid of key terms
and a workbook of activities pertaining to actualizing work-life balance. The workbook should
contain reflective questions to ponder and private activities to support each element of the KMO
framework. Then, each activity will serve as discussion material for the face-to-face workshops.
The face-to-face workshops should allow the opportunity to practice using the job aids and
receive feedback from peer review, workshop groups, role-playing, discussions, peer modeling
and teaching back to each other. In time and once available, role models should be utilized to

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deepen the understanding of the learners and share valuable lessons. The private reflections,
practice, and feedback approach should be used for each KMO component.
Evaluation of the Components of Learning

It is important to include a process for verification that learning has taken place when
designing a new program, such as the work-life balance program in this study. Demonstrating
that knowledge was gained is a logical first step before one can apply said knowledge to solve
the problem. Level 2 of the New World Kirkpatrick Model (Kirkpatrick & Kirkpatrick, 2016)
includes an evaluation component of the knowledge, skills, attitude, confidence and commitment
learning objectives. Understanding definitions and factual content is declarative knowledge,
while understanding the process or steps, and applying the learning is procedural knowledge.
Attitude, confidence, and commitment are often evaluated through observations and discussions.
Interest in the topic, valuing the content, confidence to apply the new skills, and demonstrations
of commitment to apply what they have learned are all evaluated.
Level 2 evaluations are formative and thus allow for content or delivery adjustments to
maximize learning and growth. Confidence and commitment take time to develop and
necessitate interval assessment to illuminate progress. Table 17 lists the evaluation methods and
timing for these components of learning.

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Table 17
Evaluation of the Components of Learning for the Program
Method(s) or Activity(ies) Timing
Declarative Knowledge “I know it.”
Knowledge checks during workshops Periodically during the face-to-face
workshops and documented via observation
Discussions one on one with peers or expert During the face-to-face workshops
Procedural Skills “I can do it right now.”
Action Planning - document WLB goals and
create a dynamic template for scheduling
priorities
During the face-to-face workshops
Demonstration in groups and individually of
using the job aids and tool kit forms to
successfully perform the skills
During the face-to-face workshops
Practice conversations regarding
expectations and WLB issues to be had with
supervisor
During the face-to-face workshops
Pre- and post-test assessment survey asking
participants about their level of proficiency
before and after the training
At the beginning and end of the guided
experience
Attitude “I believe this is worthwhile.”
Instructor’s observation of participants’
statements and actions demonstrating that
they see the benefit of what they are being
asked to do on the job
During the face-to-face workshops
Brainstorm positives and negatives to WLB
at the workshops and in reflective journaling
During the face-to-face workshops and as a
prompt for weekly journaling
Pre and post assessment survey to determine
if the value has increased to achieve WLB
At the beginning and end of the guided
experience
Confidence “I think I can do it on the job.”
Feedback from peers and supervisor during
workshops, meetings, and observations
During the face-to-face workshops and
meetings
Pre and post assessment survey to determine
if confidence has increased to achieve WLB
At the beginning and end of the guided
experience
Commitment “I will do it on the job.”
Document the commitment statement at the
end of each workshop and encounter
(commit to working on self-issues and
helping the organization with cultural models
and settings to support WLB)
During the face-to-face workshops
Create an individual action plan During the face-to-face workshops
Pre and post assessment survey to determine
if commitment has increased to achieve
work-life balance
At the beginning and end of the guided
experience

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Level 1: Reaction
The final level of evaluation concentrates on the reaction of learners and assesses
satisfaction, engagement, and relevance (Kirkpatrick & Kirkpatrick, 2016). To ensure that
learners are fully invested, this formative assessment must be expertly administered early, and
frequently in the process. The program must be designed with a certain degree of agility to best
meet the needs of the learners. Summative evaluations may also be used at the end of the
learning, and should include assessment beyond satisfaction, engagement, and relevance. Table
18 illustrates the methods and frequency of measuring Level 1 reactions.
Table 18
Components to Measure Reactions to the Program
Method(s) or Tool(s) Timing
Engagement
Willingness to participate and speak up in
workshops and meetings
During the guided experience
Completion of journaling and other
asynchronous activities
During the guided experience
Observation by instructor/facilitator During the face-to-face workshops
Attendance at workshops and meetings During the guided experience
Course evaluation (summative) Two weeks after the guided experience
Relevance
Brief pulse-check with participants via phone
or in-person (formative)
After every face-to-face workshop
Guided experience evaluation at end
(summative)
Two weeks after the guided experience
Customer Satisfaction
Brief pulse-check with participants via phone
or in-person (formative)
After every face-to-face workshop
Acquire testimonials to use in future ENL
workshops
After every face to face workshop
Course evaluation (summative) Two weeks after the guided experience

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Evaluation Tools
During and Immediately Following the Program Implementation

During the asynchronous portion of the guided experience, the analytics tool in the
learning platform will collect data about the completion of reflection activities by the ENLs.
These data will also indicate the engagement with the course material.
For Level 1, at the conclusion of each in-person workshop, the facilitator will conduct an
evaluation by asking the ENLs about the relevance of the content to their work, as well as the
satisfaction with the content, delivery, and environment. Level 2 will include checks for
understanding, attitude toward the material, confidence in applying the learning strategies, and
commitment to use the tools taught to improve (See Appendix D for Immediate Post-Workshop
Evaluation instrument).
Delayed for a Period After the Program Implementation

Approximately eight weeks after the final component of the guided experience, the
facilitator will administer a survey containing open and scaled items using the Blended
Evaluation approach. This survey will measure, from the ENL’s perspective, satisfaction and
relevance of the training (Level 1), confidence and value of applying the training (Level 2),
application of the training to the ENL position, and the extent to which their application of the
work-life balance tenets has impacted the internal outcomes expected (See Appendix E for
Blended (Delayed) Evaluation for Work-Life Balance Guided Experience Evaluation
instrument).
Data Analysis and Reporting
The Level 4 goal of Southern and Western Hospitals having in place and operational an
innovative work-life balance program geared toward retaining current and attracting future

155

ENLs, is measured by the actualization and utilization of said program. Each week, the program
facilitator will track progress of the creation of the program, and then the utilization of the
program by ENLs using data from the learning platform and in-person workshops. The figure
below, as an example, may be used to report the data on these measures as a monitoring tool.
Similar graphic representation is available to monitor Levels 1, 2, and 3.
Figure 4
Level 4 Internal Outcomes Over Time

Chapter Summary
The New World Kirkpatrick Model informs the implementation and evaluation plan of
this study (Kirkpatrick & Kirkpatrick, 2016). The four levels of training and evaluation are used
to ensure that exempt nurse leaders have the knowledge, motivation, and organizational support
to not only create a comprehensive work-life balance program, but to attain work-life balance
themselves. Following the model, this guided experience begins with the desired external and
internal outcomes. Highlighting the metrics and methods for each outcome ensures the results

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are sound and integrated within the organization’s goals and strategic plan. Subsequently, ENL
critical behaviors to use on the job are established and learning outcomes during the guided
experience are identified. Finally, ENL reactions to the innovative program and embedded
training are captured, specifically satisfaction, relevance, and engagement.
To implement change and maximize the program potential it is imperative to evaluate
and analyze data during program implementation. For the immediate evaluation, if the reactions
and learning expected do not materialize during the workshops, needs should be identified and
changes made as expeditiously as possible (Kirkpatrick & Kirkpatrick, 2016). When the desired
reactions and learning do meet expectations, it is equally important to query the participants to
discuss the optimizers (Kirkpatrick & Kirkpatrick, 2016). For the delayed evaluation, if
behaviors and outcomes do not meet expectations then it is important to investigate the critical
behaviors and supportive drivers. Additionally it is pivotal to assess the progress on the internal
outcomes and scrutinize all possible detractors (Kirkpatrick & Kirkpatrick, 2016). Conversely
when behaviors and outcomes are progressing, it is recommended to ascertain specific
contributors that can be further shared with the organization (Kirkpatrick & Kirkpatrick,
2016). Ultimately, it is worthwhile to assemble a final report on the guided experience
outcomes, both internal and external. This report should be shared with participating ENLs and
other stakeholders. As recommended by Kirkpatrick and Kirkpatrick (2016) this transparent
communication helps to drive individual performance, while garnering and maintaining
organizational support for the initiative. Utilizing this evaluation structure, as well as an
organizational system for accountability, will increase the value of this program and the potential
for a return on investment.

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Strengths and Weaknesses of the Approach
The application of the Clark and Estes (2008) gap analysis model offers both strengths
and weaknesses to the study. First, one of the strengths of the approach is that the gap analysis
framework is a prescriptive and descriptive tool for diagnosing human performance problems.
Second, since this approach analyzes human performance using the influential domains of
knowledge, motivation, and resource allocation within a work culture, the segmentation helps to
uncover the root causes of the problem of practice. Third, the Clark and Estes (2008) gap
analysis framework is evidence based and employs learning, motivational, and organizational
change theories.
While the strengths of the method are sound, there are unfortunately two weaknesses.
First, it is time consuming to gather data and determine influences required in this framework.
Additionally, ideally all critical stakeholder groups associated with the problem of practice
should be included in the study and relative data collected. However, the time required for this
undertaking would extend the study period and make it impractical for a dissertation.
Limitations and Delimitations
Another element of sound research is acknowledging the limitations of the study. There
are several limitations to consider that are not in the researcher’s control: truthfulness of the
interviewees, organizational leadership turnover, resistance due to the personal nature of the
concept, and timing of the data collection. While literature indicates participants do not routinely
participate in deception during the interview process, there is the possibility of lack of awareness,
shallow responses to questions, and resistance due to the personal nature of the concept. The
recent leadership turnover may lend itself to confusion or lack of experience with new ways of
doing and uncertain expectations from new supervisors. Next, ENLs may have felt threatened or

158

resistant to deeply explore the personal concept of WLB. This resistance, although not observed
by the researcher, may have affected the amount of rich data gathered from interviews. Finally,
the study was conducted during a relatively short period of time during the fourth quarter of the
year, making it dependent on the respondents’ mindset during this limited and often busy time of
year for a hospital.
Delimitations, defined as choices researchers make, are also present and deserve
consideration. These included choices such as, only ENLs that identify as females were
interviewed for this study, choice of organizational settings and models, and finally the
innovation design of the study. While each ENL had equal opportunity to participate in the
study, only female ENLs were interviewed. While not intentional, other gendered ENLs were
not included in the study due to availability and reaching saturation of data. Although the choice
of organizational settings and models comes from investigation of the literature on WLB, there
was the possibility for this organization that others could have also applied. Finally, to best
inform implementation, this study was conducted prior to the innovation being introduced.
Therefore, it is an innovation study rather than an evaluation study.
Future Research
While the data yielded salient results and findings for this study, not all discoveries could
be investigated. Five distinct observables are ripe for future research efforts: gender differences
for work-life balance within the exempt nurse leader group, how personality types affect work-
life balance, the notion of guilt verbalized by the ENLs, the issue of competition verbalized as
resentment when comparing work-life balance experiences, and finally, barriers to help seeking
behaviors for the nurse leader population.

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This study explored the experiences of work-life balance through the shared stories of 10
female nurse leaders. While nursing as a profession is predominately female, it would be
valuable to retrieve the male nursing leader perspective as they may define, conceptualize, value,
and work toward work-life balance uniquely to females. While not an intentional omission,
including males in future research of this topic would help to deepen the literature.
Several literature pieces on work-life balance mentioned the plausible interaction
between personality type and work-life balance efforts. The ‘my personality’ influence was
included in the conceptual exercise as well as the self-efficacy exercise. Six ENLs chose
personality as a factor, and 80% of ENLs had moderate to low self-efficacy to alter the
potentially negative influence their personality may have on work-life balance. The domain of
personality is complex, colossal, and could yield fascinating data to the work-life balance
conversation.
The notion of guilt was speckled throughout the interviews. A total of 18 guilt references
were captured and it was established as an open code. Seven out of 10 participants included
guilt, in some respect, within their experience of striving for work-life balance. Using the asset
and need verification, this would qualify as a need. It is important to consider this influence for
future research as it has far reaching implications and potentially negative relationships with
motivation, psychological safety, and work-life balance overall.
The subject of competition was revealed in several interviews when discussing other
ENL work habits. Participant ENLs acknowledged work-life balance role models were not
identified within the organization, and furthermore, they may not be well respected due to
suspicion, resentment, judgment, and envy. Interview findings already presented alluded to a
culture of suspicion and resentment regarding those employees who try to achieve work-life

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balance. One observation captured during the data collection period was with an ENL not
participating in the study. This ENL was referencing their workload, work schedule, and was in
the presence of several participating ENLs when they said, “If I have to work the weekend, then
so does she.” Excerpts from previously discussed interviews and the statement made from this
ENL demonstrate a culture not of support, but rather of collective misery and unhealthy attitudes
toward colleagues. While it is difficult to know exactly the motivation behind the extraneous
comment, a culture where this attitude is supported does not also support work-life balance. This
illuminates a challenging culture and further illustrates the need for examination.
Finally, future research in the area of nurse leaders and their reluctance toward help-
seeking behaviors may illuminate unique obstacles for this population. In this study, despite
knowledge, motivation, and organizational needs, one ENL managed to improve her work-life
balance and executed the three elements of motivation: active choice, perseverance, and mental
effort. A deeper dive could reveal helpful information stemming from this divergent data.
Conclusion
The problem of practice examined by this study was the struggle for exempt nurse leaders
to achieve work-life balance due to the overwhelming responsibilities and design of the position.
It is important to solve this problem of practice for several reasons. First, when nurse leaders are
burnt out due to work-life imbalance the healthcare environment is negatively affected and since
burnout is contagious, it is transferred to their teams. Second, the transfer of stress to the staff
nurse makes it harder to succession plan for the leadership position. Finally, when leaders leave
their position it is very costly for the hospital. Not only does knowledge and experience leave
with them, but it is roughly 125% of the nurse leader salary to onboard a replacement. If this
problem of practice is not addressed consequences will continue.

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An exhaustive literature review provided a wealth of theoretical and empirical evidence
demonstrating the scope and importance of the problem. Employing Clark and Estes gap
analysis framework, this case study was qualitative in nature, and conducted from a
constructivism lens, which allowed for the capture of meanings, concepts, experiences, and
personal perspective. The analysis of the rich data from interviews, observations, and documents
illuminated the stark difference between knowledge, motivation, and organizational assets and
needs. Through open coding two unexpected influences emerged and further demonstrated the
need for advanced study on exempt nurse leaders and work-life balance. To achieve the desired
internal and external outcomes of achieving a work-life balance program, it is necessary for the
knowledge and motivation needs to be addressed and the organizational culture to be supportive.
While an exact recipe for the work-life balance program referenced in the organizational
goal is not provided, tools to create the experience and meet the goal are contained within. By
knowing and articulating the desired outcomes, there was alignment of the recommendations and
planned interventions throughout. Theories, critical behaviors, context-specific
recommendations, and evaluation instruments come together to provide support for the
herculean, albeit worthy task.
This study recognizes the paradigm shift required of individuals and organizations for
exempt nurse leaders to achieve a healthy work-life balance. While the stakeholder group of
focus for this study was exempt nurse leaders, these recommendations for practice may
positively affect the working environment for others as well. Ultimately it is hoped that by
investing resources into a program for improving exempt nurse leader work-life balance there
will be a fundamental shift in how exempt nurse leaders and organizations work together in the
future.

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References
Agocs, C. (1997). Institutionalized resistance to organizational change: Denial, inaction and
repression. Journal of Business Ethics, 16(9), 917-931.
Ambrose, S. A., Bridges, M. W., DiPietro, M., Lovett, M. C., & Norman, M. K. (2010). How
learning works: Seven research-based principles for smart teaching. John Wiley & Sons.
American Organization of Nurse Executives (2018). AONE guiding principles for creating
value and meaning for the next generation of early careerist. Retrieved from
http://www.aone.org/resources/guiding-principles.shtml
Andrews, D. & Dziegielewski, S. (2005). The nurse manager: Job satisfaction, the nursing
shortage and retention. Journal of Nursing Management, 13(4), 286–295.
Andrews, H., Tierney, S., & Seers, K. (2019). Needing permission: The experience of self-care
and self-compassion in nursing: A constructivist grounded theory study. International
Journal of Nursing Studies, 101, 103436.
Arenofsky, J. (2017). Work-life balance. Santa Barbara, California: Greenwood, an imprint of
ABC-CLIO, LLC.
Avgar, A. C., Givan, R. K., & Liu, M. (2011). A balancing act: Work–life balance and multiple
stakeholder outcomes in hospitals. British Journal of Industrial Relations, 49(4), 717-
741.
Baker, L. (2006). Metacognition. Retrieved from: http://www.education.com/reference/article/
metacognition/.
Bakhamis, L., Paul III, D. P., Smith, H., & Coustasse, A. (2019). Still an epidemic: The burnout
syndrome in hospital registered nurses. The Health Care Manager, 38(1), 3-10.

163

Bakker, A. B., & Costa, P. L. (2014). Chronic job burnout and daily functioning: A theoretical
analysis. Burnout Research, 1(3), 112-119.
Bakker, A. B., & Demerouti, E. (2007). The job demands-resources model: State of the art.
Journal of Managerial Psychology, 22(3), 309-328.
Batcheller, J., Zimmermann, D., Pappas, S., & Adams, J. M. (2017). Nursing's leadership role
in addressing the quadruple aim. Nurse Leader, 15(3), 203-206.
Bensimon, E. M. (2005). Closing the achievement gap in higher education: An organizational
learning perspective. New Directions for Higher Education, 2005(131), 99-111.
Berger, B. (2014). Read my lips: Leaders, supervisors, and culture are the foundations of
strategic employee communications. Research Journal of the Institute for Public
Relations, 1(1).
Bogue, R. J., & Carter, K. F. (2019). A model for advancing nurse well-being: Future
directions for nurse leaders. Nurse Leader, 17(6), 526-530.
Bonneville, L., & Grosjean, S. (2016). Information-Communication Technologies (ICTs) and
time pressures: A case study of nurse-managers strategies to “let go”. Canadian
Journal of Nursing Informatics, 11(2).
Borgogni, L., Russo S. D., & Latham, G. P. (2011). The relationship of employee perceptions of
the immediate supervisor and top management with collective efficacy. Journal of
Leadership and Organizational Studies, 18, 5–13.
Braun, S., & Peus, C. (2018). Crossover of work–life balance perceptions: Does authentic
leadership matter? Journal of Business Ethics, 149(4), 875–893.

164

Brown, P., Fraser, K., Wong, C. A., Muise, M., & Cummings, G. (2013). Factors influencing
intentions to stay and retention of nurse managers: A systematic review. Journal of
Nursing Management, 21(3), 459–472.
Buchanan, D., Parry, E., Gascoigne, C., & Moore, C. (2013). Are healthcare middle
management jobs extreme jobs? Journal of Health Organization and Management, 27(5),
646–664.
Buckingham, M., & Coffman, C. (2014). First, break all the rules: What the world's greatest
managers do differently. Simon and Schuster.
Bulger, C. A., Matthews, R. A., & Hoffman, M. E. (2007). Work and personal life boundary
management: Boundary strength, work/personal life balance, and the segmentation-
integration continuum. Journal of Occupational Health Psychology, 12(4), 365.
Caproni, P. J. (2004). Work/life balance: You can’t get there from here. The Journal of Applied
Behavioral Science, 40(2), 208-218.
Casper, W. J., Vaziri, H., Wayne, J. H., DeHauw, S., & Greenhaus, J. (2018). The jingle-jangle
of work–nonwork balance: A comprehensive and meta-analytic review of its meaning
and measurement. Journal of Applied Psychology, 103(2), 182.
Catmull, E., & Wallace, A. (2014). Creativity, inc.: Overcoming the unseen forces that stand in
the way of true inspiration. Random House.
Chang, A., McDonald, P., & Burton, P. (2010). Methodological choices in work-life balance
research 1987 to 2006: A critical review. The International Journal of Human Resource
Management, 21(13), 2381–2413.

165

Chávez, V., Duran, B., Baker, Q. E., Avila, M. M., & Wallerstein, N. (2008). The dance of race
and privilege in CBPR. Community-Based Participatory Research for Health: From
Process to Outcomes, 91-105.
Chiejina, E. N. & Ebenebe, R. C. (2013). Metacognition: Usage by nursing students in the
university. International Journal of Pure and Applied Sciences and Technology, 17(2), 1-
8.
Chittenden, E. H., & Ritchie, C. S. (2011). Work-life balancing: Challenges and strategies.
Journal of Palliative Medicine, 14(7), 870-874.
Clark, S. C. (2000). Work/family border theory: A new theory of work/family balance. Human
Relations, 53(6), 747-770.
Clark, R. E., & Estes, F. (2008). Turning research into results: A guide to selecting the right
performance solutions. Charlotte, NC: Information Age Publishing, Inc.
Controlling Smart-Phone Abuse: The Fair Labor Standards Act’s Definition of “Work” in
Nonexempt Employee Claims for Overtime. (2010). Kansas Law Review.
Creswell, J. W., & Creswell, J. D. (2018). Research design: Qualitative, quantitative, and mixed
methods approaches. Thousand Oaks, CA: Sage Publications.
Delecta, P. (2011). Work life balance. International Journal of Current Research, 3(4), 186-189.
Dembo, M. H., & Eaton, M. J. (2000). Self-regulation of academic learning in middle-level
schools. The Elementary School Journal, 100(5), 473-490.
Demerouti, E., Bakker, A. B., Nachreiner, F., & Schaufeli, W. B. (2001). The job
demands-resources model of burnout. Journal of Applied Psychology, 86(3), 499.
Denning, S. (2006). The leader's guide to storytelling. John Wiley & Sons.

166

Dyrbye, L. N., Shanafelt, T. D., Sinsky, C. A., Cipriano, P. F., Bhatt, J., Ommaya, A., West, C.
P., & Meyers, D. (2017). Burnout among health care professionals: A call to explore and
address this underrecognized threat to safe, high-quality care. NAM perspectives.
Discussion paper, National Academy of Medicine, Washington, DC.
Eccles, J. (2006). Expectancy value motivational theory. Retrieved from:
http://www.education.com/reference/article/expectancy-value-motivational-theory/
Elmore, R. (2003). Accountability and capacity. The new accountability: High schools and
high-stakes testing, 195-209.
Erez, M., & Gati, E. (2004). A dynamic, multi‐level model of culture: From the micro level of
the individual to the macro level of a global culture. Applied Psychology, 53(4), 583-598.
Fernández, L. M., & Rainey, H. G. (2006). Theory to practice. Public Administration Review,
66(2), 1-25.
Freudenberger, H. J. (1974). Staff burn‐out. Journal of Social Issues, 30(1), 159-165.
Frone, M. R. (2003). Work-family balance. Handbook of Occupational Health Psychology, 7,
143-162.
Gardner, E. A. (2006). Instruction in mastery goal orientation: Developing problem solving and
persistence for clinical settings. The Journal of Nursing Education, 45(9), 343-347.
Gaskin, C. J., Ockerby, C. M., Smith, T. R., Russell, V., & O'Connell, B. (2012). The challenges
acute care nurse unit managers face and the strategies they use to address them:
Perceptions of directors of nursing and nurse unit managers. Journal of Management and
Organization, 18(5), 625-640.
Glesne, C. (2011). Chapter 6: But is it ethical? Considering what is “right.” In Becoming
qualitative researchers: An introduction (4th ed.). Boston, MA: Pearson.

167

Glower, M. M. (2006). Six Sigma: Bringing it to your team. Nurse Leader, 4(2), 44-46.
Greenblatt, E. (2002). Work/life balance: Wisdom or whining. Organizational Dynamics,
31(2), 177–193.
Greenhaus, J. H., Collins, K. M., & Shaw, J. D. (2003). The relation between work–family
balance and quality of life. Journal of Vocational Behavior, 63(3), 510-531.
Harter, J. K., Schmidt, F. L., Asplund, J. W., Killham, E. A., & Agrawal, S. (2010). Causal
impact of employee work perceptions on the bottom line of organizations. Perspectives
on Psychological Science, 5(4), 378-389.
Heeb, J.-L., & Haberey-Knuessi, V. (2014). Health professionals facing burnout: What do we
know about nursing managers? Nursing Research and Practice, 1–7.
Hewison, A. (2006). Editorial. Middle management and nursing. Journal of Nursing
Management, 14(1), 1–4.
Hewko, S. J., Brown, P., Fraser, K. D., Wong, C. A., & Cummings, G. G. (2015). Factors
influencing nurse managers’ intent to stay or leave: A quantitative analysis. Journal of
Nursing Management, 23(8), 1053-1066.
Holdren, P., Paul III, D. P., Coustasse, A. (2015, March). Burnout syndrome in hospital nurses.
Paper presented at BHAA International 2015 in Chicago, IL.
Horsburgh, D. (2003). Evaluation of qualitative research. Journal of Clinical Nursing, 12(2).
Howse, E. L. (2006). Factors that motivate hospital nurse middle managers to share
knowledge related to boundary spanning roles. Library and Archives Canada =
Bibliothèque et Archives Canada, Ottawa.
Janet, J. (2014). Psychosocial stress burnout among professional managers in health service
institutions. Indian Journal of Health and Wellbeing, 5(5), 539.

168

Johnson, B. (1998). Polarity management: A summary introduction. Polarity Management
Associates, 1-16.
Johnson, R. B., & Christensen, L. B. (2015). Educational research: Quantitative, qualitative,
and mixed approaches. (5th ed.). Thousand Oaks: SAGE.
Judkins, S., Massey, C., & Huff, B. (2006). Hardiness, stress, and use of ill-time among nurse
managers: Is there a connection? Nursing Economics, 24(4), 187 - 192.
Judkins, S., Reid, B., & Furlow, L. (2006). Hardiness training among nurse managers:
Building a healthy workplace. The Journal of Continuing Education in Nursing, 37(5),
202–207.
Karger, H. J. (1981). Burnout as alienation. Social Service Review, 55(2), 270-283.
Kath, L. M., Stichler, J. F., Ehrhart, M. G., & Sievers, A. (2013). Predictors of nurse manager
stress: A dominance analysis of potential work environment stressors. International
Journal of Nursing Studies, 50(11), 1474-1480.
Kelly, L. A., Lefton, C., & Fischer, S. A. (2019). Nurse leader burnout, satisfaction, and
work-life balance. JONA: The Journal of Nursing Administration, 49(9), 404-410.
Keys, Y. (2014). Looking ahead to our next generation of nurse leaders: Generation x nurse
managers. Journal of Nursing Management, 22(1), 97–105.
Kim, M., & Windsor, C. (2015). Resilience and work-life balance in first-line nurse manager.
Asian Nursing Research, 9(1), 21-27.
Kinser, P., Braun, S., Deeb, G., Carrico, C., & Dow, A. (2016). “Awareness is the first step”:
An interprofessional course on mindfulness & mindful movement for healthcare
professionals and students. Complementary Therapies in Clinical Practice, 25, 18–25.

169

Kirkpatrick, J. D., & Kirkpatrick, W. K. (2016). Kirkpatrick's four levels of training evaluation.
Association for Talent Development.
Kirschner, P., Kirschner, F., & Paas, F. (2006). Cognitive load theory. Retrieved from
http://www.education.com/reference/article/cognitive-load-theory/.
Krathwohl, D. R. (2002). A revision of Bloom’s taxonomy: An overview. Theory Into
Practice, 41(4), 212–218.
Kravits, K., McAllister-Black, R., Grant, M., & Kirk, C. (2010). Self-care strategies for nurses:
A psycho-educational intervention for stress reduction and the prevention of burnout.
Applied Nursing Research, 23(3), 130-138.
Krosgaard, M. A., Brodt, S. E., & Whitener, E. M. (2002). Trust in the face of conflict: The role
of managerial trustworthy behavior and organizational context. Journal of Applied
Psychology, 87(2), 312.
Labrague, L. J., McEnroe-Petitte, D. M., Leocadio, M. C., Van Bogaert, P., & Cummings, G. G.
(2018). Stress and ways of coping among nurse managers: An integrative review. Journal
of Clinical Nursing, 27(7–8), 1346–1359.
Lee, H., & Cummings, G. G. (2008). Factors influencing job satisfaction of front-line nurse
managers: A systematic review. Journal of Nursing Management, 16(7), 768–783.
Leiter, M. P., Day, A. L., Harvie, P., & Shaughnessy, K. (2007). Personal and organizational
knowledge transfer: Implications for work life engagement. Human Relations, 60(2),
259-283.
Leiter, M. P., & Maslach, C. (2017). Burnout and engagement: Contributions to a new vision.
Burnout Research, 5, 55–57.
Lewis, L. (2019). Organizational change. John Wiley & Sons, Incorporated.

170

Linzer, M., Levine, R., Meltzer, D., Poplau, S., Warde, C., & West, C. P. (2014). 10 bold steps to
prevent burnout in general internal medicine. Journal of General Internal Medicine,
29(1), 18–20.
Lips-Wiersma, M., & Morris, L. (2009). Discriminating between ‘meaningful work’ and the
‘management of meaning.’ Journal of Business Ethics, 88(3), 491–511.
Loveridge, S. (2017). Straight talk: Nurse manager role stress. Nursing Management, 48(4),
20-27.
Maslach, C., & Goldberg, J. (1998). Prevention of burnout: New perspectives. Applied and
Preventive Psychology, 7(1), 63–74.
Maslach, C., Jackson, S. E., Leiter, M. P., Schaufeli, W. B., & Schwab, R. L. (1986). Maslach
burnout inventory (Vol. 21, pp. 3463-3464). Palo Alto, CA: Consulting psychologists
press.
Maslach, C., & Schaufeli, W. (1993). History and conceptual specificity of burnout. Recent
Developments in Theory and Research, Hemisphere, 1, 44-52.
Maslach, C., Schaufeli, W. B., & Leiter, M. P. (2001). Job burnout. Annual Review of
Psychology, 52(1), 397-422.
Matlakala, M. C., Bezuidenhout, M. C., & Botha, A. D. H. (2014). Challenges encountered by
critical care unit managers in the large intensive care units. Curationis, 37(1).
Maxwell, J. A. (2013). Qualitative research design: An interactive approach (3rd ed.).
Thousand Oaks: SAGE.
Mayer, R. E. (2011). Applying the science of learning. Boston, MA: Pearson/Allyn & Bacon.
Mazerolle, S. M. & Goodman, A. (2013). Fulfillment of work-life balance from the
organizational perspective: A case study. Journal of Athletic Training, 48(5), 668-77.

171

McEwan, E. K., & McEwan, P. J. (2003). Making sense of research: What's good, what's not,
and how to tell the difference. Corwin Press.
Mellner, C., Aronsson, G., & Kecklund, G. (2014). Boundary management preferences,
boundary control, and work-life balance among full-time employed professionals in
knowledge-intensive, flexible work. Nordic Journal of Working Life Studies, 4(4), 7-23.
Merriam, S. B., & Tisdell, E. J. (2016). Qualitative research: A guide to design and
implementation (4th ed.). San Francisco, CA: Jossey-Bass.
Merriam-Webster Dictionary (2020). https://www.merriam-webster.com/dictionary/burnout
Middaugh, D., & Willis, A. (2018). Managerial burnout: Putting out the flames. Medsurg
Nursing, 27(2), 121-122.
Moody, R. C., & Pesut, D. J. (2006). The motivation to care: Application and extension o
motivation theory to professional nursing work. Journal of Health Organization and
Management, 20(1), 15 - 48.
Morrison, E. W., & Milliken, F. J. (2000). Organizational silence: A barrier to change and
development in a pluralistic world. Academy of Management Review, 25(4), 706-725.
Mullen, K. (2015). Barriers to work – life balance for hospital nurses. Workplace Health &
Safety, 96 – 99.
Munn, S. L. (2013). Unveiling the work–life system: the influence of work–life balance on
meaningful work. Advances in Developing Human Resources, 15(4), 401-417.
National Academy of Sciences (2020). The quadruple aim.
Nelson, K. E. (2017). Nurse manager perceptions of work overload and strategies to address it.
Nurse Leader, 15, 6, 406-408.
Northouse, P. G. (2016). Leadership: Theory and Practice. Sage.

172

Oates, J. (2018). What keeps nurses happy? Implications for workforce well-being strategies.
Nursing Management, 25(1), 34-41.
Olson, R., Crain, T. L., Bodner, T. E., King, R., Hammer, L. B., Klein, L. C., & Buxton, O. M.
(2015). A workplace intervention improves sleep: Results from the randomized
controlled work, family, and health study. Sleep Health, 1(1), 55–65.
Pacific Healthcare. (2018). Pseudonym.
Pajares, F. (2006). Self-efficacy theory. Retrieved from:
http://www.education.com/reference/article/self-efficacy-theory/.
Parkes, L. P., & Langford, P. H. (2008). Work–life balance or work–life alignment? A test of
the importance of work-life balance for employee engagement and intention to stay in
organizations. Journal of Management & Organization, 14(3), 267-284.
Parris, M. A., Vickers, M. H., & Wilkes, L. (2008). Caught in the middle: Organizational
impediments to middle managers’ work-life balance. Employee Responsibilities and
Rights Journal, 20(2), 101-117.
Patel, A. S., Bowler, M. C., Bowler, J. L., & Methe, S. A. (2012). A meta-analysis of
workaholism. International Journal of Business and Management, 7(11).
Patton, M. Q. (2002). Chapter 7: Qualitative interviewing. In Qualitative research & evaluation
methods (3rd ed.). Thousand Oaks: SAGE Publications.
Patton, M. Q. (2014). Qualitative research & evaluation methods: Integrating theory and
practice. Sage publications.
Peeters, M. C. W., Montgomery, A. J., Bakker, A. B., & Schaufeli, W. B. (2005). Balancing
work and home: How job and home demands are related to burnout. International
Journal of Stress Management, 12(1), 43–61.

173

Peiró, J. M., González-Romá, V., Tordera, N., & Mañas, M. A. (2001). Does role stress predict
burnout over time among health care professionals? Psychology & Health, 16(5), 511-
525.
Pines, A. M., & Keinan, G. (2005). Stress and burnout: The significant difference. Personality
and Individual Differences, 39(3), 625–635.
Pintrich, P. R. (2003). A motivational science perspective on the role of student motivation in
learning and teaching contexts. Journal of Educational Psychology, 95, 667–686.
Raso, R. (2018). The state of nurse leader wellness: Results of the nursing management wellness
survey. Nursing Management (Springhouse), 49(2), 24–31.
Rogoff, B. (2003). The cultural nature of human development. Oxford university press.
Ross, A., Bevans, M., Brooks, A. T., Gibbons, S., & Wallen, G. R. (2017). Nurses and health‐
promoting behaviors: Knowledge may not translate into self‐care. Association of
periOperative Registered Nurses (AORN) Journal, 105(3), 267-275.
Rubino, C., Luksyte, A., Perry, S. J., & Volpone, S. D. (2009). How do stressors lead to
burnout? The mediating role of motivation. Journal of Occupational Health Psychology,
14(3), 289.
Rudan, V. T. (2002). Where have all the nursing administrative students gone? Issues and
solutions. Journal of Nursing Administration, 32(4), 185-188.
Rueda, R. (2011). The 3 dimensions of improving student performance. New York: Teachers
College Press.
Salanova, M., Del Líbano, M., Llorens, S., & Schaufeli, W. B. (2014). Engaged, workaholic,
burned‐out or just 9‐to‐5? Toward a typology of employee well‐being. Stress and Health,
30(1), 71-81.

174

Sánchez-Hernández, M. I., González-López, Ó. R., Buenadicha-Mateos, M., & Tato-Jiménez, J.
L. (2019). Work-Life Balance in Great Companies and Pending Issues for Engaging New
Generations at Work. International Journal of Environmental Research and Public
Health, 16(24), 5122.
Sarker, S., Sarker, S., Xiao, X., & Ahuja, M. (2012). Managing employees’ use of mobile
technologies to minimize work-life balance impacts. MIS Quarterly Executive, 11(4),
143-157.
Schaufeli, W. B., Leiter, M. P., & Maslach, C. (2009). Burnout: 35 years of research and
practice. Career Development International, 14(3), 204–220.
Schein, E., & Schein, P. (2017). Organizational culture and leadership (Fifth edition). Hoboken:
Wiley.
Schlossberg, N. K. (1989). Marginality and mattering: Key issues in building community. New
Directions for Student Services, 1989(48), 5-15.
Schraw, G., & McCrudden, M. (2009). Information processing theory. Retrieved from:
https://project542.weebly.com/uploads/1/7/1/0/17108470/information_processing_theory
__education.com.pdf
Schultz, J. L., & Higbee, J. L. (2010). An exploration of theoretical foundations for working
mothers’ formal workplace social networks. Journal of Business & Economics Research,
8(4), 87-94.
Scott, S., & Palincsar, A. (2006). Sociocultural theory. Education.com.
Shingo Institute. (2020). The Shingo model. Retrieved from: www.Shingo.org
Shirey, M. (2006). Stress and coping in nurse managers: Two decades of research. Nursing
Economics, 24(4), 192 – 203.

175

Shirey, M. R., Ebright, P. R., & McDaniel, A. M. (2008). Sleepless in America: Nurse managers
cope with stress and complexity. JONA: The Journal of Nursing Administration, 38(3),
125–131.
Shirey, M. R., McDaniel, A. M., Ebright, P. R., Fisher, M. L., & Doebbeling, B. N. (2010).
Understanding nurse manager stress and work complexity: Factors that make a
difference. JONA: The Journal of Nursing Administration, 40(2), 82–91.
Sirkin, H. L., Keenan, P., & Jackson, A. (2005). The hard side of change management. Harvard
Business Review’s 10 Must Reads on Change, 99.
Sliwiriski, L. J. (2004). Work life balance and exempt employees: Making sense of work in the
broader context of life (Doctoral dissertation). Retrieved from ProQuest.
Son, J. S., & Chen, C. C. (2018). Does using a smartphone for work purposes “ruin” your
leisure? Examining the role of smartphone use in work–leisure conflict and life
satisfaction. Journal of Leisure Research, 49(3-5), 236-257.
Southern Hospital. (2019). Pseudonym.
Spence Laschinger, H. K., & Finegan, J. (2008). Situational and dispositional predictors of nurse
manager burnout: A time-lagged analysis. Journal of Nursing Management, 16(5), 601–
607.
Spence Laschinger, H. K., Wong, C. A., Macdonald-Rencz, S., Burkoski, V., Cummings, G.,
D’amour, D., … Grau, A. (2013). Part 1: The influence of personal and situational
predictors on nurses’ aspirations to management roles: Preliminary findings of a national
survey of Canadian nurses. Journal of Nursing Management, 21(2), 217–230.

176

Spence Laschinger, H., K., Purdy, N., Cho, J., & Almost, J. (2006). Antecedents and
consequences of nurse managers' perceptions of organizational support. Nursing
Economics, 24(1), 20-9, 3.
Steege, L. M., Pinekenstein, B. J., Arsenault Knudsen, É., & Rainbow, J. G. (2017). Exploring
nurse leader fatigue: A mixed methods study. Journal of Nursing Management, 25(4),
276-286.
Stichler, J. F. (2008). Succession planning: Why grooming their replacements is critical for nurse
leaders. Nursing for Women's Health, 12(6), 525-528.
Sullivan, T. A. (2014). Greedy institutions, overwork, and work‐life balance. Sociological
Inquiry, 84(1), 1-15.
Swearingen, S. (2009). A journey to leadership: designing a nursing leadership development
program. The Journal of Continuing Education in Nursing, 40(3), 107-112.
Tariq, A., Aslam, H. D., Siddique, A., & Tanveer, A. (2012). Work-life balance as a best
practice model of human resource management: A win-win situational tool for the
employees and organizations. Mediterranean Journal of Social Sciences, 3(1), 577-585.
Thoreau, H. D. (1971). Walden. 1854. Ed. J. Lyndon Shanley. Princeton: Princeton UP.
Tuckman, B. (2006). Operant conditioning. Retrieved from: http://www.education.com/
reference/article/operant-conditioning/.
Udod, S. & Care, W. D. (2011). Nurse managers’ work stressors and coping experiences:
unravelling the evidence. Nursing Leadership, 24(3), 57-72.
Udod, S., Cummings, G. G., Care, W. D., & Jenkins, M. (2017). Role stressors and coping
strategies among nurse managers. Leadership in Health Services, 30(1), 29-43.

177

Ueda, Y. (2012). The relationship between work-life balance programs and employee
satisfaction: Gender differences in the moderating effect of annual income. Journal of
Business Administration Research, 1(1).
United States Census Bureau. (2018). Retrieved from: https://factfinder.census.gov/faces/nav/
jsf/pages/community_facts.xhtml?src=bkmk
Valcour, M. (2016). Beating burnout. Harvard Business Review, 94(11), 98-101.
Veltman, A. (2016). Meaningful work. New York, NY: Oxford University Press.
Warshawsky, N. E., & Havens, D. S. (2014). Nurse manager job satisfaction and intent to leave.
Nursing Economics, 32(1), 32-9.
Warshawsky, N. E., Lake, S. W., & Brandford, A. (2013). Nurse managers describe their
practice environments. Nursing Administration Quarterly, 37(4), 317–325.
Western Hospital. (2019). Pseudonym.
Wigfield, A., & Cambria, J. (2010). Students’ achievement values, goal orientations, and
interest: Definitions, development, and relations to achievement outcomes.
Developmental Review, 30, 1–35.
Wolcott, H. F. (1990). Writing up qualitative research. Newbury Park, CA: Sage.
Wong, C. A., Laschinger, H. K., Macdonald-Rencz, S., Burkoski, V., Cummings, G.,
D’amour, D., Grinspun, D., Gurnham, M. E., Huckstep, S., Leiter, M., Perkin, K.
MacPhee, M., Matthews, S., O’Brien-Pallas, L., Ritchie, J., Ruffolo, M., et al. (2013).
Part 2: Nurses’ career aspirations to management roles: Qualitative findings from a
national study of Canadian nurses. Journal of Nursing Management, 21(2), 231–241.
Yough, M., & Anderman, E. (2006). Goal orientation theory. Retrieved from http://www.
education.com/reference/article/goal-orientation-theory/.

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Appendix A
Recruitment letter
Date: 10/7/2019
Dear
My name is Shelly (Sheli) Hicks from the University of Southern California (USC). I am a
doctoral candidate with the Rossier School of Education, and I am conducting a research study
exploring exempt nurse leaders experiences with work-life balance.

You are invited to participate in this research study. Your participation is voluntary. This
document explains information about this study. Please ask questions about anything that is
unclear to you.
USC IRB, as well as xxxxxxxxx IRB, have approved the study and classify it as exempt,
meaning it is no more than minimal risk to participate. Furthermore, xxxxxxxxxxxxx,
xxxxxxxxx, and xxxxxxxxxx are all aware of and support the research.
This study is qualitative in nature, and I am striving to interview ten (10) exempt nurse leaders.
You may be eligible to participate in the study if you:
● Have been an exempt nurse leader for more than one year at xxxxxxxxxxxxxxxxxx
● Are in the position permanently
● Have the official title of Director, Manager, Assistant Nurse Manager, Clinical Supervisor
● Supervise frontline caregivers in a nursing department
Participation is voluntary. If you agree, you will be asked to participate in one interview lasting
approximately 60 minutes. The interview will be scheduled around your availability within the
next four to six weeks.
Confidentiality is important. Your name and all information you share will be kept confidential.
Furthermore, recognizable information within the dissertation, such as hospital names, location,
etc. will be de-identified and given pseudonyms.
Please indicate your willingness to participate in this study by checking the corresponding box
below and return this form to me. You are under no obligation to participate.
□ Yes □ No
Participant Signature __________________________________________________
Thank you.
Shelly (Sheli) Hicks, EdD(c), MSN, MS, RN, CNOR, CLT

179

Appendix B
Interview Questions
Shelly Hicks, Dissertation Exempt Nurse Leader and Work-Life Balance
Influence Area Interview Question

Factual Knowledge –
Exempt nurse leaders need
to define work-life balance

What is your definition of work-life balance (WLB)?

Conceptual Knowledge –
Exempt nurse leaders need
to understand the concept of
work-life balance

(Card activity) The literature indicates there are many factors
that influence WLB.

What are the top 5 items that influence YOUR WLB?

● Working hours
● Work schedule
● Control over workday tasks
● Control over my personal time
● Bringing work home
● Bringing life to work
● Last minute requests
● Other ENLs work habits
● Calls, emails, or texts from my personal life at work
● Calls, emails, or texts from my work during my personal
time
● My personality
● The exempt status of my position
● Use of technology (cell phone, computer, etc.)
● Other:

Tell me about the ones you ranked the highest.

Procedural Knowledge -
Exempt nurse leaders need
knowledge of the steps to
balance work and life

What strategies are you aware of that could help you with your
WLB?

If you were told tomorrow that you must have a balance of your
work and life, what would you do first?

Metacognitive Knowledge –
Exempt nurse leaders need
knowledge of how work-life
balance applies to self.
What things do YOU currently do that influences your work-
life balance either positively or negatively?

180

Expectancy Value
Motivational Theory

Exempt nurse leaders need
to see value in having a
healthy work-life balance.

What do you think you may gain by having a healthy WLB?

What do you think you might lose?
Self-efficacy

Exempt nurse leaders must
believe they are capable to
have a healthy work-life
balance.
Rate your degree of confidence by recording a number from 0
to 100 using the scale below.

0 = not confident at all
10
20
30
40
50 = moderately confident
60
70
80
90
100 = highly confident

Please rate how confident you are that you are capable to do the
following right now...

___ control working hours
___control work schedule
___control workday tasks
___control over personal time
___not bring work home
___not bring life to work
___control last minute requests
___ignore other ENLs work habits
___avoid calls, emails, or texts from personal life at work
___avoid calls, emails, or texts from work during personal time
___alter your personality
___change the exempt status of the ENL position
___limit use of technology (cell phone, computer, etc.)

Goal Orientation –
Mastery or performance

Exempt nurse leaders
should work toward
balancing work and life.

Are you happy with where your work-life balance is right now?

What are you doing to actively improve your work-life
balance?

How important is it to you to be proficient at balancing your
work and life?

181

How do other ENL work habits influence your WLB?
Organizational Setting -
The organization needs to
ensure resources meet
demands.

How many direct reports do you have?
Do you have the necessary resources to handle the workload of
your position?
What resources are available at work to help you improve your
work-life balance?
Organizational Setting -
The organization needs to
support a culture of
communication that
supports work-life balance.
How does organizational communication influence your WLB?

What is communicated about work-life balance?

Organizational setting –
The organization needs to
ensure ENL expectations
are compatible with work-
life balance.
What do you believe are your supervisor’s expectations about
your availability?

How do these expectations influence your WLB?

Organizational model -
The organization needs to
support a culture of
meaningful work.
How much of your job is meaningful work?

How does that influence your WLB?

Organizational model -
The organization needs to
support a culture of
psychological safety.
How comfortable do you feel to speak up at work when you
have a question or safety concern?

How safe do you feel in the organization’s social climate to
discuss issues around work-life balance?

Organizational model -
The organization needs to
support a positive work
environment that fosters
work-life balance.

How is WLB perceived within this organization?

How does the overall work environment influence your work-
life balance?

182

The literature indicates there are many factors that influence WLB.

What are the top 5 items that influence YOUR WLB?

● Working hours
● Work schedule
● Control over workday tasks
● Control over my personal time
● Bringing work home
● Bringing life to work
● Last minute requests
● Other ENLs work habits
● Calls, emails, or texts from my personal life at work
● Calls, emails, or texts from my work during my personal time
● My personality
● The exempt status of my position
● Use of technology (cell phone, computer, etc.)
● Other:

183

Rate your degree of confidence by recording a number from 0 to 100 using the scale below.
0 = not confident at all
10
20
30
40
50 = moderately confident
60
70
80
90
100 = highly confident

Please rate how confident you are that you are capable to do the following right now...
___ control working hours
___control work schedule
___control workday tasks
___control over personal time
___not bring work home
___not bring life to work
___control last minute requests
___ignore other ENLs work habits
___avoid calls, emails, or texts from personal life at work
___avoid calls, emails, or texts from work during personal time
___alter your personality
___change the exempt status of the ENL position
___limit use of technology (cell phone, computer, etc.)

184

Appendix C
Observation/Document Analysis Form
Observation Form and Document Analysis
Date: ________________ Observer: ___________ Organization:________
Start Time: ___________ End Time: ___________ Type: Document/Meeting
Subject/Content: ___________________________________________________
Attendees (or) Document Authors: ____________________________________
Knowledge (Influences and Method of Assessment)
# Assumed Knowledge Influence Observation Observed?
0 = no evidence
1= some evidence
2=strong evidence
Document
Analysis
1 Exempt nurse leaders need to
define work-life balance.

Factual

2 Exempt nurse leaders need to
understand the concept of work-
life balance.

Conceptual

3 Exempt nurse leaders need
knowledge of the steps to balance
work and life.

Procedural Knowledge

Organization
blog on health
benefits: Notice
of expansion of
virtual mental
health and
wellness
services
4 Exempt nurse leaders need
knowledge of how work-life
balance applies to self.

Metacognitive

185

Motivation (Influences and Method of Assessment)

# Assumed Motivation Influence Observation Observed?
0 = no evidence
1= some evidence
2=strong evidence
Document
Analysis
1 Expectancy Value Motivational
Theory (Utility Value) –

Exempt nurse leaders need to see
value in having a healthy work-
life balance.

Observe the
workspace
for family
photos,
vacation
memories, or
other life
represented.

Observe the
ease of
recruitment,
scheduling,
and
completion
of the
interview.

2 Self-Efficacy –

Exempt nurse leaders must
believe they are capable to have a
healthy work-life balance.
Activity form.
3 Goal Orientation –
Mastery or performance

Exempt nurse leaders should
work toward balancing work and
life.

186

Organizational (Influences and Method of Assessment)

# Assumed Organization
Influence
Observation Observed?
0 = no evidence
1= some
evidence
2=strong
evidence
Document
Analysis
1 The organization needs to ensure
resources meet demands.

Observe the
ease of
scheduling
the interview
based on
availability
of the ENL
to fit this
time into
their
schedule.

2 The organization needs to
support a culture of
communication that supports
work-life balance.
Observe the
climate of
the
workspace
and if the
interview is
interrupted.
Outgoing email
message during
time away.
3 The organization needs to ensure
ENL expectations are compatible
with work-life balance.
Organization
website, career
opportunities:
Job Description
of Nurse
Manager.

Outgoing email
message during
time away.
4 The organization needs to
support a culture of meaningful
work.

187

5 The organization needs to
support a culture of
psychological safety.
Observe the
climate of
the
workspace
and the
physical
positioning
of participant
and
researcher
during the
interview.

Display of
emotions.
New Employee
Orientation, High
Reliability
Organization
hand-out related
to “Speaking Up
for Safety”
6 The organization needs to
support a positive work
environment that fosters work-
life balance.

Human resources
benefits:
● PTO benefits
● Caregiver
Assistance
Program

Spiritual Care
Services

Organization
website, career
opportunities:
● Job
Description of
Nurse
Manager
● Wellness
Program

Nursing Annual
Report 2018:
Strategic Plan

188

Appendix D
Immediate Post-Workshop Evaluation
Workshop Name ___________________ Your Name (optional) _____________________

Workshop Date ____________________ Facilitator Name(s) _______________________

Thank you for participating in today’s work-life balance workshop. To help us improve the
entire guided experience and this workshop for the future, please take a few moments to
complete this survey. Using the scale provided, please circle the choice that best matches your
perceptions.

Engagement
I took responsibility for being fully engaged during this workshop.
1 = Strongly Disagree 2 3 4 5 6 7 8 9 10 = Strongly Agree

This workshop held my interest.
1 = Strongly Disagree 2 3 4 5 6 7 8 9 10 = Strongly Agree

I am COMMITTED to improving my work-life balance for myself and my organization.
1 = Strongly Disagree 2 3 4 5 6 7 8 9 10 = Strongly Agree

Relevance
The workshop was relevant to my current needs.
1 = Strongly Disagree 2 3 4 5 6 7 8 9 10 = Strongly Agree
I will be able to use what I learned immediately.
1 = Strongly Disagree 2 3 4 5 6 7 8 9 10 = Strongly Agree

I believe it will be worthwhile to apply what I learned.
1 = Strongly Disagree 2 3 4 5 6 7 8 9 10 = Strongly Agree

I believe that I will see an impact in my work-life balance if I consistently apply what I
learned in the workshop.
1 = Strongly Disagree 2 3 4 5 6 7 8 9 10 = Strongly Agree

The workshop has improved my understanding of work-life balance.
1 = Strongly Disagree 2 3 4 5 6 7 8 9 10 = Strongly Agree

The workshop helped me to see the importance of actively working on my work-life balance.
1 = Strongly Disagree 2 3 4 5 6 7 8 9 10 = Strongly Agree

189

Satisfaction
Attending this workshop was worth my time today.
1 = Strongly Disagree 2 3 4 5 6 7 8 9 10 = Strongly Agree

I will recommend this workshop to fellow exempt nurse leaders.
1 = Strongly Disagree 2 3 4 5 6 7 8 9 10 = Strongly Agree

What is your major take-away from today’s workshop?

What is one thing you would recommend to improve your overall learning experience?

For future surveys, I would like to see them administered: (select one)
On paper at the end of the workshop
Through my email due the week after the workshop
QR code through my phone at the end of the workshop

Thank you.

190

Appendix E

Blended (Delayed) Evaluation for Work-Life Balance Guided Experience
Your Name (optional) _________________________ Date ____________________
Thank you for participating in the Work-Life Balance Guided Experience. To help us
improve the experience for future participants, please take a few moments to complete this
survey. Using the scale provided, please circle the choice that best matches your
perceptions.

Level one (engagement, relevance, satisfaction)
I remained fully engaged during this guided experience.

1 = Strongly Disagree 2 3 4 5 6 7 8 9 10 = Strongly Agree

The content in the guided experience held my interest.

1 = Strongly Disagree 2 3 4 5 6 7 8 9 10 = Strongly Agree

The content I learned during the guided experience has been pertinent to my current needs.
1 = Strongly Disagree 2 3 4 5 6 7 8 9 10 = Strongly Agree
Looking back, what information from the guided experience was most relevant to you?

Looking back, what information from the guided experience was least relevant to you?

Level two (Learning, F, C, P, M, Value, Mastery, confidence, commitment, attitude)
The guided experience improved my understanding of work-life balance.
1 = Strongly Disagree 2 3 4 5 6 7 8 9 10 = Strongly Agree

191

The guided experience helped me to see the importance of structuring a work-life balance plan.
1 = Strongly Disagree 2 3 4 5 6 7 8 9 10 = Strongly Agree

I remain committed to improving my work-life balance for myself and my organization.

1 = Strongly Disagree 2 3 4 5 6 7 8 9 10 = Strongly Agree

I understand how self-reflection can help me with my work-life balance.

1 = Strongly Disagree 2 3 4 5 6 7 8 9 10 = Strongly Agree

After the guided experience, I feel more confident about my ability to influence my work-life
balance.
1 = Strongly Disagree 2 3 4 5 6 7 8 9 10 = Strongly Agree
It is clear why it was important for me to participate in this guided experience.
1 = Strongly Disagree 2 3 4 5 6 7 8 9 10 = Strongly Agree

Participating in this guided experience was worth my time.
1 = Strongly Disagree 2 3 4 5 6 7 8 9 10 = Strongly Agree

Looking back, what content do you remember the most?

Level three (application, supervisor, strategies, participation, reflection, on-going needs, drivers)
I have created a workable definition of work-life balance for myself.

1 = Strongly Disagree 2 3 4 5 6 7 8 9 10 = Strongly Agree

I have successfully applied one or more of the strategies I learned in the guided experience.

1 = Strongly Disagree 2 3 4 5 6 7 8 9 10 = Strongly Agree

I have received performance support from my supervisor in order to apply what I learned
successfully.

1 = Strongly Disagree 2 3 4 5 6 7 8 9 10 = Strongly Agree

192

What additional help or support could increase your success in applying what you learned?

The executive team in my hospital models healthy work-life balance.

1 = Strongly Disagree 2 3 4 5 6 7 8 9 10 = Strongly Agree

I have observed recognition given for positive work-life balance efforts.

1 = Strongly Disagree 2 3 4 5 6 7 8 9 10 = Strongly Agree

I have pursued additional professional development opportunities for on-going work-life balance
needs I have.

1 = Strongly Disagree 2 3 4 5 6 7 8 9 10 = Strongly Agree

I regularly self-reflect to enhance my metacognition with regards to work-life balance.

1 = Strongly Disagree 2 3 4 5 6 7 8 9 10 = Strongly Agree

ENLs have dedicated time available to discuss work-life balance at meetings or huddles.

1 = Strongly Disagree 2 3 4 5 6 7 8 9 10 = Strongly Agree

Since this innovative Work-Life Balance Guided Experience began, the culture at my
organization is more supportive of work-life balance.

1 = Strongly Disagree 2 3 4 5 6 7 8 9 10 = Strongly Agree

Level four (internal outcomes, satisfaction, burnout, psych safety, succession, participation)

I am making progress in improving my work-life balance as a result of applying what I learned
during this guided experience.
1 = Strongly Disagree 2 3 4 5 6 7 8 9 10 = Strongly Agree

I feel more comfortable speaking to my colleagues about work-life balance.

1 = Strongly Disagree 2 3 4 5 6 7 8 9 10 = Strongly Agree

193

I have recommended this guided experience to fellow exempt nurse leaders.

1 = Strongly Disagree 2 3 4 5 6 7 8 9 10 = Strongly Agree

My levels of burnout have decreased since participating in this guided experience.

1 = Strongly Disagree 2 3 4 5 6 7 8 9 10 = Strongly Agree

Thank you.

Abstract (if available)

Abstract This study applies a combination of learning, motivational, and organizational theories with the application of the Clark and Estes (2008) gap analysis framework to understand exempt nurse leader (ENL) work-life balance. The purpose of this project was to identify the knowledge, motivation, and organizational assets and needs influencing the ENL ability to maintain work-life balance considering the workload and design of the position. With a qualitative design, this study included a vast literature review, and triangulated data from 10 interviews, 74 observations, and 32 organizational documents. The literature review identified 15 knowledge, motivation, and organizational influences pertinent to work-life balance. Analysis of the data revealed that 12 influences emerged as needs, and subsequently illuminated the necessity for individuals and organizations to work together to positively influence this problem of practice. Key points from the data analysis recognized the need for procedural and metacognitive development, self-efficacy, resource management, meaningful work, compatible expectations, and psychological safety. Based on the findings, and in conjunction with the literature, this project recommends the creation of, and on-going support for, a comprehensive work-life balance guided experience to provide individual and organizational support for ENLs to navigate and thrive in the dynamic terrain of nursing leadership. The Kirkpatrick and Kirkpatrick New World Model (2016) was utilized in the development of recommendations and evaluation mechanisms. This study helps to inform how individuals, who work in health care, and other critical services, especially in leadership positions, can move toward a balance of their work and personal life.

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Asset Metadata

Creator Hicks, Shelly Ann (author)

Core Title Improving exempt nurse leader work-life balance: an innovation study

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Publication Date 07/08/2020

Defense Date 05/13/2020

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

Tag Burnout,gap analysis,meaningful work,nurse leader,OAI-PMH Harvest,psychological safety,work-life balance

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Yates, Kenneth (committee chair), Andres, Mary (committee member), Sparangis, Themistocles (committee member)

Creator Email shelihic@usc.edu,shelihicks@hotmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-324525

Unique identifier UC11664046

Identifier etd-HicksShell-8642.pdf (filename),usctheses-c89-324525 (legacy record id)

Legacy Identifier etd-HicksShell-8642.pdf

Dmrecord 324525

Document Type Dissertation

Rights Hicks, Shelly Ann

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

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