This study indicated how the frequency at which nurse managers perform various work activities, nurses’ job satisfaction, patient satisfaction and medication errors are related on a unit level. Both negative and positive relationships were found. Three subareas of nurse managers’ work (i.e. Work well-being, Development of nursing and Communication) were found to influence nurses’ job satisfaction. It should be noted that even though the effects were minor, all of these relationships were negative (i.e. increasing nursing manager commitment to these classes of activities decreased nurses’ job satisfaction). Furthermore, the frequencies describing how often nurses managers performed five classes of work activities (i.e. Organizing, Clinical nursing, Development of nursing, Financial management and Work well-being) negatively influenced patient satisfaction, while the frequency at which nurse managers participated in Communication had a positive impact on patient satisfaction. However, only one aspect of both nurse managers’ work (Planning and evaluation of activities) and patient satisfaction (Outcomes variables), in addition to the specific hospital, significantly affected the incidence of medication errors at the unit level.
Concerning nurses’ job satisfaction, Requiring factors of work was negatively affected by nurse managers’ focus on Development of nursing and by patient satisfaction regarding Cognition of physical needs, while this aspect of job satisfaction was positively linked to patient views of Outcomes variables. A potential explanation is that a nurse manager’s decision to allocate resources to nursing processes, along with the education and orientation of staff, would reduce the resources for bedside nursing, and therefore, may influence nurse staffing. According to several studies, scheduling and organizing are part of nurse managers’ daily work responsibilities (13,19,20).
Furthermore, patient satisfaction with Outcomes variables positively affected nurses’ job satisfaction in terms of both Requiring factors of work and total job satisfaction. Recent research by De Simone et al. (2018) and Zaghini et al. (2020) provides support for these findings, i.e. both of these studies reported correlations between patient satisfaction and nurses’ job satisfaction (54,55). Nurses are motivated to provide high-quality care (48); as such, it is logical that patient satisfaction with the outcomes of care will improve nurses’ job satisfaction.
The frequency at which nurse managers perform Communication tasks negatively affected nurses’ total job satisfaction, along with the following aspects of nurses’ job satisfaction: Motivating factors of the work; Working environment; and Leadership. The subarea of Communication includes preparing for and participating in meetings, managing unit meetings, and conversations with personnel. These findings were similar to the results reported by Kirchhoff & Karlsson (2019), more specifically, nurse managers who frequently engage in meetings with management, such as networking with other managers and involvement in management-level projects, were less visible in the organizational unit (31). Several studies have reported that nurse managers need to be visible, accessible, and provide regular feedback to their staff (26,34,35). This could be the reason why nurses were less motivated and satisfied when their managers were highly focused on communication tasks. An alternative explanation is that a large proportion of nurses felt that multiple staff meetings were unnecessary and unmeaningful. These results suggest that nurses managers should focus on their communication skills, e.g. discussing difficult questions, listening to different opinions, delivering construtive feedback, and disseminating up-to-date information, rather than the time they spend on communication tasks (27,56).
When rating the Working environment aspect of job satisfaction, nurses evaluate whether they are provided appropriate work facilities that are safe and secure. Fang et al. (2018) found that over one-third of nurses thought that they work with unsafe equipment and did not feel adequately supported, while nearly half of nurses felt unsafe in the workplace. However, additional research found that nurses believe that nurse managers are able to change the work systems and equipment to promote nurse safety (57). In addition, Agnew et al. (2014) found that a nurse manager’s behavior regarding the monitoring (e.g. auditing) and recognizing (e.g. rewarding) of safety issues influences the compliance of staff. Another study reported that the hospital and number of nurses influence both nurses’ perceptions of the work environment and/or nurse managers’ leadership abilities. Consequently, nurses from units with less staff were more satisfied with their managers’ leadership behavior than nurses from units with more staff. On the other hand, units with less nurses were more characterized by lower ratings of their work environment in comparison to units with more nursing staff. The nursing practice environment has been found to impact staff perceptions’ of staffing and resource adequacy. However, staffing is not the sole reason for dissatisfaction among nurses. For example, dissatisfaction can also be the result of poor leadership and management, lack of lifelong learning opportunities, poor nurse empowerment, an insecure work environment, and strained nurse-physician relationships (58). In addition, other organizational factors - such as environment or culture, organizational support, and staffing adequacy – can contribute to nurses’ job satisfaction (40,59).
The performed analyses revealed that total patient satisfaction is significantly influenced by nurse managers’ Work well-being, nurses’ Working welfare and medication errors. This means that patients are satisfied when nurse managers treat staff members equally, are interested in staff well-being, provide staff feedback with the aim of developing work, and are interested in work results and outcomes (19). Hence, nurse managers influence patient satisfaction in various ways.
Nurses’ satisfaction with Leadership had a positive impact on patients’ Outcomes variables, which describes the goals of treatment and satisfaction with outcomes and care, while the number of medication errors had negative influence on this aspect of patient satisfaction. For example, an increase in nurses’ perceptions of their nurse managers’ leadership behavior could be expected to improve patient outcomes. Several previous studies have also confirmed that nurse managers’ leadership is related to nurses’ job satisfaction (40,60,61). Furthermore, additional studies have linked nurses’ job satisfaction with patient outcomes (53) and patient satisfaction (6,59).
An interesting finding of this study was that the frequency at which nurse managers performed numerous tasks had a negative impact on different components of patient satisfaction. For example, a nurse manager’s decision to dedicate more time to Organizing, Work well-being, Work atmosphere, Financial management, Clinical nursing or Development of nursing care was found to decrease at least one subscale of patient satisfaction. However, it should be noted that most of these observed decreases were rather slight. In contrast, a nurse manager’s focus on Communication improved patient evaluations of Pain and apprehension. It is also important to note that the frequency at which a nurse manager performs a certain task does not necessarily denote an improvement in the quality of work. For example, several recent studies have emphasized that nurse managers are overwhelmed by their workloads. According to Steege et. al. (2017), fatigue among nurse managers decreases the quality of their work, and can impact decision-making (62). On the other hand, research by Labrague et al. (2018) suggests that – in some cases - more control over a job, along with a higher extent of responsibility, lead to less occupational stress. For these reasons, it is important to review and evaluate how nurse managers' work activities are scheduled, and concentrate to developing collaboration with colleagues and supervisors.
Several of the tested variables significantly influenced the incidence of medication errors. These included the frequency at which nurse managers performed certain tasks, patient satisfaction, and the studied hospital, each of which affected the incidence of medication errors at the unit level. There were large inter-hospital differences, as hospitals 1 and 2 had nearly 10 and 15 times more medication errors, respectively, than hospital 3. Another important finding was that the frequency at which nurse managers participated in Planning and evaluating activities significantly increased the amount of medication errors at a unit. Nurse managers are responsible for the fluency of nursing processess and ensuring that all staff members understand the organizational goals. Consequently, they connect the clinical environment with the organizational culture. Accordingly, units with strong patient safety culture are characterized by organizational learning, continuous improvement, nonpunitive responses to errors, as well as feedback and open communication, and therefore have a lower incidence of adverse events than units that do not perform as strongly across these safety culture aspects. Furthermore, these environments include an atmosphere in which employees feel safe to report medication errors, discuss them, and learn from previous mistakes.(3,63). Patient evaluations of their care and treatment were negatively related with medication errors, i.e., units with patients who were satisfied with their care show less medication errors that units in which patients are not as satisfied with their care.
In summary, the increased share of administrative duties alloted to nurse managers means that they are rarely in the vicinity of patients and nurses. Although nurse managers are responsible for organizing their units, it is equally important that they find sufficient time to support and motivate their staff. However, it is important to note that nurse managers can indirectly improve patient care and outcomes by fostering a safe work environment in their unit.
Strengths & Limitations
The main limitation of this study was that only three hospitals were involed in the study, from which only 28 units met the inclusion criteria. Accordingly, the study include a small sample of nurse managers because there is usually one (rarely two or more) nurse managers per unit. The small amount of units limited the choice of an appropriate analytic method. Therefore, structural equation modelling was excluded, with analysis of covariance chosen to investigate relationships between the variables (51). Nevertheless, the fact that 305 nurses and 651 patients participated in the study could be considered a strength when considering that the power analysis specified that 344 nurses and 342 patients should be included to obtain accurate descriptions of the interactions between variables. In addition, we only studied patient satisfaction and nurses’ job satisfaction at the unit level. However, we did examine how the number of nurses per nurse manager affects patient satisfaction, nurses’ job satisfaction, and medication errors. Hence, the presented results provide information about possible interactions between nurse managers’ work content, nurses’ job satisfaction, patient satisfaction, and medication errors.
The NMWCQ is a new instrument and, as such, needs to be tested more. It is also important to note that all of the questionnaires (NMWCQ, KUHJSS, and RHCS) are based on self-assessment, which can introduce a certain degree of bias as respondents tend to overestimate their own skills (64). However, several studies have reported that the KUHJSS and RHCS are reliable and valid instruments. Medication error data from the HaiPro register are based on nurses’ initiative to report medication errors. Therefore, it is impossible to know whether every medication error has been reported. However, it should be noted that HaiPro is the first adverse event reporting system that was introduced in Finland and is now widely used. To gain a representative picture of medication errors, we decided to collect medication error data over one year, whereas other data were collected over a time period of approximately one month.
Although, the study has been conducted in Finland, the results can be utilized – to a certain degree - in the evaluation and development of nurse managers’ work on an international level. In the future, it would be interesting to examine whether the hours each registered nurse spent per patient affected patient satisfaction or medication errors. In addition, it would be worthwhile to further develop the NMWCQ and apply it in studies which include far larger samples than what was analyzed in the current study. This means that future studies should involve more hospitals and units than the three investigated in this study. This would allow researchers to use different statistical methods - such as structural equation modeling – to assess the relationships between nurse managers’ work content, nurses’ job satisfaction, patient satisfaction and medication errors. Furthermore, it is important to state that the presented results could be verified by applying different measures of nurse managers’ workload and daily tasks.