JOGNN. As the direct interface between the clinical. Predictors and Outcomes of Nurse Leader Job Stress Experienced by AWHONN Members R ESEARCH

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1 JOGNN Predictors and Outcomes of Nurse Leader Job Stress Experienced by AWHONN Members Lisa M. Kath, Jaynelle F. Stichler, Mark G. Ehrhart, and Tressa A. Schultze Correspondence Jaynelle F. Stichler, DNSc, RN, NEA-BC, FACHE, FAAN, Department of Nursing, San Diego State University, PO Box 28278, San Diego, CA Keywords nurse manager job stress job satisfaction intent to quit turnover intentions ABSTRACT Objective: To measure the relationships among stressors (personal factors, job/role factors, hospital factors), job stress, and outcomes experienced by nurse leaders and examine moderation of autonomy and leadership style on outcomes of job stress. Design: A cross-sectional, quantitative design. Setting: Acute and nonacute care settings throughout North America. Participants: A nonprobability convenience sample of 392 was drawn from a population of nurse leaders across the United States and Canada who were members of the Association of Women s Health, Obstetric and Neonatal Nurses (AWHONN). Methods: A mailing list was obtained from AWHONN, and a total of 3,986 recruitment and follow-up postcards were sent to nurse leaders. Participants were asked to complete the survey online or request a hard copy to return by mail. Study variables were measured using previously published scales with demonstrated psychometric properties. Results: Nurse leaders reported stress averages above the midpoint of the scales. Personal factors did not significantly predict stress, but role overload, organizational constraints, and role ambiguity were found to be the best predictors of stress. Job satisfaction, intent to quit, and mental health symptoms were the most significant outcomes of stress. Autonomy moderated relationships between perceptions of stress and outcomes with low autonomy showing greater negative outcomes when levels of stress are higher. Conclusion: Nurse leaders experience significant job stress that may suggest a need to design and implement evidence-based interventions to reduce stress among this group. JOGNN, 42, E12-E25; DOI: /j x Accepted August 2012 Lisa M. Kath, PhD, is an assistant professor, San Diego State University, San Diego, CA. Jaynelle F. Stichler, DNSc, RN, NEA-BC, FACHE, FAAN, is a professor, San Diego State University, San Diego, CA. (Continued) The authors report no conflict of interest or relevant financial relationships. As the direct interface between the clinical workforce and healthcare executives, nurse leaders have a direct influence on professional practice, staff experience/attitudes/retention, and unit culture and climate (McNeese-Smith, 1997). Shirey (2006) reported that the stress of nurse leaders has been directly affected by the reengineering efforts of many hospitals and health systems in the mid-1990s. Increased span of control, scope of responsibilities, and financial and operational performance demands have seriously challenged nurse leaders. Performance expectations and the need for staff resources create pressure as nurse leaders deal with the demands of competing priorities. In the face of intense job-related demands, many nurse leaders report symptoms of burnout (Adams, 1991; Sherman, 2005; Shirey, 2006), and some transition to less-demanding positions. With an increase in experienced nurse leaders nearing retirement age, attrition of nurse leaders for less demanding roles, and fewer nurses electing to attend graduate school (preparing them for leadership roles), a serious leadership void is anticipated that could adversely affect nursing care quality and patient outcomes (Institute of Medicine, 2004). Although job stress experienced by clinical/bedside nurses has been studied extensively, there is a serious need to study stressors experienced by nurse leaders that lead to job stress and to identify effective stress moderators that will minimize negative outcomes from nurse leader job stress. Review of the Literature To guide the development of the conceptual model, a literature search was conducted in E12 C 2012 AWHONN, the Association of Women s Health, Obstetric and Neonatal Nurses

2 Kath, L. M., Stichler, J. F., Ehrhart, M. G., and Schultze, T. A. organizational psychology and nursing using CIN- HAL, PubMed, and PsycINFO using keywords such as nurse leader stress, job stress, organizational stress, role stressor, autonomy, empowerment, nurse leadership, nurse satisfaction, and turnover. It has long been acknowledged that the role of a manager/leader is inherently stressful (Rafferty & Griffin, 2006; Rodham & Bell, 2002; Shirey, 2006; Shirey, McDaniel, Ebright, Fisher, & Doebbeling, 2010). Middle managers in health care reported significant workload and job stress due to topdown changes recommended from administration and bottom-up changes requested by subordinates (Conway & Monks, 2011). Different than most business managers, nurse leaders are required to have clinical expertise as well as knowledge of business management (Omoike, Stratton, Brooks, Ohlson, & Storfjell, 2011). Additionally, implementation of organizational change has been noted as a stressor for many managers (Rafferty & Griffin; Sparks, Faragher, & Cooper, 2001). Nurse leaders often chart the course for organizational change (Maragh, 2011), which is ever present in health care. They also prepare for stressful regulatory and accrediting site visits (Elkins et al., 2010). Despite research that supports the notion that management positions are inherently stressful, to the best of our knowledge, no one has quantitatively examined the nurse leaders perceived job stress across multiple organizations. Personal Factors and Job Stress The job demands-resources (JD-R) model (Bakker & Demerouti, 2007) posits that employees can call upon a number of personal and job resources to help manage the job demands placed upon them. From the perspective of the JD-R model, age, education, and experience (as represented in this study by tenure as a registered nurse [RN] and tenure in nursing management) could serve as important personal resources that could lead to reduced nurse leader stress (Carstensen, Fung, & Charles, 2003; Judkins, Massey, & Huff, 2006; Schmied & Lawler, 1986). Because these personal factors have not been studied in a sample of nurse leaders, it is important to examine how personal factors may be related to nurse leader stress. Job/Role Factors and Job Stress Role stress theory (Beehr & Glazer, 2005) posits that employees typically have several roles. For example, nurse leaders have a role in supporting patient outcomes or staff satisfaction and another Nurse leaders often feel the stress of responding to competing priorities. role in managing budgets. According to Beehr and Glazer, when these roles are not well defined (role ambiguity), are too demanding (role overload), or create incompatible demands (role conflict), employees are likely to feel stressed. A large number of direct reports could lead to increased role overload, and higher organizational level could lead to increased role ambiguity. Role stressors are frequently reported by nurse leaders as they manage multiple competing priorities for their time (role conflict), work with unclear perceptions of responsibilities and the range of their authority to make decisions autonomously (role ambiguity), and manage the role overload associated with a large span of control and responsibilities (Cathcart et al., 2004; Kleinman, 2003; Shirey, 2006). Spector and Jex (1998) conceptually defined organizational constraints as situational barriers to performance and interpersonal conflict as experiences of hostility or rudeness from others at work, both of which are job demands associated with job stress. The nurse manager role is often characterized by organizational constraints such as limited human and financial resources, hostility from physicians, or angry staff during work process changes. Nurse leaders in unionized hospitals report more stress related to union activities because of the complexity of the interdependent hospital and union structures (New, 2009). Because one of the benefits of the Magnet initiative is to improve the work environment, it would seem that nurse leaders in Magnet-designated hospitals would report less stress and increased job satisfaction, although there is no documented evidence to support this assumption for nurse leaders (Upenieks, 2003). There is also a dearth of evidence that might indicate if hospital types (e.g., university, community tertiary) or community type (rural, suburban, or urban) might contribute to nurse leader stress. The Relationships between Job Stress and Outcomes (Strains) The organizational psychology and nursing literature is full of studies of the negative effects of job stress (Milliken, Clements, & Tillman, 2007; Örtqvist & Wincent, 2006; Shirey et al. 2010; Thorpe & Loo, 2003), but there is little reported Mark G. Ehrhart, PhD, is an associate professor, San Diego State University, San Diego, CA. Tressa A. Schultze, MS, is a survey research associate, San Diego State University, San Diego, CA. JOGNN 2013; Vol. 42, Issue 1 E13

3 Predictors and Outcomes of Nurse Leader Job Stress Experienced by AWHONN Members about the specific effects of job stress on nurse leaders. Nurse leader stress has been reported to negatively affect psychological and physical health (Judkins et al., 2006; Lindholm, Dejin- Karlsson, Ostergren, & Uden, 2003; Schmied & Lawler, 1986). Literature has also shown a relationship between job stress and burnout (emotional exhaustion, inability to accomplish all that is perceived to be required, and depersonalization) in nurse managers (Jamal & Baba, 2000). This nascent literature supports the notion that job stress is associated with negative outcomes, but this needs to be examined further in this population. Possible Moderators of the Relationships between Job Stress and Outcomes Autonomy (i.e., decision latitude, job control, empowerment) has long been theorized and empirically supported as a key component of a motivating and satisfying job (Hackman & Oldham, 1976; Laschinger, Purder, & Almost, 2007), as well as a moderator of the stress-outcome relationship (Karasek, 1979). Goddard and Laschinger (1997) identified lack of empowerment structures available to first-line managers contributed to their feelings of frustration and job dissatisfaction. Other research has shown that empowerment can lead to improvements in nurse managers job satisfaction (Laschinger et al.; Regan & Rodriguez, 2011), which hints at empowerment or autonomy as a possible buffer of job stress for nurse leaders. Transformational leadership was conceptually defined as leaders who inspire their direct reports to rally around a vision, include direct reports in decision making, and help their direct reports develop and grow (Avolio & Bass, 1998; Avolio, Zhu, Koh, & Bhatia, 2004). Indeed, research in nursing has demonstrated that support from leaders can be an important buffer against negative effects of stress (Failla & Stichler, 2008; Kleinman, 2004; Laschinger, Wong, McMahon, & Kaufmann, 1999; Lindholm et al., 2003; Wayne, Shore, & Liden, 1997). Transformational leadership is also an important construct for nursing and is one of the essential components in the Magnet model (American Nurses Credentialing Center, 2011). As a result of the literature search, it seems cogent to examine a broad sweep of possible personal, job, and hospital factors that might affect nurse leaders perceptions of job stress, job attitudes (job satisfaction, organizational commitment, and intentions to quit), and psychosomatic symptoms (physical and mental health symptoms). Because the literature indicates autonomy and leadership style have been shown to moderate the relationship between stress and outcomes, it is important to study these moderating factors for nurse leadersaswell. Conceptual Framework The main theoretical model of job stress upon which the conceptual framework of the current study rests includes job stress, stressors, outcomes, and moderators (Sulsky & Smith, 2006). Job stress is conceptually defined as a state that arises when job demands are perceived to exceed abilities and resources (Moos, 1992; Westman, 2005). Stressors are conceptually defined as factors that can contribute to perceptions of stress (Sulsky & Smith). The stressors in this study are divided into three major categories: (a) personal factors (age, education, tenure as an RN, and tenure in a management role), (b) job/role factors (number of direct reports, organizational level, role ambiguity, role overload, role conflict, organizational constraints, and interpersonal conflict), and (c) hospital factors (Magnet designation, nurse unionization status, hospital type, and community type). Outcomes are conceptually defined as negative outcomes resulting from stressors (Sulsky & Smith). The outcomes in this study include job satisfaction, organizational commitment, intentions to quit, and physical/mental health symptoms. Finally, moderators are conceptually defined as factors that influence the effects of stressors on outcomes. Moderators in this study include autonomy and leadership style. This comprehensive measurement of the stressors, outcomes, and moderators was expected to provide a detailed picture of the factors that influence nurse leaders perceptions of stress, the outcomes they may experience, and moderating factors that may buffer nurse leaders from negative outcomes (see Figure 1). Study Purpose The purpose of this study was to describe job stress experienced by nurse leaders who are members of the Association of Women s Health, Obstetrics and Neonatal Nursing (AWHONN). Job stress in clinical/bedside nurses has been studied often, but the relationships among stressors, stress, outcomes, and moderators has not yet been quantitatively examined in a sample of nurse leaders. It is important to identify the relationships E14 JOGNN, 42, E12-E25; DOI: /j x

4 Kath, L. M., Stichler, J. F., Ehrhart, M. G., and Schultze, T. A. Figure 1. Conceptual framework. among these study variables to develop interventions that support effective moderators that have been shown to help nurse leaders minimize the outcomes of job stress. Research Questions Specific goals of this research were to answer the following research questions (RQ) related to stressors, stress, outcomes, and moderators reported by nurse leaders (see Figure 1): RQ1. What are the relationships among stressors (personal factors, job/role factors, hospital factors), job stress, and outcomes experienced by nurse leaders? RQ2. Are the outcomes of job stress moderated by autonomy and leadership style? Method This study used a nonexperimental, crosssectional, quantitative design. The population included all AWHONN members who listed their position in the membership roster as shift supervisor, nurse manager, director, or chief nursing officer (CNO). Data Collection Procedure After Institutional Review Board approval from San Diego State University and AWHONN organizational approval, nurse leaders who were listed on a membership list obtained from AWHONN were invited by postcard to participate in an online survey (paper surveys were mailed to participants upon request). A total of 4,053 postcards were initially mailed, but many postcards were returned as undeliverable. That information was used to clean the mailing list before reminder postcards (3,986) were sent, approximately 6 weeks after the first mailing. Postcards were also distributed at the AWHONN annual conference. Sample In total, 456 participants started the survey with 392 completing all items in the survey, yielding a response rate of 9.8% for fully completed surveys (from 3,986 usable addresses). To maximize statistical power for all analyses, listwise deletion within each analysis was used to address missing data, resulting in different N s for each analysis. A large majority of participants completed the survey online (N = 379). The study sample is primarily White, experienced RNs, nearly one half of whom have a graduate degree. Sample demographic variables are presented in Table 1. However, the demographic survey did not include a question about gender to avoid the remote possibility that anonymity of male participants could be compromised by examining all demographics simultaneously. JOGNN 2013; Vol. 42, Issue 1 E15

5 Predictors and Outcomes of Nurse Leader Job Stress Experienced by AWHONN Members Table 1: Sample Demographics Personal Factors Personal Subcategory M (SD) or Factor Percentage (n) Age M (SD) 47.7 (9.10) Ethnicity White 92% (412) Non-White 8% (38) Education level Diploma/associate s degree 15% (66) Bachelor s degree 40% (177) Graduate degree 45% (203) RN tenure M (SD) 23.9 (9.38) Nursing management tenure M (SD) 10.9 (8.25) Current position tenure M (SD) 5.8 (5.32) Number of direct reports M (SD) 49.8 (53.66) Organizational level Shift supervisor 10% (41) Nurse manager 58% (249) Nurse director (or higher) 25% (107) Other (e.g., educators, specialists) 7% (30) Location Canada 3% (12) United States 97% (381) Of those who responded, 17% indicated their workplace had Magnet designation, and 30% indicated that nurses at their workplaces were unionized. Most of the participants worked in a community acute-care facility (53%), whereas others worked at community tertiary acute-care facilities (22%), academic acute-care facilities (16%), outpatient facilities (2%), nursing homes (1%), and other facilities (6%), such as military hospitals. There was a fairly even mix for community type, with 29% of nurse leaders working in rural settings, 39% working in suburban settings, and 32% working in urban settings. Most respondents worked in labor & delivery/labor, delivery, recovery & postpartum (L&D/LDRP) (n = 275) or postpartum/nurseries (n = 253), with some working in neonatal intensive care unit (NICU)/intermediatecare nurseries (n = 126), administration (n = 67), or other units (n = 158). Because respondents could mark multiple units, these numbers exceed the number of respondents in our sample. All the scales had sound psychometric properties (e.g., Cronbach s alphas greater than.70). In two scales (organizational commitment and turnover intentions), the wording of the items was changed from organization to hospital. Changes of this type are frequent in organizational psychology research, with the rationale being that minor rewording of items to better reflect the exact situation of the respondents will improve the accuracy of the responses, thereby maintaining/improving the validity of the scale. The scales were ordered such that predictors were measured after the outcomes, so as not to inflate the correlation between the two through priming. Unless indicated otherwise, scales utilized a 5-point Likert-type scale, where 1 (strongly disagree) and 5 (strongly agree). Items were reversecoded as needed and averaged to create a total scale score. Higher values indicated higher levels of the construct. Instruments The survey instrument was a compilation of scales from a number of published instruments (Table 2) that were chosen because the scales were thought to be understood well by the target population. Perceptions of Stress. Job stress perceptions were measured using two different scales because this is a central concept of interest, and it was not clear if the scales would operate equivalently with nurse leaders. The first was the E16 JOGNN, 42, E12-E25; DOI: /j x

6 Kath, L. M., Stichler, J. F., Ehrhart, M. G., and Schultze, T. A. Table 2: Scale Name, Instrument Name, Alphas, and Number of Items for Scales Used Scale Name Instrument Name Alpha # Items Role Ambiguity Breaugh & Colihan Role Ambiguity Scale.86 6 Role Overload Seashore et al. Role Overload Scale.83 4 Role Conflict Haynes et al. Role Conflict Scale.70 4 Organizational Constraints Spector & Jex Organizational Constraints Scale Interpersonal Conflict Spector & Jex Interpersonal Conflict Scale.79 4 Stress in General (SIG) Stanton et al. Stress in General Scale SIG-Threatened Stanton et al. Stress in General subscale.86 8 SIG-Pressured Stanton et al. Stress in General subscale.81 7 Subjective Stress (SS) Motowidlo et al. Subjective Stress Scale.82 4 Job Satisfaction Cammann et al. Job Satisfaction Scale.85 3 Organizational Commitment Allen & Meyer Affective Commitment Scale.86 6 Intentions to Quit Seashore et al. Turnover Intentions Scale.85 3 Physical Health Symptoms Kristensen et al. Somatic Stress Scale.82 9 Mental Health Symptoms Kristensen et al. Mental Health Scale.87 5 Autonomy Smith et al. Job Control-Decision Authority Measure.77 3 Transformational Leadership Rafferty & Griffin Transformational Leadership Scale item Stress in General (SIG) scale (Stanton, Balzer, Smith, Parra, & Ironson, 2001) which consisted of two subscales: Threatened and Pressured. All items were preceded by the question What is your job like MOST OF THE TIME? Responses were indicated on a No,?, (indicating a neutral response or undecided) and Yes scale, which were recoded (according to the scale instructions) such that No = 1,? = 1.5, and Yes = 3. The second measure of stress perceptions was the 4-item Subjective Stress scale (Motowidlo, Packard, & Manning, 1986). Personal Factors. Measurement of the personal factors was taken from the demographic survey, which included fill-in items asking about participants age, a multiple-choice item about their highest level of education, two fill-in items asking about the number of years they had been an RN (RN tenure), and the number of years they had held their current management position (management tenure). Education was dummy coded such that participants with a graduate degree were the referent group. Job/Role Factors. Measurement of number of direct reports and organizational level were determined from fill-in items in the demographic survey. Organizational level was initially dummy coded such that nurse managers were the referent group. Role ambiguity was operationalized using a 6- item scale from Breaugh and Colihan (1994). Role overload was measured using a 3-item scale from Seashore, Lawler, Mirvis, and Cammann (1982). Role conflict was measured using a 4-item scale (Haynes, Wall, Bolden, Stride, & Rick, 1999). Organizational constraints were measured using the 11-item Organizational Constraints Scale (Spector & Jex, 1998). The response scale for this construct was a 5-point frequency scale, where 1 (less than once per month or never), 2 (once or twice per month), 3 (once or twice per week), 4 (once or twice per day), and 5 (several times per day). Interpersonal conflict was measured using the 4- item Interpersonal Conflict at Work Scale (Spector & Jex). The response scale for this construct was the same 5-point frequency scale as was used for the organizational constraints measure. Hospital Factors. Participants were asked on the demographic survey whether their hospital had Magnet designation or not (0 = non-magnet, 1 = Magnet). Similarly, participants reported their hospital s unionization status (0 = nonunionized, 1 = unionized). Participants also reported their hospital type (e.g., community, university) and community type (1 = rural, 2 = suburban, and 3 = urban). Hospital type was initially dummy JOGNN 2013; Vol. 42, Issue 1 E17

7 Predictors and Outcomes of Nurse Leader Job Stress Experienced by AWHONN Members Nurse leaders reported above-midpoint levels of stress. Role overload, organizational constraints, and role ambiguity were the best predictors of stress. coded such that nonacute care settings were the referent group, and community type was dummy coded such that urban was the referent group. Autonomy is defined as the level of decision authority perceived by the employee/participant. This construct was measured using a 3-item scale (Smith, Tisak, Hahn, & Schmieder, 1997). Leadership was measured using a 15-item transformational leadership scale by Rafferty and Griffin (2004). As is common practice in organizational research that does not focus on individual components of transformational leadership (e.g., Avolio et al., 2004; Bass, Avolio, Jung, & Berson, 2003; Walumbwa, Avolio, & Zhu, 2008), items were averaged across the five subscales to provide an overall score of transformational leadership. Outcomes. Job satisfaction was measured using a 3-item scale (Cammann, Fichman, Jenkins, & Klesh, 1983). Organizational commitment is a measure of one s emotional attachment to one s organization, and this construct was measured using a 6-item scale from Allen and Meyer (1990). Intentions to quit are a measure of the extent to which an employee may be planning to leave the organization. This construct was measured using a 3-item scale (Seashore et al., 1982). Physical health symptoms were measured using the 9-item Somatic Stress scale from the Copenhagen Psychosocial Questionnaire (COP- SOQ) (Kristensen, Hannerz, Hogh, & Borg, 2005), which asks about somatic symptoms (such as headaches, palpitations) experienced during the past 4 weeks. Responses were indicated on a 5-point frequency scale, where 1 (never/hardly ever), 2 (seldom), 3 (sometimes), 4 (often), and 5(always). Mental health symptoms were measured using the 5-item COPSOQ Mental Health scale (Kristensen et al.), which asks about mental state (such as felt downhearted and blue ) experienced during the past 4 weeks. Responses were indicated on a 6-point frequency scale, where 1(none of the time),2(alittleofthetime),3(some of the time), 4 (a good bit of the time), 5 (most of the time), and 6 (all of the time). Results The mean score on SIG-overall was 1.96 (SD =.70), on a scale of 1 to 3. There were two subscales in the SIG scale, (a) threatened (M = 1.58, SD =.85) and (b) pressured (M = 2.40, SD =.70). For subjective stress, the mean score was 3.66 (SD =.85), with a scale of 1 to 5. This indicates that AWHONN nurse leaders experience moderate levels of subjective stress. None of the personal factors (age, education, tenure as an RN, or tenure in nursing leadership) had a significant regression coefficient predicting any of the stress measures As shown in Table 3, several job/role factors predicted the four stress measures used. Number of direct reports and interpersonal conflict were nonsignificant predictors in the final model for all stress measures. Organizational level was a significant predictor for SIG-pressured only: those with supervisory responsibilities had higher pressured stress than those in the other category. Because this was the only difference, organizational level was dichotomized (supervisory vs. nonsupervisory) for mediation analyses below. Role overload had the highest standardized regression coefficients (i.e., betas) in all of the models, with organizational constraints and role ambiguity having the second- and third-highest betas, respectively. Of the hospital factors, Magnet designation and unionization status were nonsignificant predictors in the final models for all stress measures (Table 4). Hospital and community type were significant predictors of only one stress measure: SIG-pressured. Nurse leaders in acute-care settings experienced more pressured stress than those in nonacute care. Nurse leaders in urban settings also experienced more pressured stress than those in suburban or rural settings. Results indicated that all outcomes of stress measured were significantly correlated with perceptions of stress (p.05), but three outcomes had correlations over.50: job satisfaction, intentions to quit, and mental health symptoms. It was noted that SIG-pressured consistently had the lowest correlations with outcomes. Based on logic outlined in the classic mediation article by Baron and Kenny (1986), only stressors that demonstrated significant prediction of stress (mediator) and outcomes were included in mediation models. Because all stress measures were significantly correlated with all outcomes, all outcomes were included. Rather than test a single predictor-mediator-outcome model at a time, more modern mediation analyses were conducted, E18 JOGNN, 42, E12-E25; DOI: /j x

8 Kath, L. M., Stichler, J. F., Ehrhart, M. G., and Schultze, T. A. Table 3: Results of Multiple Regressions of Job/Role Factors Predicting Perceptions of Stress Outcome SIG a SIG-Threat b SIG-Pressure c Subjective Stress Predictor Beta R 2 Beta R 2 Beta R 2 Beta R 2 Number of direct reports.02 ns.01 ns.06 ns.05 ns Organization level (Other) d.07 ns.03 ns ns Organization level (Supervisor) d.00 ns.01 ns.01 ns.08 ns Organization level (ND and up) d.02 ns.00 ns.04 ns.00 ns Role ambiguity ns.17 Role overload Role conflict.06 ns ns.04 ns Organizational constraints Interpersonal conflict.08 ns.07 ns.06 ns.07 ns Overall variance Note. N ranges from 336 to 371. Standardized betas are reported. a SIG = Stress in General Scale. b SIG-Threat = Stress in General-Threatened subscale. c SIG-Pressure = Stress in General-Pressured subscale. d Organizational level dummy coded with nurse manager as the referent group. p <.05. p <.001. Table 4: Results of Multiple Regressions of Hospital Factors Predicting Pressured Stress SIG-Pressure Predictor Beta R 2 Magnet designation Unionized Hospital type (Academic) a Hospital type (Community 1 ) a Hospital type (Community 3 ) a Community type (Rural) b Community type (Suburban) b Overall variance.01 ns.08 ns Note. SIG = Stress in General. N = 343. Standardized betas are reported. a Hospital type dummy coded with nonacute care settings as the referent group. b Community type dummy coded with urban as the referent group. p <.05. using path analysis of multiple predictors and outcomes simultaneously. Because none of the personal factors significantly predicted stress, no mediation analyses were conducted using that set of stressors. Several job/role factors predicted stress, and regression analyses were used to develop mediation models to test for each of the measures of job stress. For SIG-overall, a path analysis was run with role ambiguity, role overload, and organizational constraints as predictors. All path coefficients were significant and in the expected directions, but when using recommended cutoffs (Hoyle, 1995; Laschinger & Grau, 2012), the data did not fit the model very well: χ 2 (15) = 107.7, p <.01, Comparative Fit Index (CFI) =.95, root mean square of error approximation (RMSEA) =.12. For SIGthreatened, a path analysis was run with role ambiguity, role overload, role conflict, and organizational constraints as predictors. As before, all path coefficients were significant and in the expected directions, but the data did not fit the model very well: χ 2 (20) = 112.5, p <.01, CFI =.95, RMSEA =.10. For SIG-pressured, a path analysis was run with organizational level (dichotomized as described above), role overload, and organizational constraints. Path coefficients for everything but organizational level were significant and in the expected directions, but even after the nonsignificant path from organizational level and SIGpressured was trimmed, the data still did not fit the model very well: χ 2 (10) = 91.5, p <.01, CFI =.95, RMSEA =.14. Finally, for subjective stress, a path analysis was run with role ambiguity, role overload, JOGNN 2013; Vol. 42, Issue 1 E19

9 Predictors and Outcomes of Nurse Leader Job Stress Experienced by AWHONN Members and organizational constraints as predictors. All path coefficients were significant and in the expected directions, but, as before, the data did not fit the model very well: χ 2 (15) = 134.8, p <.01, CFI =.93, RMSEA =.13. To simplify the mediation model for hospital factors, hospital type (acute-care vs. nonacute care) and community type (urban vs. nonurban) were dichotomized based on regression results. All path coefficients were significant and in the expected directions, and the data did fit the model quite well: χ 2 (10) = 8.20, p >.05, CFI = 1.00, RMSEA =.00. Moderators (RQ2) were tested using hierarchical multiple regression, such that predictors were centered on the mean (Cohen, Cohen, West, & Aiken, 2003) and the interaction term was entered in a separate step. Leadership was not found to moderate any of the relationships between job stress (measured four ways) and outcomes (five types). However the effects of stress varied based on the amount of autonomy the nurse leader reported. As shown in Table 5, autonomy interacted with subjective stress when predicting job satisfaction, organizational commitment, and mental health symptoms. Figure 2 displays the interaction of subjective stress and autonomy on job satisfaction, which represents the regression lines when the predictor and moderator are one SD above and below the mean. This figure indicates that the effect of stress on job satisfaction was attenuated for those with high autonomy. The graph for organizational commitment as an outcome looks very similar to Figure 2. Figure 3 shows that, similarly, autonomy buffered the effects of stress on mental health symptoms. Autonomy also buffered the relationship between perceptions of stress and intentions to quit (see Table 6). Figure 4 displays the interaction for SIGoverall and autonomy on intent to quit (the interaction with SIG-pressured looks very similar). What the figure shows is that, in general, those with high autonomy had lower intent to quit than those with low autonomy (main effects). Additionally, the effect of stress on intent to quit was attenuated for those with high autonomy. Discussion This study was significant because it is the first of its kind to study the stress experiences of nurse leaders across organizations in such a comprehensive way. Understanding the job stress of nurse leaders is important because of the influence that nurse leaders have on their clinical nurses and because it is increasingly difficult to recruit and retain nurse leaders (Shirey, 2006; Shirey et al., 2010). Aspiring nurse leaders have many other options to further their careers without assuming the stress of the management position. By identifying the stressors and outcomes experienced by nurse leaders, it was hoped that these results could offer insight into potential interventions that can be developed to recruit, train, and retain nurse leaders. As evidenced by the high mean scores on the stress measures, nurse leaders do indeed experience high levels of stress on the job. For example, high scores on the SIG-Pressured subscale would indicate that nurse leader positions are highly demanding, pressured, hectic, and stressful. However, it was interesting that none of the personal factors (age, education, or tenure) predicted job stress. This finding suggests stress management interventions might be more effective if focused on other predictors of job stress. A number of job/role factors significantly predicted job stress. Because nurse managers and above experience significantly more job stress than shift supervisors or other nurse leader roles, organizations might be advised to focus limited resources on stress management for these higher-level positions. Role overload, organizational constraints, and role ambiguity were consistently the most significant job stressors for nurse leaders, which is similar to findings reported by other authors (Sherman, 2005; Shirey, 2006; Shirey et al., 2010). These findings make it critical that hospitals take steps to alleviate these stressors or assist nurse leaders in managing these stressors. To reduce role overload, supervisors could ensure that the role is not too much for one person to effectively handle. Supervisors and peers can also support newer nurse leaders in learning to manage the demands of a nursing leadership role, which would reduce perceptions of role overload. Moreover, hospital administrators could attempt to remove as many constraints within the organization as possible so nurse leaders can be more effective. This can include ensuring adequate supplies, equipment, support, training, and instructions. Together, the evidence from this study supports the need for evidence-based stress management interventions for nurse leaders to help them better cope with stressors, especially role overload and E20 JOGNN, 42, E12-E25; DOI: /j x

10 Kath, L. M., Stichler, J. F., Ehrhart, M. G., and Schultze, T. A. Table 5: Results of Autonomy Moderating Relationships of Subjective Stress with Strains Job Organizational Mental Health Satisfaction Commitment Symptoms Predictor Beta R 2 R 2 Beta R 2 R 2 Beta R 2 R 2 Step Subjective stress Autonomy Step Subjective stress autonomy Note. N = 372. Standardized betas are reported. p <.05. p <.001. organizational constraints. Clearly more research is needed to determine the effectiveness of various organizational interventions on nurse leader stress at all levels of hierarchy. Results indicated that, for hospital factors, nurse leaders in acute-care settings and in urban areas experienced more pressured stress than nurses in nonacute care settings and/or in rural or suburban areas. Therefore, these results suggest that nurse leaders working under these conditions may need to be supported by stress management interventions, although pressured stress was the stress measure with the weakest correlations with study outcomes. The need for evidence-based stress management interventions is underscored when examining the outcomes of stress. Nurse leaders experienced lower job satisfaction, increased intentions of quitting, and more mental health symptoms when experiencing high levels of stress. These outcomes can have serious and detrimental effects on nursing units and hospitals as a whole, as individuals with low job satisfaction and high intentions to quit may spread their negative attitudes to employees they interact with on a consistent basis. Moreover, increased mental health symptoms can lead to increased absences and reduced productivity. To help tie these results together, path analyses were conducted to more explicitly test the role of job stress as a mediator of the relationship between stressors and outcomes. In all path analyses for job/role factors, the path coefficients Figure 2. Interaction effect of subjective stress and autonomy on job satisfaction. JOGNN 2013; Vol. 42, Issue 1 E21

11 Predictors and Outcomes of Nurse Leader Job Stress Experienced by AWHONN Members Nurse leaders who were stressed but reported higher autonomy experienced higher job satisfaction, higher organizational commitment, and fewer mental health symptoms. supported the model, although the overall fit indices fell just short of supporting good fit. The path analysis with the hospital factors had appropriate path coefficients and fit indices, yet the overall variance accounted for by these factors as predictors of stress was quite low (R 2 =.06, see Table 4). Future research should continue to study the relationships between stressors and outcomes, and, as noted below, that research needs to include study designs that better support tests of mediation. Regarding the moderation analyses, autonomy was shown to moderate the relationships between perceptions of stress and outcomes. Nurse leaders with high stress and low autonomy showed greater negative outcomes (lower job satisfaction, lower organizational commitment, more mental health symptoms, and higher intent to quit). Therefore, hospitals are encouraged to attempt to increase the levels and awareness of autonomy in the nurse leader roles. Limitations Although this study aimed to be comprehensive, it is not without its limitations. First, there was a low response rate to the survey. As a result, the findings may not be representative of nurse leaders who are members of AWHONN, with the number of Canadian respondents as particularly low. It is logical to suggest, though, that the results may underestimate the stress experienced by nurse leaders, as those under extreme amounts of job stress are probably most likely to decline participation in a research study. What is not known is how the outcomes and moderators of stress may differ if the response rates had been higher, and generalization of the study results to all nurse leaders who are members of AWHONN is not recommended. Another limitation of the current study is its use of a correlational design, which eliminates the ability to draw causal inferences from the results found. However, correlational designs are most appropriate for the study of job stress, as experimentally manipulating job stress levels is unethical, and every effort was made to ground the conceptual model in existing theories of workplace stress. Nevertheless, readers are reminded not to assume, for example, that role overload perceptions cause increased perceptions of job stress. This particular relationship is likely to exhibit reciprocal causality, which can only be tested with longitudinal data. Implications Besides implications discussed above, there is a research implication for the study of nurse leader stress. Job stress was measured four different ways, and this led to a very in-depth look at the stress measurement of nurse leaders. The Stress Figure 3. Interaction effect of subjective stress and autonomy on mental health problems. E22 JOGNN, 42, E12-E25; DOI: /j x

12 Kath, L. M., Stichler, J. F., Ehrhart, M. G., and Schultze, T. A. Table 6: Results of Autonomy Moderating the Relationships Between Perceptions of Stress and Intent to Quit Intent to Quit in General Scale differentiated stress that is threatening from stress that is pressured. Nurse leaders reported higher pressured stress than threatened stress, yet pressured stress had the lowest correlation with stress outcomes. Autonomy was a moderator of the effects of SIG-overall, SIGpressured, and subjective stress but had no effect of SIG-threatened. If threatened stress is the most damaging type of stress, as results suggest, then more research should focus on what can support nurse leaders experiencing this lesscommon but potentially more injurious type of stress. Predictor Beta R 2 R 2 Step SIG-Overall Autonomy Step Stress a Autonomy.09 Step SIG-Pressured Autonomy Step Stress a Autonomy.09 Note. SIG = Stress in General. N = 372. Standardized betas are reported. a Stress was measured by Stress in General Overall in the top half of the table and by Stress in General Pressured in the bottom half of the table. p <.05. p <.01. There are also implications for AWHONN as an organization. Nurse leaders report stress levels above the midpoint of the scale, and these stress levels are correlated with important negative effects, such as decreased job satisfaction, decreased organizational commitment, and increased intent to quit. Nurse leaders stress not only affects their personal health and the work environment, but also has been shown to indirectly affect patient outcomes (Milliken et al., 2007; Shirey et al., 2010). As a result, it may be helpful for AWHONN to engage in program planning for conferences and creation of online learning modules that address the stressors experienced by nurse leaders and offer recommendations for managing the stressors operationally. Sessions on stress management and positive coping mechanisms could also be offered to assist AWHONN s nurse leaders in staying healthy physically and mentally, which then has implications on the general nursing workforce s satisfaction and indirect implications on patient outcomes. Mentoring programs could also be developed pairing an experienced nurse leader with those who are new in their management roles. Acknowledgment Funded by an AWHONN Hill-Rom Grant. Figure 4. Interaction effect of Stress in General-overall and autonomy on intent to quit. JOGNN 2013; Vol. 42, Issue 1 E23

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