November 7, 2024 The negative impact of nurse manager transitions - and how to avoid them

What the data says

This article builds on the fall 2024 report, Trends and Innovations in Nurse Manager Retention, a co-publication between Laudio Insights and the American Organization of Nurse Leaders (AONL). The analysis is from a three-year longitudinal study of 8,500 managers and their team members in over 75 acute care facilities and hundreds of ambulatory locations nationwide.

Of the four main types of nurse manager transitions shown above (i.e., promotion, department change, exit from management role, and exit from the organization), all are associated with a two to four percentage point decrease in the annual retention rates of the RNs on the team that the manager left in the 12 months post-transition. The association with RN retention rates changes are statistically significant for all four transition types. In all cases, nurse managers are most often replaced with a more junior manager who may need time to reach a similar level of leadership proficiency. 

The impact of the transitions are all similar; however, a nurse manager changing departments has the greatest impact on the team they left. Managers may take some of their own local leadership team with them in such cases, leading to an even greater level of disruption. 

The distribution of the four main paths for nurse managers when they leave is shown below – the distribution is roughly even across these four. The fifth and largest path is multiple changes (e.g., a manager moves to another department and returns to a front-line team member role within a three-month window); as this category is a mix of other categories, it is not further discussed.

What it means   

1. Executives should be thoughtful about changing managers’ departments whenever it can be avoided.
   1. • Of the four areas, promoting managers to the next step in their career appears to be an opportunity where the benefit to the manager outweighs the short-term turbulence to the team.
      • This is not the case for the other three types of manager transition events, which should be avoided whenever possible, especially managers leaving the role or organization. When managers change departments, it may be due to their preference, in which case the value may be justified. When they change departments due to an organizational request where other options may be available, the value may not be justified relative to the cost to the team.
        
        
2. One way to increase RN retention is to minimize nurse managers leaving management roles and/or the organization.
   1. • 36% of the nurse manager transitions are managers either leaving management (i.e., returning to a non-management role) or leaving the organization altogether, per the chart above.
      • Both of these events bring the cost of finding and onboarding a replacement manager (even if the replacement manager is found internally, the frontline RN role would then need to be replaced), which is as costly as an RN turnover event. National estimates on the cost of RN turnover replacement are $56,300 (NSI 2024).
      • Both of these events are associated with a 2-2.5 percentage point rise in RN turnover on the team in the year following the manager exit, per the bar chart above. In a team with 50 RNs, this averages about one additional RN termination, accruing an additional $56,300 turnover cost.

What the implications are for healthcare leaders 

1. 1. Build a leadership pipeline so that when new leadership opportunities become available, non-manager team members can be promoted to them without affecting other current managers.
      1. • One way to do this is to develop Leadership Ladders with multiple tracks, including management. RNs can learn and apply different aspects of leadership (including clinical specialties, education, and formal management) giving multiple team members the foundation and potential to move into a manager role.
         • See a prior article, “The next rung up: Building organization-wide ‘Leadership Ladders’”, for more detail.
           
           
   2. Invest in your managers, especially in their early years of leadership, to minimize manager attrition.
      1. • The Laudio-AONL report showed that managers are most likely to leave their positions within the first four years – indicating a key window for leadership investment and support. Offer leadership training early for managers that focuses on learning and practicing both relational and operational aspects of management.
         • Empower managers with a foundation of practical resources and tools to set them up for success. For example, Laudio’s book, “Leader Inspired Work: Insights and Tools by and for Healthcare Managers,” facilitates ongoing leadership development for both individuals and groups.
         • Considering the extensive and demanding duties of nurse managers, executives may find it beneficial to collaborate with HR and IT leaders to find technology solutions that alleviate administrative burdens.
         • Executives should consider technology solutions tailored to alleviating workload and supporting the everyday tasks of nurse managers, rather than solutions focused primarily on executive processes or reporting. Solutions that enhance coaching, check-ins, and team member recognition in particular can augment RN retention efforts.
           
           
   3. Prioritize and implement retention strategies rooted in feedback from nurse managers themselves.
      1. • The Fall 2024 report also details the top priorities nurse managers identified in interviews – in particular, their request for executives to focus on investing in increasing the level of support in the fundamental aspects of their roles. For example, managers want executives to dedicate time with them to actively problem-solve challenges during executive rounds.
         • For more of the nurse manager interview takeaways, access the Trends and Innovations in Nurse Manager Retention report.
           
           

Notes on the analysis
We fit a Bayesian hierarchical logistic regression model with non-informative priors to estimate RN retention as a function of manager change and residual variation at the system, facility, manager, and individual level. Variation within each level was estimated using random intercept terms. Data included 569,189 employee-months across 32,513 unique RNs reporting to 3,104 distinct nurse managers. These personnel were drawn from 93 facilities within 12 organizations with multiple years’ longitudinal data. The different layers of an organizations’ structure contribute to the overall variation in retention outcomes. The hierarchical model accounts for commonalities within the subjects of each layer.

References
Cost of RN turnover: NSI Nursing Solutions, Inc., 2024 NSI National Health Care Retention & RN Staffing Report, page 1.

NOTE: Some of the charts and findings in this article were previously published in Trends and Innovations in Nurse Manager Retention in Fall 2024, a joint publication between Laudio Insights and the American Organization for Nursing Leadership (AONL).