Annotated Bibliography 12 articles

Received: 14 December 2020   |  Revised: 26 February 2021   |  Accepted: 2 March 2021 DOI: 10.1111/jonm.13301

O R I G I N A L A R T I C L E

Comparing nurse leader and manager perceptions of and strategies for nurse engagement using a positive deviance approach: A qualitative analysis

Amanda C. Blok PhD, MSN, RN, PHCNS- BC 1,2  | Ekaterina Anderson PhD 3,4  | Lakshman Swamy MD, MBA 5  | David C. Mohr PhD 6,7

Published 2021. This article is a U.S. Government work and is in the public domain in the USA

1 Center for Clinical Management Research , Veterans Affairs (VA) Ann Arbor Healthcare System, United States Department of Veterans Affairs , Ann Arbor , MI , USA

2 Systems, Populations and Leadership Department , School of Nursing , University of Michigan , Ann Arbor , MI , USA

3 Center for Healthcare Organization and Implementation Research , Veterans Affairs (VA) Bedford Healthcare System , Bedford , MA , USA

4 Department of Population and Quantitative Health Sciences , Division of Health Informatics and Implementation Science , University of Massachusetts Medical School , Worcester , MA , USA

5 The Pulmonary Center , Boston University School of Medicine , Boston , MA , USA

6 Center for Healthcare Organization and Implementation Research , Veterans Affairs (VA) Boston Healthcare System , Boston , MA , USA

7 Boston University School of Public Health , Boston , MA , USA

Correspondence Amanda C. Blok, PhD, MSN, RN, PHCNS- BC, Veterans Affairs (VA) Center for Clinical Management Research, Veterans Affairs (VA) Ann Arbor Healthcare System, United States Department of Veterans Affairs, 2215 Fuller Road, Mail Stop 152, Ann Arbor, MI, United States. Email: amanda.blok@va.gov

Funding information This study received funding from Veterans Health Administration: VISN 1 Innovation Grant (T518- 18- 083).

Abstract Aims : To understand nurse leader and manager perspectives on employee engage- ment and their own role to foster engagement. To examine differences between managers of units with high versus low engagement. Background : Health systems recognize the impact of employee engagement, yet alignment of leader and frontline– manager perspectives remains unclear. Methods : A qualitative study at the Veteran Affairs New England Healthcare System. Leaders at five facilities ( N = 13) and managers of units with high and low nurse en- gagement ( N = 31) were interviewed. Results : Nurse leaders almost universally conceptualized staff engagement as in- volvement in quality improvement service, while managers defined engagement as either commitment to excellence in direct patient care or involvement in quality improvement efforts. Intra- and interprofessional attitude contagion, and organisa- tional factors of staffing— time— workload and senior leadership support were most common to support or detract from nurse engagement. A variety of strategies were identified, including protecting nurses as people and professionals. Differences in perceived roles and constraints to engaging nurse staff exist between managers of units with high versus low engagement. Conclusion : Nurse managers and leaders perceive engagement differently; strategies exist to facilitate engagement. Implications for Nursing Management : Leader and manager partnerships are needed to provide clarity on and resources for engagement.

K E Y W O R D S

direct patient care , Nurse engagement , nurse management , organisational leadership , quality improvement

|  J Nurs Manag. 2021;29:1476–1485.wileyonlinelibrary.com/journal/jonm1476

1 |  I N T R O D U C T I O N

Increasing evidence suggests that engaged employees in health care and other professions have a better experience of their work, less ab- senteeism and better job performance (Halbesleben & Wheeler, 2008 ; Imamura et al., 2016 ; Roelen et al., 2015 ). In the nursing profession, engagement is associated with fewer unfavourable job outcomes (dis- satisfaction, burnout and plans to leave organisation), higher ratings of care quality and safety and higher patient satisfaction ratings (Dempsey & Assi, 2018 ; Halbesleben et al., 2010 ; Kutney- Lee et al., 2016 ).

The concept of ‘engagement’ has evolved over time. Schaufeli suggests work engagement manifests as employees’ ‘vigor, dedica- tion, and absorption’ in the work itself (Schaufeli et al., 2002 ). Both Harter and Jenaro describe the engaged employee as in touch with the pulse of the organisation, ‘emotionally connected’ and focused on contributing to and growing with the organisation itself (Harter et al., 2003 ; Jenaro et al., 2011 ). While the former definition em- phasizes individual dedication to the work itself, the later focuses on organisational commitment. These definitions are often used interchangeably, potentially causing confusion on what the change towards engagement would look like and what could be done to en- hance engagement.

The impact of nurse leaders, defined as individuals in executive and leadership positions with broad organisation- level responsi- bilities, on staff engagement has been shown (White et al., 2017 ). Recent work suggests that nurse managers, defined as nurses who are responsible for allocation of staff resources and manage work- load and resources of typically one unit (Dempsey & Assi, 2018 ; Lundgrén- Laine et al., 2013 ; Siirala et al., 2016 ), may have a similarly large influence on staff nurse retention, quality of patient care and nurse work engagement (Conley, 2017 ; García- Sierra et al., 2016 ; Mackoff & Triolo, 2008 ).

Several gaps exist in the nursing engagement literature. First, al- though research has examined nurse leader perceptions— with nurse

engagement generally perceived as improved trust, communication and satisfaction as evidenced by involvement in organisational ini- tiatives for clinical excellence— (George & Massey, 2020 ), there has been less exploration of nurse manager perspectives on engagement. While organisations and nurse leaders are increasingly embracing the task of addressing engagement (Gokenbach & Drenkard, 2011 ; Swensen et al., 2016 ), it is unclear whether academic or organisa- tional definitions of engagement a) reflect the perspectives of nurse managers and b) whether nurse managers and nurse leaders differ in their understandings of engagement. Second, not enough is known about the strategies that successful nurse managers employ to en- gage staff, which impedes the dissemination of best practices to fos- ter staff engagement.

This qualitative project aims to examine the perspectives of nurse leaders and nurse managers on employee engagement, barri- ers and facilitators to nurse engagement, and their own role in fos- tering engagement. We aim to examine differences between nurse leaders’ and managers’ perspectives, and identify engagement prac- tices that may differ between nurse managers of units with high- versus low- engagement scores.

2 |  M E T H O D S

2.1 |  Setting and sample

The Veterans Health Administration (VHA) is the largest integrated health care system in the United States. The New England Health System (NEHS) consists of eight VA medical centres (VAMC) em- ploying 10,000 staff and serving 240,000 veterans each year (US Department of Veteran Affairs, 2019 ). We approached nurse ex- ecutives at all eight VAMCs, and five were able to participate and commit the time of their staff. Facility characteristics are described in Table 1 . Unit- level data are not given to help protect participant

T A B L E 1   Facility- level descriptive characteristics

Facility

Inpatient setting Primary care clinic setting

Total beds

Medical– surgical unit beds

Psychiatric unit beds

Nursing home RN% a   RN HPPD b   RN% a  

RN encounter hours c  

N N N N Mean Mean Mean Mean

National average 268 75 26 96 56.45 5.73 50.8 0.61

range range range range range range range range

Facility 1 400– 500 0– 25 25– 50 300– 350 >25% lower >50% lower Similar Similar

Facility 2 100– 200 0– 25 75– 100 25– 50 >25% lower >50% lower Similar >25% greater

Facility 3 100– 200 50– 75 0– 25 100– 150 >25% lower >50% lower Similar Similar

Facility 4 0– 100 25– 50 0– 25 0– 25 >25% greater >50% greater Similar Similar

Facility 5 100– 200 0– 25 0– 25 100– 150 Similar Similar Similar Similar

a %RN: Nurse skill- mix measure (per cent of registered nurses in nursing workforce), calculated RN/(RN + LPN+NA). b HPPD: Empirically derived workload ‘hours per patient day’ measure for inpatient setting. c RN encounter hours: Empirically derived workload measure for clinic setting.

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identity. All interviews were conducted in the Spring and Summer of 2018. Interviews with nurse leaders— the nurse executive and other nurse leaders focused on facility- wide initiatives— and nurse manag- ers in charge of clinical units occurred at each facility.

Nurse leaders included nurse executives, associate directors of patient care and chiefs or heads of quality management, pa- tient safety and informatics; those who self- identified as impact- ing nurse engagement at the facility level and volunteered for interview. Nurse managers were chosen based on unit- level staff engagement scores. An annual survey of all employees (Osatuke et al., 2012 ) measures staff engagement, defined as ‘the employ- ees’ sense of purpose that is evidenced in their display of dedica- tion, persistence, and effort in their work and overall attachment to their organisation and its mission’, (US Office of Personnel Management, 2015 ). The Employee Engagement Index (EEI) from the annual survey is an eight- item scale developed by the VA in 2016 that measures self- reported agreement to statements on

employees’ feelings about the organisation and personal connec- tion to the work (Appendix S1 ). Using unit- level data of EEI, we identified highly engaged units and less engaged units at each facility. For organisational grounding, the NEHS average score was used to classify a unit as ‘high’ if above the average score and ‘low’ if below the average. If the majority of the units at a facility were lower than the NEHS average, then the VHA national av- erage score was used to identify ‘high’ and ‘low’ units. We then selected managers to interview, targeting the three ‘highest’ and three ‘lowest’ units by facility ( N = 30). We interviewed 13 lead- ers at 5 hospitals and 31 nurse managers on 32 units— with one manager cross- covering two units. We attempted to interview an equal amount of nurse managers with highly engaged staff and less engaged staff at each facility (Table 2 ). Due to missing data on unit engagement for five units, we omitted five managers of the thirty- one interviewed when analysing the high ( N = 12) and low ( N = 14) engagement units.

T A B L E 2   Nurse workgroup differences in engagement and supervisory support

Engagement level

No. of nurse manager interviews

No. of nurses in work groups Types of workgroups

Engagement Supervisor support

Mean ( SD ) Mean ( SD )

National N /A 38,262 All nurse respondents 4.02 (0.68) 3.85 (1.11)

NEHS a   N /A 1,482 All nurse respondents 4.12 (0.62) 3.97 (1.06)

Facility 1

High 2 54 Community living centre, inpatient unit, hospice unit

4.15 (0.67) 4.45 (0.80)

Low 4 24 Short- term stay unit, long- term care unit, serious mental illness unit

3.80 (0.75) 3.52 (1.21)

Facility 2 b  

High 3 30 Inpatient PTSD unit, acute psych and detox unit, primary care clinics

4.34 (0.60) 4.35 (0.75)

Low 2 16 Primary care clinics with specialty clinics, long- term care unit and sub- acute psych unit

4.10 (0.54) 3.88 (0.89)

Facility 3 b  

High 1 8 Department of medicine and specialty clinics 4.11 (0.56) 4.25 (0.80)

Low 3 43 Urgent care, community living centre, primary care clinic

3.67 (0.59) 3.73 (1.09)

Facility 4

High 3 45 Same- day surgery unit, medical– surgical unit, emergency department

4.12 (0.78) 3.71 (1.12)

Low 3 9 Specialty clinics, mental health clinics, operating room

3.81 (0.75) 3.26 (1.25)

Facility 5 b  

High 3 43 Medical– surgical unit, home telehealth, mental health clinic

4.09 (0.53) 3.96 (0.90)

Low 2 32 Inpatient hospice unit, dementia long- term care unit

3.63 (0.69) 3.41 (1.08)

a NEHS: New England Healthcare System b We interviewed additional managers at these facilities, yet the managers’ workgroups did not have adequate numbers of nurses responding to the survey (< 5 nurses) for confidence in a ‘high’ or ‘low’ rating to include in comparative qualitative analysis.

|     BLOK ET AL.1478

The research study protocol was approved by the VA Boston Healthcare System.

2.2 |  Data collection

One in- person, individual, semi- structured interview was conducted with each participant at their facility by a nurse scientist (AB). The initial interview guide contained questions informed by a priori cat- egories derived from an overview of the existing literature on engage- ment and included questions on the following: (1) understanding of staff engagement, (2) perceptions of barriers and facilitators to staff engagement and (3) perceptions of the nurse manager role in foster- ing engagement (see Appendix S2 ). After the first several interviews, we revised the interview guide inductively to incorporate novel topics brought up by project participants. Interviews were audio- recorded for transcription and generally lasted between 30 and 45 min.

2.3 |  Analysis

Our multidisciplinary qualitative team consisted of a nurse sci- entist (AB), an anthropologist (EA) and a physician- scientist (LS). Our analysis strategy was informed by the framework analysis ap- proach, a form of qualitative content analysis (Gale et al., 2013 ). After we independently reviewed a sample of transcripts ( N = 4) to gain a deeper understanding of the data, we met as a group to develop an initial codebook. The codebook comprised both overarching domains derived from the study questions (defini- tions of engagement, facilitators of engagement, strategies for engagement, etc.) and specific codes for a priori and emergent categories within each domain (e.g. engagement as involvement in QI). Individual coders then applied the draft codebook to a second group of interviews ( N = 13), meeting regularly to refine and finalize the code structure. The remaining interviews ( N = 27) were coded by team members independently. Regular meetings were used to resolve questions or disagreements (Cook, 2011 ; Hill et al., 2005 ).

To facilitate analysis, a summary of information and illustra- tive examples pertinent to each category was abstracted for each interviewee into the matrix form. The team reviewed the resulting matrices to analyse the content of each category, identifying differ- ences and similarities across interviewees. Theoretical saturation was reached, which was determined retrospectively; that is, no new concepts were identified after analysing matrix data for the last few interviewees (Saunders et al., 2018 ).

3 |  R E S U LT S

Nurse leaders and managers involved in the qualitative project ( N = 44) were 93.0% white, 81.4% women, an average of 51 years of age and had an average of 10 years of VA service (Table 3 ). Below, we summarize findings for four categories of analysis: definitions

of engagement, perceptions of leadership ' s role in staff engage- ment, perceived barriers and facilitators of staff engagement and described strategies for engagement. For each area of inquiry, we further contrast the responses of managers with highly engaged staff and less engaged staff (see Table 4 for comparison; Appendices S3- S7 for illustrative quotes).

3.1 |  Defining engagement

Regarding our first research question on how nurse leaders and man- agers interpret engagement, we discovered that interviewees lacked a unified definition of engagement. Nurse leaders almost universally conceptualized staff engagement as involvement in quality improve- ment (QI) service (either formal or informal, unit level or facility level), while nurse managers defined engagement as either commitment to excellence in direct patient care or involvement in QI efforts.

High versus low- engaged units Over a third of managers ( N = 10) perceived nurse engagement to include multiple facets, including QI work, direct patient care and/or togetherness as engagement (Appendix S3 ). Multiple man- agers directly juxtaposed and contrasted direct patient care and QI service. Among participants whose perspective on engagement was patient care- focused, they explicitly framed QI work as an obligation that competes for the nurses’ attention. For example, ‘[Nurse staff] look to this whiteboard project as just something else they are asking us to do when we don ' t have time for anything’ (Manager 3).

Managers of highly engaged units primarily considered QI ser- vice (formal or informal) as an indication of nurse staff engagement. Managers of less engaged units primarily perceived excellence in direct patient care as an indication of nurse staff engagement. Perception of nurse engagement as a sense of togetherness was present, but infrequent.

3.2 |  Leadership for staff engagement

Both managers and leaders agreed that the role of nurse manager sets the tone of the unit ' s culture to either promote or hamper en- gagement. Managers and leaders described techniques to engage staff that aligned well with their self- identified or inferred style: traditional management, servant leadership, coaching or directive management styles (Appendix S4 ). Traditional management tech- niques typically included information distribution, staff- led solu- tions and general support for staff in their work. Servant leaders commonly gave staff time, support and resources to help the staff do the best job they could. Coaching- oriented leaders generally in- vested in individual staff members by considering their professional development and their progression in their field or in the depart- ment. Managers with a directive style provided staff with decisive directions for action and few options, expecting prompt compliance and little flexibility.

     |  BLOK ET AL. 1479

High- versus low- engaged units The servant leadership style, defined as managers that ‘help build and give the resources that [staff] need to actually do the work’ (Manager 28), was commonly found in managers of highly engaged units (50%), while traditional management, defined as managers that ‘figure out how to take [leadership ' s directive] in- formation and sort it out correctly at the frontline’ (Manager 14), was most commonly found in low- engaged units (42%). Coaching as a style of nurse manager leadership was slightly more likely in highly engaged units than low- engaged units (25% versus 17%). There were few managers found embodying a directive manage- ment style.

3.3 |  Barriers and facilitators for staff engagement

When asked what drives and hampers engagement in nurses, re- sponses largely fell into three categories: (1) the individual level, (2) the unit or workplace level and (3) the organisational level.

3.3.1 |  Individual- level barriers and facilitators

Internal motivation was a common individual- level factor influenc- ing engagement, as described by nurse managers and leaders alike. For these interviewees, engaged staff nurses are ‘generally internally motivated’ (Leader 1) and ‘have a more positive attitude and… just want to make improvements’ (Manager 13). Conversely, the lack of internal motivation, or a ‘negative attitude’, was described as a major barrier to engagement by numerous respondents. A negative atti- tude was typically associated with resistance to changing practice, as exemplified in one statement that ‘certain people are just set against change and they just [keep] saying things and making comments’ (Manager 2).

High- versus low- engaged units Positive attitude and the perceived ability to enact change on a unit were cited as facilitators for engagement in both high- and low- engaged units (Appendix S5 ). Managers in highly engaged units were more likely to describe engaged nurses as those with a sense

T A B L E 3   Demographic and clinical practice characteristics of nurse interview participants

All nurses a   N = 44

All nurses

Nurse leaders N = 13 (30.0%)

Nurse managers N = 31 (70.0%)

N % N % N %

Demographic characteristics

Age (years), mean ( SD ) 51 (8.8) 52.2 (10.2) 51.0 (8.4)

Age range 32– 72 32– 63 33– 72

Gender

Male 8 18.6 2 15.4 6 20.0

Female 35 81.4 11 84.6 24 80.0

Race/ethnicity

White 40 93.0 11 84.6 29 96.7

African American 1 2.3 1 7.7 0 0.0

Hispanic 2 4.6 1 7.7 1 3.3

Highest degree obtained

Associates degree (AD) 2 4.6 0 0.0 2 6.7

Bachelor of science in nursing (BSN)

17 39.5 3 23.1 14 46.7

Master of science in nursing (MSN)

24 55.8 10 76.9 14 46.7

Clinical practice characteristics

Mean ( SD ) Mean ( SD ) Mean ( SD )

Years of nurse experience 20.5 (9.5) b   23.6 (11.1) 19.1 (8.6)

VA tenure (years) 10.3 (9.4) 12.8 (11.3) 9.3 (8.4)

Work hours per week 47.9 (7.4) 49.1 (7.7) 47.3 (7.3)

Note : All demographic characteristics had less than a 5% missing data, unless otherwise specified. a This data represents our entire sample of interviewees in this study. ; b N = 7 missing.

|     BLOK ET AL.1480

of personal responsibility and mission (33%), while managers of low- engagement units were more likely to attribute engagement to in- herent motivation or personality (36%). Negative staff attitude was the most common barrier cited by both high- and low- engaged unit managers. However, references to task orientation or ‘punching the clock’ (36%), and a lack of interest in career development (14%) were uniquely present in less engaged units.

3.3.2 |  Unit- level barriers and facilitators

Interviewees also described several unit- level facilitators and barri- ers, which primarily can be described as intra- and interprofessional attitude contagion. Nurse managers and leaders alike described how both the positive and the negative attitude of individual nurses can spread to the rest of the staff. Contagion metaphors were common in these accounts. For example, a nurse manager commented, ‘I know a can- do attitude is contagious’, adding that positive attitude can ‘[pull] people into change and [help] them to sustain change’ (Manager 8). Negative attitude, in turn, was also presented as conta- gious and able to ‘spread like cancer throughout the team’ (Manager 14), as well as a barrier to change: ‘Yeah they don ' t like a lot of change and they… don ' t see yet that is for the better, you know, it ' s gonna really make their lives easier’ (Manager 1). Supportive attitude and communication by physicians were seen as key to nurse engage- ment, with miscommunication as detrimental to engagement: ‘I feel like if the providers were not open to engaging with staff and having conversations and at least considering their ideas, then that would totally change the milieu up here’ (Manager 31).

High- versus low- engaged units Compared to high- engaged units, managers of low- engaged units cited unit- level barriers to nurse engagement more heavily (64%). These included negative attitude contagion, intrapersonal con- flict, resistance to change, burnout, rumours, miscommunication and more (Appendix S6 ; Unit- level). References to interprofes- sional tensions and communication difficulties as barriers to en- gagement were common in both high (50%)- and low- engagement units (57%), with more reported inappropriate communication and transfer of workload present in less engaged units (Appendix S6 ; Interdisciplinary- level).

3.3.3 |  Organisational barriers and facilitators

Organisation- level barriers and facilitators to engagement were fre- quently mentioned— most prominently the themes of (1) staffing, time, and workflow/workload; and (2) senior leadership attitude and support. Most of our interviewees referred to the lack of time as a major obsta- cle, often explicitly attributing this to insufficient staffing levels and/ or excessive workloads. These responses often highlighted the tension between engagement as direct patient care or as process improve- ment work described above. For instance, a nurse leader rhetorically

T A B L E 4   Emergent themes by topic, by high and low levels of engagement

Theme High engagement unit

Low- engagement unit

What engagement is, by high and low levels of engagement

(N = 12) (N = 14)

Direct patient care N = 4, 33% N = 6, 43%

Informal local improvement

N = 4, 33% N = 4, 29%

Formal QI process improvement

N = 6, 50% N = 5, 36%

Togetherness N = 2, 17% N = 1, 7%

Manager leadership style, by high and low levels of engagement

(N = 12) (N = 12)

Traditional management

N = 3, 25% N = 5, 42%

Servant leadership N = 6, 50% N = 4, 33%

Coaching N = 3; 25% N = 2; 17%

Directive management N = 2, 17% N = 2, 17%

Individual barriers and facilitators to nurse engagement

(N = 12) (N = 14)

Facilitators N = 10, 83% N = 12, 86%

Barriers N = 6, 50% N = 10, 71%

Organisational barriers and facilitators to nurse engagement

(N = 12) (N = 14)

Unit- level facilitators N = 3, 25% N = 3, 21%

Unit- level barriers N = 2, 17% N = 9, 64%

Interdisciplinary facilitators

N = 1, 8% N = 2, 14%

Interdisciplinary barriers

N = 6, 50% N = 8, 57%

Leadership- influenced facilitators

N = 3, 25% N = 5, 36%

Leadership- influenced barriers

N = 11, 92% N = 8, 57%

Nurse manager strategies for involving staff

(N = 12) (N = 14)

Involve all staff in unit conversations and activities

N = 5, 42% N = 4, 28%

Empower staff to be involved in QI service

N = 7, 58% N = 2, 14%

Recognition N = 7, 58% N = 2, 14%

Give responsibility N = 3, 25% N = 1, 7%

Rewards/incentives N = 4, 33% N = 0

Lead by example/role model

N = 2, 17% N = 5, 36%

Listen to nurse staff N = 3, 25% N = 4, 28%

Notes : Illustrative quotes for each of these categories are found in Appendices C through F. Numbers indicate comment by nurse manager, who may have multiple comments per category (or none). 5 nurse managers had a combination of different types of perceived roles and were counted in both categories they fall under.

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asked, ‘How do you get staff engaged when they can ' t get off the floor?’ (Leader 10). In this context, nurses are bound to be ‘totally focused on the most… basic nursing functions, most basic needs for themselves’ and unable to ‘implement this great new thing’ (Leader 11). Leadership- enabled time, support, flexible schedules and overtime for staff were seen as facilitators to engagement by managers. ‘The Director, Nurse Executive; they ' re very visible. And I will say the Director has the most unbelievably positive attitude. So, it can be catching’, (Manager 13).

High- versus low- engaged units Positive leadership attitude was observed to be an important facili- tator and low leadership visibility a barrier of engagement for low- engagement units (Appendix S6 ; Leadership- level). The majority of high- engaged unit managers perceived staffing shortages as affect- ing engagement (58%), as well as many reporting a lack of protected time and overwork. Low- engaged unit managers reported similar yet fewer leadership- level barriers to nurse engagement.

3.4 |  Strategies for engagement

There was a wide variety of strategies described by nurse leaders and managers as effective in engaging their staff, boosting nurse morale, as well as protecting and supporting nurses as people and professionals. Many leaders and managers thought broadly and creatively in their attempts to engage staff. As one nurse manager quipped, ‘I ' m trying to be creative in ways that I can engage my em- ployees through any opportunity I can…’ (Manager 7).

High- versus low- engaged units Managers with highly engaged staff were more likely to report ef- forts to boost nurse morale by giving recognition to nurses (58%), empower staff to be involved in QI service (58%), working to involve all staff— including staff with ‘negative’ attitudes— in unit- level con- versations and activities (42%), giving rewards or incentives (33%) and assigning responsibility for solutions to staff (25%) than man- agers of low- engagement units (Appendix S7 ). Managers with less engaged staff were more likely to report that they attempt to act as a role model or to ‘lead by example’ to engage staff (36%). Both high- and low- engaged unit managers enacted strategies to protect and support staff as individuals (emotional support, protecting work/life balance), as professionals (mediate interdisciplinary conflict, advo- cate for staff needs/workload) and as team members (team building, boosting team spirit).

4 |  D I S C U S S I O N

This project provides a novel and nuanced perspective on nurse en- gagement. Our findings from nurse leader and manager interviews reveal differences in understanding what engagement is, and differ- ences between managers with highly engaged staff versus less en- gaged staff on perceived roles and constraints to engaging nurse staff.

4.1 |  Nurse engagement

The difference between leader and manager understanding of en- gagement, and newfound tension between the two understand- ings, may be a source of miscommunication between managers and leaders looking to impact engagement. Addressing the relationship with direct patient care (DPC) and QI service could help clarify nurse roles and work expectations. For example, senior organisational leaders can affirm common nurse staff and manager understanding of engagement with a clear message that high- quality patient care matters greatly, but it cannot exist without QI. As managers have suggested, making QI service directly relatable to DPC and a unit ' s perceived needs could greatly reduce resistance and openness to change.

4.2 |  Manager perceptions of engagement

We found that managers with highly engaged staff were more likely to view engagement as modifiable and saw engagement as relating to having a sense of responsibility and mission. In contrast, managers with less engaged staff viewed engagement as an inherent attitude related to a specific type personality. Promoting a view of engage- ment as an emergent and modifiable, rather than inherent and fixed, attitude can empower managers to action.

Several strategies could help managers with less engaged staff, including providing evidence that engagement is modifiable and motivating managers to modify engagement on their units. For example, White and colleagues tested a senior leadership- led QI initiative which resulted in significant change in nurse staff work engagement levels compared to controls (White et al., 2017 ). Unit- level intervention to identify core personal values and enable a broader sense of the unit and its resources could reduce nurses’ perception of threat around change and engagement in work (Cohen & Sherman, 2014 ).

4.3 |  Unit culture

Managers of low- engaged units reported far more unit- level barriers, while managers of highly engaged units reported more organisation- level barriers. One of the major barriers was a negative unit culture: where negative attitudes are contagious, there are high levels of interpersonal conflict and resistance to change. Negative attitudes have been identified by managers in the past as a roadblock to QI work (Price et al., 2007 ).

Unit- level facilitators and barriers of communication and cul- ture, as well as organisational facilitators of leadership support and available resources, reflect the ‘inner setting’ determinants of mid- dle managers ability to implement evidence- based practices (Birken et al., 2018 ). As far as we know, many barriers to a good unit climate for nurse engagement identified in this project, such as contagious negative attitudes, task orientation of ‘punching the clock’, a lack of

|     BLOK ET AL.1482

career development, inappropriate communication from interpro- fessional colleagues and interprofessional transfer of workload as barriers to nurse engagement, are complementary, yet not currently integrated into Birken ' s model for implementation. We posit that these barriers can be addressed to support a climate open to prac- tice improvement.

4.4 |  Manager strategies for engagement

Strategies used by nurse managers in low- engaged units, such as leading by example, have mixed support in organisational literature (Goleman, 2000 ; Posner & Kouzes, 1988 ). Managers with highly en- gaged staff were more likely to use a servant leadership style, which involves a service orientation and communicating a vision for their unit (Waterman, 2011 ). Further, nurse recognition, empowerment to be involved in QI, involvement of all staff and rewards or incen- tives were employed by a third to half of managers with highly en- gaged staff, while these were noticeably absent in managers with low- engaged staff. Managers can be empowered and motivated to include these strategies for staff engagement.

4.5 |  Leadership strategies for engagement

Senior leaders may consider providing sustainable organisational support for time, resource and educational support, flexible sched- ules and overtime pay for staff seeking to better the organisation through DPC and QI services. Leaders and managers have the op- portunity to identify and address resource needs together for organi- sational priorities to move forward. Senior leadership can also clarify the career advancement process for staff, as well as provide clear pathways for advancement opportunities. Additionally, senior lead- ers can equip managers to address the heavily reported unit- level barriers by providing training and leadership- supported power to en- gage staff through mediation techniques for intrapersonal and inter- professional conflict, overcoming resistance to change and stopping the spread of rumours, miscommunication and attitude contagion. Lastly, senior leaders can work towards building trust and autonomy for nurse staff with their colleagues (Antoinette Bargagliotti, 2012 ), which may be as simple as ensuring positive leader attitudes.

4.6 |  Practice change

Our findings suggest that competing demands faced by manag- ers can influence staff engagement and a unit ' s culture conducive to practice change (Birken et al., 2018 ). If organisations are inter- ested in expanding nurses’ involvement in QI, leaders can promote change by providing resources and recognition for nurses engaged in this ‘extra work’. (Melnyk et al., 2016 ). Preparing nurses to incor- porate QI integration and evaluation into practice has largely been absent in nurse education for a decade (Cox Sullivan et al., 2017 ),

with hospitals incurring extensive costs in training for new gradu- ates (Greene, 2010 ). Including education support for QI service in- tegration may be a helpful strategy for trainees. Leading thinkers in nurse education have put forward a solution for colleges and or- ganisations to ‘train nurses to be lifelong expert learners and reflec- tive practitioners’ (Benner, 2012 ). A nurse- specific model to link QI service with DPC as a part of the nurse role is an evidence- based template that training programmes in colleges and organisations can put forward to guide the development of nurses in their organisation (Fletcher & Meyer, 2016 ).

4.7 |  Limitations and future research

The data used for this project were solely from the VHA and may not be generalizable outside of the organisation. The five facili- ties involved may not be representative of all perspectives, but saturation of themes was met. Additionally, it is possible that nurse leadership may have discovered which managers participated due to logistical scheduling of the on- site visit, yet we have reported results in a way that does not link leader or manager to a facility or unit. Nurse leaders and managers are known to rate their own posi- tive leadership qualities higher than staff, with leader and manager perspectives absent of staff perceptions as a limitation (Dunham & Klafehn, 1990 ; Dunham- Taylor, 2000 ; McDaniel & Wolf, 1992 ). Our findings are based on our interpretation of interview themes, which we acknowledge may be subject to interpretation bias. Future re- search could interview nurse staff from both high- and low- engaged units to ask their perceptions on nurse engagement, and facilitators or barriers to DPC and QI. Additionally, gaining patient and fam- ily member perspectives on what they perceive an engaged nurse and their work to look like would assist in understanding nurse engagement.

5 |  C O N C L U S I O N

Nurse leaders and managers have differences in understanding what engagement is. Clarifying the relationship with direct patient care (DPC) and QI service to staff could clarify roles and expectations. Additionally, the perspective of engagement to be modifiable and strategies employed to engage staff— including recognition, empow- erment, involvement and rewards or recognition— were present in managers with highly engaged staff and absent with those with less engaged staff. Nurse leaders and managers could iteratively identify and address resources needed for staffing and engagement.

6 |  I M P L I C AT I O N S F O R N U R S I N G M A N A G E M E N T

Leader and manager partnerships are needed. Senior leaders may consider providing sustainable organisational support for time,

     |  BLOK ET AL. 1483

support, flexible schedules and overtime for staff seeking to better the organisation through direct patient care and quality improve- ment services. Leaders and managers could identify and address re- source and informational needs together for organisational priorities to move forward. Managers have the opportunity to recognize the modifiable nature of engagement, and utilize identified styles and strategies for improvement.

E T H I C A L A P P R O VA L This study (3292- X) was approved by the VA Boston Healthcare System Research & Development Committee.

D I S C L A I M E R The contents of this paper do not represent the views of the U.S. Department of Veterans Affairs or the United States Government.

A C K N O W L E D G E M E N T S Thank you to the nurse managers and leaders of the VA New England Healthcare System (NEHS) for their time and support. This material is the result of work supported with resources and the use of facili- ties at the Bedford and Boston VA Healthcare Systems.

C O N F L I C T O F I N T E R E S T The authors have no conflict of interest to declare.

O R C I D Amanda C. Blok https://orcid.org/0000-0002-5329-0393 Ekaterina Anderson https://orcid.org/0000-0001-7109-3054 Lakshman Swamy https://orcid.org/0000-0002-4680-0906 David C. Mohr https://orcid.org/0000-0002-3184-6338

R E F E R E N C E S Antoinette Bargagliotti , L. ( 2012 ). Work engagement in nursing: A con-

cept analysis . Journal of Advanced Nursing , 68 ( 6 ), 1414 – 1428 . https:// doi.org/10.1111/j.1365- 2648.2011.05859.x

Benner , P. ( 2012 ). Educating nurses: A call for radical transformation— how far have we come? Journal of Nursing Education , 51 ( 4 ), 183 – 184 .

Birken , S. , Clary , A. , Tabriz , A. A. , Turner , K. , Meza , R. , Zizzi , A. , Larson , M. , Walker , J. , & Charns , M. ( 2018 ). Middle managers ' role in im- plementing evidence- based practices in healthcare: A systematic review . Implementation Science , 13 ( 1 ), 149 . https://doi.org/10.1186/ s1301 2- 018- 0843- 5

Cohen , G. L. , & Sherman , D. K. ( 2014 ). The psychology of change: Self- affirmation and social psychological intervention . Annual Review of Psychology , 65 , 333 – 371 . https://doi.org/10.1146/annur ev- psych - 01021 3- 115137

Conley , K. A. ( 2017 ). Nurse manager engagement: strategies to enhance and maintain engagement . Journal of Nursing Administration , 47 ( 9 ), 454 – 457 . https://doi.org/10.1097/NNA.00000 00000 000513

Cook , K. E. ( 2011 ). Reliability assessments in qualitative health promo- tion research . Health Promotion International , 27 ( 1 ), 90 – 101 . https:// doi.org/10.1093/heapr o/dar027

Cox Sullivan , S. , Norris , M. R. , Brown , L. M. , & Scott , K. J. ( 2017 ). Nurse manager perspective of staff participation in unit level shared gov- ernance . Journal of Nursing Management , 25 ( 8 ), 624 – 631 . https://doi. org/10.1111/jonm.12500

Dempsey , C. , & Assi , M. J. ( 2018 ). The impact of nurse engagement on quality, safety, and the experience of care: What nurse leaders should know . Nursing Administration Quarterly , 42 ( 3 ), 278 – 283 . https://doi. org/10.1097/NAQ.00000 00000 000305

Dunham , J. , & Klafehn , K. A. ( 1990 ). Transformational leadership and the nurse executive . Journal of Nursing Administration , 20 ( 4 ), 28 – 34 . https://doi.org/10.1097/00005 110- 19900 4000- 00007

Dunham- Taylor , J. ( 2000 ). Nurse executive transformational lead- ership found in participative organizations . Journal of Nursing Administration , 30 ( 5 ), 241 – 250 . https://doi.org/10.1097/00005 110- 20000 5000- 00005

Fletcher , K. A. , & Meyer , M. ( 2016 ). Coaching Model + Clinical Playbook = Transformative Learning . Journal of Professional Nursing , 32 ( 2 ), 121 – 129 . https://doi.org/10.1016/j.profn urs.2015.09.001

Gale , N. K. , Heath , G. , Cameron , E. , Rashid , S. , & Redwood , S. ( 2013 ). Using the framework method for the analysis of qualitative data in multi- disciplinary health research . BMC Medical Research Methodology , 13 , 117 . https://doi.org/10.1186/1471- 2288- 13- 117

García- Sierra , R. , Fernández- Castro , J. , & Martínez- Zaragoza , F. ( 2016 ). Work engagement in nursing: An integrative review of the litera- ture . Journal of Nursing Management , 24 ( 2 ), E101 – 111 . https://doi. org/10.1111/jonm.12312

George , V. , & Massey , L. ( 2020 ). Proactive Strategy to improve staff en- gagement . Nurse Leader , 18 ( 6 ), 532 – 535 . https://doi.org/10.1016/j. mnl.2020.08.008

Gokenbach , V. , & Drenkard , K. ( 2011 ). The outcomes of magnet environ- ments and nursing staff engagement: A case study . Nursing Clinics , 46 ( 1 ), 89 – 105 . https://doi.org/10.1016/j.cnur.2010.10.008

Goleman , D. ( 2000 ). Leadership that gets results . Harvard Business Review , 78 ( 2 ), 4 – 17 .

Greene , M. A. ( 2010 ). Paying for nursing orientation: A huge cost to hos- pitals . Journal for Nurses in Professional Development , 26 ( 6 ), E3 – E7 . https://doi.org/10.1097/NND.0b013 e3181 fc0459

Halbesleben , J. R. , Savage , G. T. , Wakefield , D. S. , & Wakefield , B. J. ( 2010 ). Rework and workarounds in nurse medication administration process: Implications for work processes and patient safety . Health Care Management Review , 35 ( 2 ), 124 – 133 . https://doi.org/10.1097/ HMR.0b013 e3181 d116c2

Halbesleben , J. R. , & Wheeler , A. R. ( 2008 ). The relative roles of en- gagement and embeddedness in predicting job performance and intention to leave . Work & Stress , 22 ( 3 ), 242 – 256 . https://doi. org/10.1080/02678 37080 2383962

Harter , J. K. , Schmidt , F. L. , & Killham , E. A. ( 2003 ). Employee engage- ment, satisfaction, and business- unit- level outcomes: A meta- analysis . Princeton, NJ : Gallup Organization .

Hill , C. E. , Knox , S. , Thompson , B. J. , Williams , E. N. , Hess , S. A. , & Ladany , N. ( 2005 ). Consensual qualitative research: An update . Journal of Counseling Psychology , 52 ( 2 ), 196 . https://doi.org/10.1037/002 2- 0167.52.2.196

Imamura , K. , Kawakami , N. , Inoue , A. , Shimazu , A. , Tsutsumi , A. , Takahashi , M. , & Totsuzaki , T. ( 2016 ). Work engagement as a pre- dictor of onset of Major Depressive Episode (MDE) among workers, independent of psychological distress: A 3- year prospective cohort study . PLoS One , 11 ( 2 ), e0148157 . https://doi.org/10.1371/journ al.pone.0148157

Jenaro , C. , Flores , N. , Orgaz , M. B. , & Cruz , M. ( 2011 ). Vigour and ded- ication in nursing professionals: Towards a better understanding of work engagement . Journal of Advanced Nursing , 67 ( 4 ), 865 – 875 . https://doi.org/10.1111/j.1365- 2648.2010.05526.x

Kutney- Lee , A. , Germack , H. , Hatfield , L. , Kelly , S. , Maguire , P. , Dierkes , A. , Del Guidice , M. , & Aiken , L. H. ( 2016 ). Nurse engagement in shared governance and patient and nurse outcomes . Journal of Nursing Administration , 46 ( 11 ), 605 – 612 . https://doi.org/10.1097/ NNA.00000 00000 000412

|     BLOK ET AL.1484

Lundgrén- Laine , H. , Kontio , E. , Kauko , T. , Korvenranta , H. , Forsström , J. , & Salanterä , S. ( 2013 ). National survey focusing on the crucial information needs of intensive care charge nurses and intensivists: Same goal, different demands . BMC Medical Informatics and Decision Making , 13 , 15 . https://doi.org/10.1186/1472- 6947- 13- 15

Mackoff , B. L. , & Triolo , P. K. ( 2008 ). Why do nurse managers stay? Building a model of engagement: Part 1, dimensions of engage- ment . Journal of Nursing Administration , 38 ( 3 ), 118 – 124 . https://doi. org/10.1097/01.NNA.00003 10727.43289.53

McDaniel , C. , & Wolf , G. A. ( 1992 ). Transformational leadership in nurs- ing service. A test of theory . Journal of Nursing Administration , 22 ( 2 ), 60 – 65 . https://doi.org/10.1097/00005 110- 19920 2000- 00027

Melnyk , B. M. , Gallagher- Ford , L. , Thomas , B. K. , Troseth , M. , Wyngarden , K. , & Szalacha , L. ( 2016 ). A study of chief nurse executives indicates low prioritization of evidence- based practice and shortcomings in hospital performance metrics across the United States . Worldviews Evid Based Nurs , 13 ( 1 ), 6 – 14 . https://doi.org/10.1111/wvn.12133

Osatuke , K. , Draime , J. , Moore , S. C. , Ramsel , D. , Meyer , A. , Barnes , S. , Belton , S. , & Dyrenforth , S. R. ( 2012 ). Organization development in the department of veterans affairs . The Praeger Handbook of Veterans Health: History, Challenges, Issues and Developments , 4 , 21 – 76 .

Posner , B. Z. , & Kouzes , J. M. ( 1988 ). Development and validation of the leadership practices inventory . Educational and Psychological Measurement , 48 ( 2 ), 483 – 496 . https://doi.org/10.1177/00131 64488 482024

Price , M. , Fitzgerald , L. , & Kinsman , L. ( 2007 ). Quality improve- ment: The divergent views of managers and clinicians . Journal of Nursing Management , 15 ( 1 ), 43 – 50 . https://doi. org/10.1111/j.1365- 2934.2006.00664.x

Roelen , C. , van Hoffen , M. , Groothoff , J. , De Bruin , J. , Schaufeli , W. , & van Rhenen , W. ( 2015 ). Can the Maslach Burnout Inventory and Utrecht Work Engagement Scale be used to screen for risk of long- term sickness absence? International Archives of Occupational and Environmental Health , 88 ( 4 ), 467 – 475 . https://doi.org/10.1007/ s0042 0- 014- 0981- 2

Saunders , B. , Sim , J. , Kingstone , T. , Baker , S. , Waterfield , J. , Bartlam , B. , Burroughs , H. , & Jinks , C. ( 2018 ). Saturation in qualitative re- search: Exploring its conceptualization and operationalization . Quality & Quantity , 52 ( 4 ), 1893 – 1907 . https://doi.org/10.1007/s1113 5- 017- 0574- 8

Schaufeli , W. , Salanova , M. , Gonza ' lez- Roma , V. , & Bakker , A. ( 2002 ). The measurement of engagement and burnout: A two sample

confirmatory factor analytic approach . Journal of Happiness studies , 3 ( 1 ), 71 – 92 .

Siirala , E. , Peltonen , L. M. , Lundgrén- Laine , H. , Salanterä , S. , & Junttila , K. ( 2016 ). Nurse managers ' decision- making in daily unit operation in peri- operative settings: A cross- sectional descriptive study . Journal of Nursing Management , 24 ( 6 ), 806 – 815 . https://doi.org/10.1111/ jonm.12385

Swensen , S. , Kabcenell , A. , & Shanafelt , T. ( 2016 ). Physician- organization collaboration reduces physician burnout and promotes engagement: The Mayo Clinic experience . Journal of Healthcare Management , 61 ( 2 ), 105 – 127 . https://doi.org/10.1097/00115 514- 20160 3000- 00008

US Department of Veteran Affairs ( 2019 ). VISN 1: VA New England Healthcare System . https://www.va.gov/direc tory/guide/ facil ity. asp?id=1001

US Office of Personnel Management ( 2015 ). Engaging the federal work- force: How to do it & prove it . Retrieved from https://admin.govex ec.com/media/ gbc/docs/pdfs_edit/engag ing _the_feder al_workf orce_white_paper.pdf

Waterman , H. ( 2011 ). Principles of ‘servant leadership’ and how they can enhance practice . Nursing Management , 17 ( 9 ). https://doi. org/10.7748/nm2011.02.17.9.24.c8299

White , M. , Butterworth , T. , & Wells , J. S. ( 2017 ). Healthcare Quality Improvement and ' work engagement ' ; concluding results from a na- tional, longitudinal, cross- sectional study of the ' Productive Ward- Releasing Time to Care ' Programme . BMC Health Serv Res , 17 ( 1 ), 510 . https://doi.org/10.1186/s1291 3- 017- 2446- 2

S U P P O R T I N G I N F O R M AT I O N Additional supporting information may be found online in the Supporting Information section.

How to cite this article: Blok AC , Anderson E , Swamy L , Mohr DC . Comparing nurse leader and manager perceptions of and strategies for nurse engagement using a positive deviance approach: A qualitative analysis . J Nurs Manag . 2021 ; 29 : 1476 – 1485 . https://doi.org/10.1111/jonm.13301

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