Purpose: Examine the relationships among nurse manager leadership, ambulatory and emergency care nurse workforce characteristics, and patient quality of care.

Background/significance: Nurse managers are responsible for leading nurses and the nursing care provided in their assigned departments. There is growing evidence reporting the influence of nurse manager workload and competence to direct care nurses’ job satisfaction, intent to stay, and the acute care work environment. Few studies have examined the relationship among the nurse manager, direct care nurse outcomes, and quality of care in the ambulatory care settings. Given the importance of nurse retention and quality of patient care, we sought to examine these variables in ambulatory and emergency care settings.

Methods: Data from the 2022 National Database of Nursing Quality Indicators (NDNQI) nurse surveys and clinical indicators were used to examine the relationships among the variables. Nurse manager leadership was measured using the Nurse Manager Ability, Leadership and Support (NMALS) subscale of the practice environment scale of the Nurse Work Index (PES). The 5 items quantify the presence of each item in the nurses’ work environment using a 5-point Likert scale. NDNQI survey items included intent to stay in the same position for the next year, missed nursing care, and nurse-assessed quality of care. NDNQI clinical indicators included assaults on nursing personnel, RN education, RN certification and patient falls.

Nursing departments were ranked according to nurse manager performance using their NMALS score. Outcomes for the top performers were compared to the lowest performers. Sample sizes for clinical settings included 178 ambulatory care clinics and 100 emergency care departments. T-tests identified significant differences in direct care nurse characteristics, nurse survey items, and patient clinical outcomes based on top and bottom performing nurse managers.

Results: Top-performing nurse managers in ambulatory and emergency care settings achieved significantly higher RN intent to stay, RN-assessed quality of care, and lower missed nursing care compared to bottom performing nurse managers. Top performing nurse managers in ambulatory care settings achieved significantly fewer patient falls. No significant differences were found in nurse education and certification based on nurse manager performance.

Conclusions/implications: Consistent with prevailing literature found in acute care settings, findings suggest top performing nurse managers in ambulatory and emergency care settings are associated with better nursing and patient outcomes. Evidence for acute care nurse managers suggests that effective nurse managers need reasonable workloads and organizational support. Research is needed to determine drivers of effective nurse managers in ambulatory and emergency care settings.

Nora Warshawsky PhD, RN, NEA-BC, FAAN

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