The unit-based nurse manager (NM) is one of the most significant and influential roles within an organization. Accountable for all daily operations related to the patient experience, the competence and skill with which these individuals execute their role as a nurse leader determines the success of the organization on a micro level. The performance level of unit-based managers is reflected in their actions and observable behaviors that directly influence the department’s social culture and norms, process efficiency, and quality of patient care outcomes.1–3 On a macro level, the level of NM performance, whether high or low, translates into human capital, financial success, organizational solvency, and positive community perceptions.2,4
According to the literature, high-performing NMs excel in leadership competencies, specifically those surrounding human capital and fostering healthy work environments (HWEs).4,5 These high-performing units also report higher patient quality scores and report fewer incidences of missed care.5 Conversely, units or departments with low-performing managers, or those managers perceived as toxic, report increased incidences of missed care, lower quality scores, and increased turnover rates.1,3,6 When comparing quality of care metrics across high- and low-performing NMs, high-performing NMs tend to have healthier work environments in their units.3,7 In addition, the positive correlation between strong leadership and high-performing teams is well documented.1,8 The nurse leader’s capacity to foster high levels of trust and establish norms of reciprocity among team members cultivates robust relationships and a sense of interconnectedness that builds collaborative relationships within the team.9,10 In this project, the study team seeks to understand the relationship between perceived NM competence and patient outcomes, with collaborative registered nurse (RN) relationships as a mediator.
Nurse Manager
In this study, the NM is defined as a unit or department-level frontline manager responsible and accountable for the daily operations of a patient care unit or department. Tasked with ensuring continuous quality improvement through safe and efficient patient care practices, NMs must adhere to state and federal regulations while ensuring adequate and competent staff.1–3 The competence and performance of the NMs are vital to the success of their organizations. Specifically, their ability to foster collaborative relationships and teamwork among RNs in their units through mutual trust, effective communication, and team engagement supports organizational success by creating HWEs that promote professional nursing practice.1,3 These departmental work environments shape the sociocultural norms and relational expectations, influencing nurse, patient, and organizational outcomes.1
Relational, high-performing NMs seek to inspire individuals toward achieving shared goals. They are relationship-focused, leveraging the power of influence to motivate individuals to work toward a shared goal. Furthermore, high-performing NMs are adept in creating healthy trusting relationships through mutual respect and effective communication skills.11 It is this focus on developing and nurturing relationships that translates into strong teams and teamwork.12
Collaborative RN Relationships
On a unit, collaborative relationships among RNs play a critical role in promoting effective teamwork and maintaining an HWE. These relationships are characterized by open communication, mutual trust, shared understanding, and coordinated action among nurses. Supportive leadership and effective communication skills help foster and sustain these collaborative relationships.13
Mutual trust between colleagues, a shared understanding of goals and expectations, and a proactive approach to teamwork (reciprocity) are central features of strong collaborative relationships. They are also core values for creating a healthy and productive workplace environment.5,13 Such relationships enable effective teamwork, open communication, and a supportive environment, which are all essential for high-quality care delivery. In turn, strong collaborative RN relationships create a positive feedback loop that strengthens both individual and team performance, ultimately leading to a healthier and more productive work environment4.
NM Performance and Influence on Patient Outcomes
High-performing managers are necessary to achieve strong collaborative RN relationships in the nursing workforce4. In turn, these relationships support the development of an HWE with increased teamwork, communication skills, job satisfaction, and intent to stay.4 Collectively, research demonstrates that NMs play a critical role in fostering HWEs through leadership that fosters mutual trust and respect. By cultivating strong collaborative relationships among nurses within their units, NMs enhance communication and teamwork, creating a cohesive team dynamic that directly improves patient safety.1–3 Building on prior research, this study examines collaborative relationships among nurses as the pathway through which NM leadership influences fall rates, proposing that leadership fostering mutual trust strengthens teamwork and in turn enhances patient safety (Fig.
1—hypothesized model).
Methods
Study Design and Sample
This cross-sectional study examined collaborative RN relationships as a mediator between NM leadership and patient fall rates. Data were extracted from the 2023 National Database of Nursing Quality Indicators (NDNQI), incorporating both clinical indicator data and annual RN survey data. The NDNQI is a national repository of indicators of quality nursing care, which enables researchers to evaluate nursing-sensitive patient outcomes.
NDNQI clinical indicator data are submitted quarterly by the organizations, and the NDNQI RN Survey is voluntarily submitted by direct care nurses annually by participating Press Ganey hospitals. The NDNQI data management procedures were reviewed by the Advarra Institutional Review Board (IRB) and deemed exempt from IRB oversight. The sample in this study consisted of 892 adult medical-surgical and stepdown units across 175 hospitals that participated in the NDNQI RN Survey, as well as their respective reported data on patient falls rates.
Measures
NM performance was measured using the mean score of the Nurse Manager Ability, Leadership and Support of Nurses subscale from the Practice Environment Scale of the Nursing Work Index.14 Direct care nurses score their NMs’ performance using 5 items on a 4-point Likert scale, which measures the quality of their NM’s leadership ability and support. The NMALS subscale has demonstrated strong reliability (α=0.84) and construct validity, supported by significant associations with nurse-reported outcomes and patient outcomes. Nurse-assessed NM performance using the NMALS has been associated with better nurse and patient quality outcomes.7,15
To measure collaborative RN relationships, the 5-item interprofessional RN scale from the NDNQI RN Survey was used, which assesses shared accountability for patient care, understanding colleagues’ roles and skills, focusing on root causes of adverse events rather than blame, using effective conflict management, and demonstrating respective contributions of other RNs. Using a 5-point ordinal scale: (1) no RNs; (2) a few RNs; (3) some RNs; (4) most RNs; and (5) all RNs, nurses were asked “Based on your experience, how many RNs who provide direct patient care on your unit would say,” followed by the 5 items. The composite score is calculated as the mean of the 5 items.
An expert panel developed 34 items to measure interprofessional relationships. A survey was administered to a sample of 8618 RNs working in NDNQI hospitals. Exploratory factor analysis was used to reduce the 34 items to a 5-item scale the results indicate strong internal consistency (Cronbach α=0.93), supporting the reliability of the subscale for assessing the perceptions of RN collaborative relationships (N.
Dunton, PhD, University of Kansas School of Nursing, unpublished data, 2015).
Unit-level fall rates data were retrieved from the NDNQI and matched to the NDNQI RN survey unit data. Patient fall rates, understood as a universal indicator of overall quality patient care16, were defined as an assisted or unassisted descent to the floor. Unit fall rates were measured as the rate of total falls per 1000 patient days, and the annual fall rate was calculated by averaging the 4 quarterly rates reported for each unit.
Fall rate data were drawn from hospital-reported sources and may be subject to reporting variability or underreporting across organizations. However, this method of organizational self-reporting aligns with standardized national reporting practices, including those used by the Centers for Medicare & Medicaid Services (CMS), and reflects how fall rates are commonly reported for quality monitoring and benchmarking purposes.
Statistical Analysis
Preliminary Analyses
Preliminary analyses included Pearson’s correlation coefficients to assess linear relationships among NM leadership, collaborative RN relationships and patient fall rates. Regression models were then fitted to test the assumptions of mediation. The relationship between NM leadership and collaborative RN relationships was first tested to estimate path a.
Subsequently, the collaborative RN relationships scale score was regressed on patient fall rates while controlling for NM leadership to test path b. Finally, the direct effect of NM leadership on patient fall rates was tested to estimate path c′.
Mediation Analysis
A conceptual diagram of the mediation model, including tested pathways, is presented in Figure 1. Following the preliminary analysis, a simple mediation model was tested using structural equation modeling (SEM) with the lavaan package (Ver 0.6-19) in R17 to determine whether collaborative RN relationships mediated the relationship between NM leadership and patient fall rates. The model was specified using the SEM function, with NM leadership and support as the independent variable, collaborative RN relationships as the mediator, and patient fall rates as the dependent variable.
SEM was used to estimate the model as it allows for simultaneous testing of direct and indirect effects using observed variables, along with robust bootstrapping procedures to improve estimation accuracy.
The indirect effect (ab) was estimated as the product of the effect of NM leadership on collaborative RN relationships scale score (a) and the effect of collaborative RN relationships on patient fall rates (b). The direct effect (c′) reflected the association between NM leadership and patient fall rates while accounting for the mediator. The total effect (c) was calculated as the sum of the direct and indirect effects.
To fully test the hypothesized mediation, a fully saturated model was specified, in which all paths were estimated. In such models, perfect model fit is a mathematical artifact of the model’s structure, rather than an indication of explanatory power; therefore, fit indices are not informative and were not reported. As recommended in the literature18,19, bootstrapping with 5000 resamples was used to estimate the indirect effect.
This method generates bias-corrected confidence intervals, providing more reliable estimates by addressing the non-normal distribution commonly observed in mediation effects.
Results
Hospital characteristics of the study sample are summarized in Table 1. Descriptive statistics and correlations for the study variables are presented in Table 2. All paths included in the mediation model demonstrated statistically significant correlations.
The regression analyses further supported the mediation pathways specified in the model. NM leadership significantly predicted collaborative RN relationships (B=0.327, P<0.001). In turn, collaborative RN relationships significantly predicted lower patient fall rates (B=−0.602, P<0.001) and NM leadership significantly predicted lower fall rates (B=−0.280, P=0.036).
The mediation analysis demonstrated that collaborative RN relationships significantly mediated the relationship between NM leadership and patient fall rates. Mediation results and path coefficients are presented in Table 3. NM leadership was positively related to collaborative RN relationships (a-path; β=0.402, P<0.001), suggesting that stronger leadership fosters more collaborative relationships among RNs.
In turn, collaborative RN relationships were negatively related to patient fall rates (b-path; β=−0.123, P=0.001), demonstrating that stronger collaborative RN relationships are linked to fewer falls.
The indirect effect of NM leadership on patient fall rates through collaborative RN relationships was statistically significant (a × b; β=−0.049, P=0.002), providing evidence for the mediating role of collaborative RN relationships. The direct effect of NM leadership on patient fall rates was not significant (c-path; β=−0.021, P=0.565), while the total effect (c+a × b; β=−0.070, P=0.029) remained significant.
Discussion
These findings suggest that the high-performing NM builds RN collaboration and together, NM leadership and RN collaboration reduces patient fall rates. Further, findings suggest that collaborative RN relationships are a critical pathway linking NM leadership to improved patient outcomes, specifically reduced patient fall rates. This study demonstrated that NM leadership was significantly associated with collaborative RN relationships, indicating that stronger leadership fosters more cohesive and supportive relationships among RNs.
In turn, collaborative RN relationships were significantly associated with lower patient fall rates. These findings highlight the importance of teamwork, support, and communication among RNs on their unit is critical to ensuring patient safety.
Mediation analysis, which can help elucidate how 1 variable influences the relationship between 2 other variables, revealed that the effect of NM leadership on patient fall rates was fully mediated by collaborative RN relationships, with a significant indirect effect and a nonsignificant direct effect. Thus, these findings indicate that NMs exert their influence on patient outcomes by building strong RN teams. These findings also underscore the pivotal role of RN collaboration and teamwork as the primary explanatory pathway through which nurse leadership influences patient fall rates and are supported by extant literature.20–22
Effective collaboration and communication among members of the healthcare team is crucial for enhancing patient safety and reducing fall rates. When nurses and other staff members work together in a positive, collaborative manner, they create a cohesive environment where information is shared promptly and accurately. In an HWE, relationships and interprofessional collaboration foster a culture of high trust, mutual respect, and shared responsibility among the team.
The synergy created not only enhances patient safety but also improves the overall quality of care provided.20–22
NMs who demonstrate effective leadership are able to model the cultural norms and relational behaviors that are necessary for fostering trust and collaboration across their team. They must also be transparent, fair, and consistent with their actions and hold team members accountable to expectations. In addition, NMs must follow through on commitments, maintain high standards of integrity, and demand the same of others.
To cultivate a positive environment, effective communication skills between the NMs and their team enable everyone to feel valued and heard. Encourage collaboration and teamwork by breaking down silos and fostering a sense of unity and shared purpose through team-building activities and reciprocity where team members support each other. By implementing these strategies, NM can effectively enhance teamwork and create a collaborative and trusting work environment.12,21
Limitations
Consider the following limitations when interpreting the findings. First, the cross-sectional design limits our ability to infer causality. Although the mediation model assumes a directional relationship from NM leadership to collaborative RN relationships and, in turn, to patient fall rates, the temporal ordering of these variables cannot be established.
Longitudinal studies are recommended to evaluate these associations over time. Second, both the predictor and mediator variables were derived from the RN survey, introducing the possibility of common method bias. Using the same data source for both constructs may inflate associations due to shared method variance.
Third, although the sample was limited to medical-surgical and stepdown units to minimize variability related to unit type, the mediation model did not control for other potentially relevant factors that may influence the mediating process, such as patient acuity or organizational characteristics. Lastly, to fully capture the hypothesized mediation, a saturated model was specified. While this limited assessment of model parsimony may impact generalizability, this approach is useful for theory-driven analyses focused on estimating direct and indirect effects.
Implications for Nursing Leadership
NMs foster and shape the culture and collaborative RN relationships within their units. Through their leadership, nurses in their units develop strong and positive collaborative working relationships, which, in turn, may lead to better patient outcomes. Specifically, the incidence of patient falls is generally lower in units that have strong collaborative RN relationships, and these relationships are driven by a robust, competent NM.
Organizations should offer continuous leadership training and resources for their NMs to improve patient outcomes and enhance patient outcomes. These outcomes result in higher reimbursement rates, greater patient satisfaction, and reduced risk of legal liability.
Conclusions
This study underscores the critical role of NM leadership in cultivating a culture of teamwork and collaborative RN relationships to drive high-quality patient care outcomes. It exemplifies the impact of high-performing managers who can successfully build strong collaborative RN relationships and cohesive teams to enhance patient care outcomes. The synergy created by these collaborative relationships is essential for fostering effective communication and an HWE, thereby enhancing patient safety and improving the overall quality of care provided.
Organizations should acknowledge the importance of NM leadership in shaping the culture and collaborative RN relationships within their units. Investing in ongoing leadership training and resources for NMs can lead to better patient outcomes, including a lower incidence of patient falls. By prioritizing the development of strong NM leadership, healthcare organizations can ensure that their nursing teams are equipped to provide the highest standard of care, fostering a safe and supportive environment for both patients and staff.
Conflicts of Interest
The authors declare no conflict of interest.