Nurse managers: The backbone of a strong nursing workforce

There is an adage that people don’t leave their jobs; they leave their managers. This reality is particularly critical given how important managers are to the overall success of an organization and its people. Indeed, middle managers are the heart of any organization, deeply influencing talent, culture, and employee experience. They are the face of leadership for the front lines and the bridge from executive strategy to implementation. Middle manager performance is also directly tied to an organization’s overall performance, including financial outcomes. Across industries, companies with top-performing managers see three to 21 times higher average total shareholder returns compared with those with average or below-average managers.

The importance of strong managers holds true in the nursing workforce as well. This is particularly salient today, as clinical-care organizations stand at a precipice. Organizations are actively trying to support growing patient volumes amid a nursing shortage in the United States that could reach roughly 400,000 by 2030, according to our research.

Organizations that invest in nurse managers see benefits beyond improving workforce stability, team culture, and quality of care. Their investments can also deliver a clear financial benefit by reducing turnover for both frontline nurses and nurse managers. Our work over the past five years has delved into the nursing deficit and evaluated strategies to address its primary reasons—support across tenures, the growing burden of workload, and burnout and mental health. In our latest McKinsey Nursing Pulse Survey, we’ve turned our attention to the relationship between frontline registered nurses (RNs) and nurse managers (see sidebar, “Research methodology”).

Our latest survey reveals compelling insights for healthcare organizations to consider. On the one hand, a smaller share of nurses say they intend to leave their jobs compared with surveys we’ve conducted over the past four years. However, as we see in our latest research, encouraging frontline nurses to fill leadership positions could potentially be challenging. Furthermore, among frontline nurses who are considering leaving their jobs, insufficient support from their leaders continues to be a top reason for doing so, highlighting the influence that nurse managers can have. Looking at just those nurses who intend to leave their roles because of leadership concerns, we estimate that US healthcare systems could save between $400 million and $700 million annually related to costs associated with frontline-nurse turnover.

In this article, we share insights on the state of the nursing workforce and offer recommendations on how healthcare organizations can empower and better support their nurse managers while also improving the workplace for frontline nurses, advancing patient care, and delivering financial returns.

The importance of nurse managers and the state of the nursing workforce

Nurse managers typically wear multiple hats and often are responsible for influencing team culture, managing productivity, and maintaining quality of care. In fact, strong managers are correlated with fewer falls among patients, a reduced rate of hospital-acquired infections, and a 68 percent increase in frontline-nursing retention. The goal of our latest research was to gain a deeper understanding of frontline nurses’ experiences with management, the support they need, and their interest in pursuing nurse management, while also understanding the role of nurse managers, including what their day-to-day work looks like, the obstacles they encounter, and the factors that could increase their job satisfaction.

In evaluating intent to leave, we focused on frontline RNs, who provide direct patient care, and RN managers, who are nurses with at least one nursing direct report and responsibility for a single department. Among frontline nurses who report being likely to leave their roles, feeling undervalued continues to be a driver of intent to leave: not feeling valued by their leaders, at 41 percent, or the organization, at 40 percent, were behind only looking for a better job, at 53 percent, as reasons for being likely to leave (Exhibit 1).

Twenty percent of frontline-nurse respondents say they intend to leave their jobs in the next six months. In our prior survey, 30 percent noted they were considering leaving. Among nurse manager respondents, 11 percent express a desire to leave their current positions.

Even though 60 percent of frontline-nurse respondents report that their managers improve
their job satisfaction, attracting frontline nurses to leadership roles remains a challenge. Fifty-four percent of surveyed frontline nurses say they are not interested in leadership positions, citing administrative burdens, high stress, and significant responsibility as key deterrents.

This disinterest in leadership seems to develop as nursing careers progress: 72 percent of early-tenure nurses (those with less than five years of experience) note wanting to pursue a leadership position, but only 53 percent of midtenure nurses (those with six to 20 years of experience) feel the same. This drop in interest provides an opportunity for healthcare organizations to evaluate leadership roles in an effort to make leadership an attractive specialty across nursing tenures.

Breakdown of activities

To assess how clinical-care organizations can better support nurse leaders given their influence on team success, we surveyed nurse managers to understand how they are spending their time and the key drivers of satisfaction and frustration. Nurse managers say they spend the bulk of their time on people management activities—for example, team huddles and mentorship (Exhibit 2).

Drivers of satisfaction

Encouragingly, the tasks that nurse managers spend most of their time on are also the activities that spark the most satisfaction for them and are of most importance to frontline nurses. When nurse managers were asked to rank the top five daily tasks that they find most satisfying, all the tasks related to people management activities (Exhibit 3). What’s more, people management responsibilities, such as providing feedback and facilitating open communication, are what frontline nurses say they value most about nurse managers.

Key challenges

Despite enjoying their roles and core activities, nurse managers are frequently caught between administrative demands and the need to lean in meaningfully with their teams. When asked to rank the daily activities that frustrate them the most, responses primarily focus on administrative tasks, such as managing callout coverage and handling incident reports and complaints (Exhibit 4).

Furthermore, RN managers face substantial structural challenges that may limit their ability to have meaningful impact on their teams, on patients, and on the organization. Nurse manager respondents report wide variability across workload and responsibilities: up to 250 direct reports, with an average of 30 direct reports. Additionally, nurse managers say they work up to 90 hours a week, with an average of 46 hours per week. These differences can contribute to perceptions of inequity among nurse managers in an organization and potentially to staff and patient dissatisfaction. Addressing these challenges could not only enhance the effectiveness of nurse managers but also demonstrate a clear commitment to supporting leadership roles within the nursing profession. This, in turn, could encourage more frontline nurses to aspire to and pursue managerial positions.

Approach to supporting nurse managers

Given how critical nurse managers are to team effectiveness and retention—including the overall success of an organization—healthcare organizations can actively support managers in balancing frontline demands with administrative responsibilities. When asked about factors influencing likelihood to leave, 48 percent of nurse managers point to unmanageable workloads. To address this, organizations can focus on strategic role design, invest in upskilling, and implement best-in-class tools that enable managers to thrive in their roles.

Redesign roles to relieve workloads

Considering nurse managers often oversee large teams, it can be challenging for them to provide personalized, one-on-one interactions with their team members, as well as consistent feedback and professional-development coaching. Clinical-care organizations can consider reviewing unit structures and evaluating if workloads could be improved by tapping additional assistant nurse managers, whose presence in departments has also been shown to decrease RN turnover rates. They can also standardize responsibilities for nurse managers across units (for example, administrative expectations such as budgeting and strategic planning, as well as staff onboarding and hiring expectations) to ensure fair distribution of work, provide consistent and clear expectations, and improve accountability and resource allocation.

Additionally, exploring hybrid-work options could help improve work–life balance. Fifty-two percent of nurse manager respondents say that not having work–life balance factors into their considerations to leave their jobs, and 75 percent report that they believe they could continue their work in some capacity remotely. While there will always be critical in-person components to the role, organizations could evaluate what level of flexibility may be appropriate (and potentially highly valued by managers in return).

Invest in training to upskill nurses

Because of the range of tasks that nurse managers are often responsible for and given how they spend their time, they need to master a variety of skills. However, their leadership training is often limited to only the essentials (for example, working with the HR systems needed to perform their duties). This can lead to frustrations in how to manage these disparate yet equally important aspects of the role. Furthermore, nurse managers with varying levels of training and experience take on leadership positions. Some may have advanced degrees in clinical nursing leadership, for example, while others may have shown exceptional clinical skills and longevity in their unit without any managerial or administrative background.

Additionally, there is often variability in onboarding and training, with nurse managers learning on the job itself. Organizations can address this by offering standardized training to establish the skills needed for the role, including the technical skills to handle tasks such as balancing a schedule or managing a budget and the interpersonal skills to deal with activities such as conflict resolution, stakeholder management, and coaching. Such upskilling can help empower nurse leaders to more effectively manage their departments. Ochsner Health, for example, attributes its low 6.67 percent nurse manager turnover to the Ochsner Leadership Institute, which provides mentorship and training at all leadership levels.

Moreover, organizations can enhance their overall talent development strategy by implementing mentoring programs. Given that nurses’ interest in management roles tends to wane over time, mentorship initiatives can serve as a vital way to sustain engagement and equip nurses with the necessary leadership skills. Additionally, fostering frontline nurses’ advancement into leadership positions helps to establish a robust succession plan, which in turn helps to ensure continuity and stability in leadership.

Take advantage of tools for administrative tasks

When we asked nurse managers which activities led to the most daily frustration in their roles, nine of the top ten were related to administrative tasks (for example, incident reports, schedules, chart audits, work orders or budgets, and inventory management). Technology, including AI-enabled automation, can provide a reprieve for some of these tasks and allow managers to focus on high-level, specialized activities. Nearly all nurse managers (98 percent) say that technology that could simplify staffing, support team recognition, manage audits, and streamline onboarding and hiring would make their jobs easier.

Some healthcare organizations that have invested in these solutions have seen measurable impact. Nebraska Medicine launched tech-enabled capabilities specifically to support its nurse leaders—for example, by tracking and providing reminders about employee milestones (such as work anniversaries and certification achievement). This reduced first-year-nurse turnover by nearly 50 percent. Similarly, Mercy, in St. Louis, adopted staffing software that focused on creating flexible schedules for nurses while reducing the administrative burden of creating schedules that meet unit needs and staff requests. It saw a 9 percent decrease in first-year-nurse turnover, a 20 percent reduction in time spent on staffing and scheduling, and an 8 percent reduction in overall nurse turnover.

It’s important to note that while McKinsey research suggests that tools such as gen AI may automate up to 30 percent of business activities by 2030, healthcare stands apart. Indeed, we expect the demand for healthcare workers to increase as the population ages. What’s more, nurse managers shoulder significant responsibilities both in people management and on the front lines of patient care with their teams, making them indispensable to their units and organizations.

As healthcare systems grapple with an ever-changing workforce landscape, it is crucial for them to rethink how best to support and develop their nurse managers, particularly since turnover among this cohort exacerbates frontline-nurse turnover. Strategic action can build capacity and morale for both roles, reducing turnover and the associated costs of recruitment, onboarding, and lost productivity. Healthcare organizations that prioritize their nurse managers can help build and sustain a more resilient and engaged workforce.

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