Middle managers—such as Nurse Unit Managers (NUMs), Midwifery Unit Managers (MUMs), and departmental leaders—play a critical role in translating strategic priorities into frontline care.

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They are the vital link between executive leadership and clinical teams. Yet, despite their pivotal position, they often operate without adequate recognition, consistent support, or inclusion in broader organisational acknowledgements.

The Problem: Recognition Gaps and Emotional Toll

Middle managers are expected to be leaders, problem solvers, mentors, and operational decision-makers—frequently all within the same shift. They are tasked with managing staffing shortfalls, quality improvement projects, accreditation requirements, patient care escalations, and broader business impact assessments.

However, middle managers feel overlooked, emotionally exhausted, and unsupported. Their work is rarely acknowledged in organisational communications, and they are often excluded from recognition frameworks that highlight other staff achievements.

This perceived invisibility contributes to burnout, disengagement, and an increasing risk of attrition—issues that threaten both workforce stability and patient care quality. While praise is sometimes offered informally, there is a difference between hearing “you’re doing a great job” and feeling genuinely valued through systemic and visible support structures.

The Evidence Behind the Issue

Numerous studies support the importance of middle managers in shaping care outcomes and organisational success:

• Wong & Cummings¹ found a direct relationship between nursing leadership and patient outcomes.
• Warshawsky & Havens² highlighted how job satisfaction among nurse managers is a predictor of retention.
• Birken et al.³ identified middle managers as key drivers of healthcare innovation.

These findings reinforce that failing to invest in this cohort comes at a cost—to safety, morale, continuity, and innovation.

A Collective Reality

The urgency of the issue is not hypothetical. Clinical managers have reported working at unsustainable levels, juggling overwhelming workloads, often without the time or space to reflect, reset, or grow.

While short check-ins with directors occur, they are often focused on operations rather than wellbeing or leadership development. There is little protected space to discuss how middle managers are coping—not just operationally, but emotionally. A culture of psychological safety—where vulnerability, emotional debriefing, and real conversations are welcomed—is still lacking for this group.

Many middle managers actively support the staff they lead in returning to work under flexible arrangements following maternity leave. It is not uncommon for frontline staff to return on reduced hours, and middle managers are often the ones advocating for and facilitating these transitions to promote work-life balance and staff wellbeing.

However, this same flexibility is rarely extended to middle managers themselves. Upon returning from maternity or extended leave, they are often expected to resume their roles at full-time capacity, with limited consideration for job share arrangements or reduced hours options. Additionally, middle managers are frequently expected to cover their own leave, given the limited capacity to backfill such complex roles. Many managers even go as far as rearranging their own leave plans—aware of the operational strain their absence may cause—prioritising the needs of their team over their own wellbeing.

This imbalance raises significant concerns around equity and sustainability. While middle managers continue to model empathy and flexibility for their teams, they are often not afforded the same level of organisational support. At its core, this dynamic can be perceived as unfair and contributes to growing frustration, ongoing fatigue, and burnout among this essential leadership cohort. Addressing this inequity is vital to ensuring that middle managers are not only retained but also treated with the same compassion and flexibility they so often provide to others.

The Broader Imperative: Why This Matters Now

On one hand, middle managers fully understand that the responsibilities they carry are part of the role, and that these are reflected in their remuneration. On the other hand, it can be disheartening when recognition opportunities are overlooked, especially given the sustained effort, emotional labour, and unwavering commitment they bring to their roles. Middle managers are not seeking accolades—they are asking for sustainable support. Their ongoing commitment to the organisation is evident, but without meaningful recognition, structured reflection time, and dedicated wellbeing support, this group is at serious risk of burnout. If the course continues the cumulative pressures of leadership can affect even the most resilient leaders. If middle managers begin to disengage or step away, the operational and clinical stability of our services could be significantly compromised. These leaders are holding together critical components of service delivery, team morale, and patient care. Their contribution cannot be taken for granted.

Supporting middle managers is not only essential for their retention—it has a ripple effect across the entire workforce. When middle managers feel seen, supported, and valued, they are more capable of modelling professional resilience, navigating change with steadiness, and creating psychologically safe environments where staff feel heard and empowered. They are also key to mentoring junior nurses, addressing early signs of burnout in their teams, and setting the cultural tone for respectful, person-centred care. By investing in the wellbeing and recognition of middle managers, organisations reinforce stability, morale, and performance from the centre outward—safeguarding both workforce sustainability and patient outcomes.

Middle managers recognise that the healthcare system faces financial pressures and competing demands. However, recognition and support do not always require large investments. Small, intentional actions—such as acknowledging leadership efforts in staff communications, creating space in forums for clinical managers to share their work, or enabling regular emotional debriefing—can have a powerful and lasting impact.

Future-Proofing Leadership: Why Action Can’t Wait

There is often little opportunity to engage in quality improvement initiatives, leadership development, or innovation for middle managers. This absence of protected time is not just a workload concern; it represents a critical barrier to career advancement. Without opportunities to lead beyond the daily grind, middle managers are deprived of the experience and exposure needed to evolve into future directors, executives, and system leaders. Similarly, without access to meaningful leadership experiences and professional growth, many middle managers are left feeling stagnant and undervalued despite being expected to lead. Over time, this can contribute to burnout and disillusionment, making it less likely they will pursue higher leadership roles. These not only weakens the leadership pipeline but also threatens overall retention in nursing. When middle managers are supported and given space to grow, they are more likely to stay, lead with purpose, and inspire others to do the same—strengthening leadership continuity and workforce sustainability across the system.

If we fail to act now, middle management roles will become increasingly unattractive to the next generation of nurses. Generation Z and the emerging Generation Alpha are entering the workforce with very different expectations from their predecessors. They value psychological safety, mental health support, flexible working arrangements, and visible, meaningful recognition. They are less likely to tolerate burnout as a norm or accept leadership roles that demand everything and offer little in return.

Without tangible changes to how we support and recognise middle managers, these roles risk becoming vacancies no one wants to fill. The long-term consequences could include:

• Leadership voids, leading to instability in team management and service delivery
• Weakened succession planning, making it harder to develop future leaders internally
• Increased staff turnover, as frontline workers see little incentive to progress into management roles
• Erosion of team culture, as overstretched managers struggle to model wellbeing and resilience

To attract and retain the next generation of nurse leaders, we must reimagine what middle management can look like. That means embedding structures of support, recognition, and balance now—not later.

Proposal: Strategies for Recognition and Support

To address these challenges, a multi-pronged recognition strategy is proposed, focusing on visibility, wellbeing, and leadership development. Many of these strategies are cost-neutral and culturally impactful:

1. Formal Acknowledgement

• Introduce an annual “Excellence in Leadership” award for middle managers.
• Include NUMs and departmental managers in quarterly recognition events and leadership forums.

2. Visibility and Voice

• Provide opportunities for middle managers to present innovations or team achievements at executive or board-level meetings.
• Regularly highlight middle manager contributions in internal communications such as newsletters or intranet bulletins.

3. Professional Development Support

• Fund access to leadership coaching, CPD courses, and conferences.
• Protect time for reflective practice, peer support groups, and structured leadership development.

4. Wellbeing and Appreciation Initiatives

• Host appreciation breakfasts, informal thank-you campaigns, or spotlight managers during Access Huddles.
• Offer targeted wellbeing check-ins tailored to the emotional demands of leadership roles.

5. Peer Recognition Toolkit

• Develop templates and guidance for peer-to-peer recognition among managers.
• Encourage real-time acknowledgement of leadership contributions at all levels.

6. Develop Equity in Flexibility on the Position

• Pilot job-sharing arrangements for NUMs/ MUMs

• Develop a pool of experienced interim leaders (e.g., senior nurses, acting NUMs/ MUMs) to cover planned leave and short-term absences.

Evaluation: Measuring What Matters

To ensure impact, organisations can monitor:

• Biannual surveys on leadership wellbeing and perceived recognition.
• Turnover, sick leave, and unplanned leave rates among middle managers.
• Qualitative feedback from leadership development sessions and manager forums.

Creating a culture that truly values and supports middle managers is not just beneficial. Investing in recognition and support for this group is not just about morale—it’s about retention, safety, and sustainability.

References

1. Wong CA, Cummings GG. The relationship between nursing leadership and patient outcomes: a systematic review. Journal of Nursing Management [Internet]. 2007 Jul;15(5):508–21. Available from: https://pubmed.ncbi.nlm.nih.gov/17576249/

2. Warshawsky NE, Havens DS. Nurse manager job satisfaction and intent to leave. Nursing Economic$ [Internet]. 2014 Jan 1;32(1):32–9. Available from: https://pubmed.ncbi.nlm.nih.gov/24689156/

3. Birken SA, Lee SYD, Weiner BJ, Chin MH, Schaefer CT. Improving the Effectiveness of Health Care Innovation Implementation. Medical Care Research and Review [Internet]. 2012 Aug 28;70(1):29–45. Available from: https://journals.sagepub.com/doi/abs/10.1177/1077558712457427

Author

Mandy Dias Nurse Unit Manager|Gynaecology & Cancer Services and Complex Care Unit, The Royal Women’s Hospital, Melbourne Australia