**5. Conclusions**

This conceptual paper examined the research question: How can nurse managers and nurses provide quality patient care by making better decisions under time pressure? Many factors contribute to nurse managers experiencing time pressure, such as: (1) patient safety; (2) patient satisfaction; (3) hiring; (4) sta ffing; (5) up-to-date, required education of the nurses; (6) playing the role of a front line nurse when the unit is understa ffed; (7) serving as the liaison go-between, communicating changes on new policies or procedures that come from the administration and keeping up with Joint Commission on Hospital Accreditation requirements; (8) serving as the liaison go-between of the front line nurses

and the hospital administration; (9) keeping doctors satisfied; (10) dealing with higher patient acuity; and (11) addressing the high stress among nurses, which includes burnout, suicide, and substance abuse (Davidson et al. 2018). Given this list of responsibilities, it is understandable why nurse managers are also described as nurse executives. In that, they have responsibilities in line with someone with a business degree requiring knowledge on financial management, sourcing and procurement, operations, and other business skills that must be learned on the job, all while meeting their patient and nurse responsibilities (Roussel et al. 2020). Therefore, readers of this paper who are not healthcare providers but who are in similarly time-pressured situations may find the model and suggested practices useful as well.

As with other professions that experience significant time pressure, handling an amalgam of such diverse concerns can cause emotional exhaustion and often lead to burnout for the nurse manager (Warshawsky and Havens 2014). However, we contend that the reason nurse managers incur such consequences is because they carry much of the load of their units in providing quality care and meeting administrative objectives. Operating as the center of the unit rather than as a facilitator of their team's growth and development can hinder deliberative improvement of their processes and practices. As a result, they may find themselves running from one crisis to another. The nurses on the unit also experience this time pressure, as nurse managers often do not model appropriate time managemen<sup>t</sup> skills and operational e fficiencies and improvements. However, it is our hope that by applying the practices of time managemen<sup>t</sup> and self-leadership encompassed in the Time Pressure Mitigation Model for Nurse Managers, more interactions with a nurse manager's sta ff will be positive and productive.

Helping nurses to become better time managers should be a part of each nurse manager's day with their sta ff. Deliberate and persistent use of time managemen<sup>t</sup> and self-leadership practices will also reduce the dissatisfiers that drain time and energy on the unit and open up more opportunities to find the little fixes that add marginal time savings as well. Workshops and on-the-job training implementing evidence-based approaches in time managemen<sup>t</sup> (Waterworth 2003) and self-leadership (Neck et al. 2019) would provide structure in reaching these objectives. As Waterworth (2003, p. 433) observed, "Literature on time managemen<sup>t</sup> in nursing is mainly anecdotal", without providing structure regarding what specific strategies to use and when. Additionally, with regard to self-leadership, practitioners may confuse this research tradition with popular books that fall into the commercial category McGee calls "Self-Help, Inc." (McGee 2005). However, self-leadership, like time management, has proponents in academia as well as popular culture, and it is the evidence-based practices that our model advises nurse managers to apply. Application of anecdotal work alone can lead to hit-and-miss results, which may lead practitioners to abandon a focus on better time managemen<sup>t</sup> and self-leadership, and fall back into their past habits. The importance of a model like the one proposed in this article is that it is comprised of key variables related to a phenomenon of concern (time pressure and its effect on psychosocial care), evidenced-based practices grounded in extensive research traditions (time managemen<sup>t</sup> and self-leadership), and explanation for how the variables create the potential for better performance (the negative relationship between time pressure and psychosocial care and the positive moderating e ffects time managemen<sup>t</sup> and self-leadership practices have on that relationship). As Lewin stated (Lewin 1952, p. 169), "There is nothing more practical than a good theory." A good theory is based on many studies of a phenomenon of concern that over time leads to better practices for progress in a field. Thus, it is our hope that nurse managers who apply practices in a research-based model as the one proposed in this conceptual paper may find their pursuit of better psychosocial care in their units to be met with more e fficiency and e ffectiveness. Before long, the unit will find it has more time to focus on the work they care about and be in a less stressed state of mind for handling the crises that do inevitably arise.

In a qualitative study of nursing, nurse managers summarized the complexity of their workplaces: "Keeping everyone happy—the docs, the administration, the patients, the nurses". "I'm a sta ff morale-booster, the problem solver, and counselor, and anything else I can think of to keep people relatively happy" (Tuckett et al. 2015). The breadth and scope of nurse manager roles can be tremendous. However, because front-line nurse managers are "close to the action," they are in paramount positions to foster change in creating a positive work environment for nurses that parleys the emergen<sup>t</sup> pressures that are commonplace. Many organizations place their managers in similar situations as nurse managers when they are confronted with many of the same challenges found in today's healthcare environments where time pressure is a common occurrence. Another common managerial issue is the promotion of high-performing front-line employees into managemen<sup>t</sup> positions. What worked for the manager as an individual performer will not necessarily be e ffective for the frontline they now oversee. With regard to nurse managers, many are promoted from front-line nursing status without master's degrees or leadership certifications that could have prepared them for the complexities of the position (Mathena 2002). While the tasks and responsibilities of the position can be learned fairly quickly, leadership is a skill that takes time to hone. However, learning self-leadership skills can have incredible results if consistently applied with employees.

It is our hope that this conceptual paper sheds light on the dynamics of these situations, and provides helpful advice for improving decision making, reducing time pressure and its related stressors, and bettering the healthcare experience. Metatriangulation with thorough research traditions in time pressure, psychosocial care, time management, and self-leadership provide support that the Time Pressure Mitigation Model for Nurse Managers warrants application in hospital units. But support for the model would be enhanced by empirical research. A common practice in emergency departments that requires sound decision making in often stressful situations is triage. Triage places a registered nurse in a situation to assess the treatment acuity—that is, how long a patient should be allowed to wait for needed medical care—and decide which interventions are required for emergency care in the moment. Nurse managers hold significant responsibility for the outcomes of triage in their units. For future study to further support the Time Pressure Mitigation Model, researchers could test whether time managemen<sup>t</sup> and self-leadership practices improve psychosocial care in units with similar time pressure as emergency departments face. Given the literature on triage practices and decision making though (Mackway-Jones et al. 1997; Gerdtz and Bucknall 1999, 2001; Cone and Murray 2002; Barberà-Mariné et al. 2019), triage decisions in an emergency department may be a good starting point for future empirical research. Yet, the model in this paper is not limited to nurse managers. As warranted by metatriangulation, models based on thorough research can be applied to di fferent domains as well. In most cases, extensions of the model in this paper could be achieved by replacing psychosocial care with another outcome variable. For example, hospitality managers often face time pressure serving large numbers of guests during busy periods such as hosting conferences and conventions. In a hotel setting, gues<sup>t</sup> satisfaction could be measured as the dependent variable pre- and post-test to time managemen<sup>t</sup> and self-leadership training. Other fields could perform similar experiments by modifying the performance outcome. We contend that the model in this conceptual paper provides one route to improving decision making for a wide range of leaders in time pressured environments.

**Author Contributions:** Conceptualization, E.G., M.G., C.B.N. and C.P.N.; Writing—original draft, E.G. and M.G.; Writing—review & editing, C.B.N. and C.P.N. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Conflicts of Interest:** The authors declare no conflict of interest.
