**1. Introduction**

People who agree to assume important managemen<sup>t</sup> roles in organizations often bear many responsibilities to a varied set of stakeholders in their daily work. Given the impact managers have on their organizations, research has examined many facets of the challenging nature of this work. The better scholars can shed insight into managing and mitigating the stressors managemen<sup>t</sup> positions hold, the better the manager will perform as both a professional and person. In turn, the better the manager performs, the better the organization will do as well (Bakker and Demerouti 2007). The job demands research tradition is one managemen<sup>t</sup> area that holds particular significance for studying issues managers face in their daily work (Demerouti et al. 2001). Specifically, job demands have been defined as "the degree to which a given executive experiences his or her job as difficult or challenging" (Hambrick et al. 2005, p. 473). Job demands are not inherently a negative phenomenon in the workplace. If job demands are reasonably manageable, many managers may find the challenges interesting and satisfying, as the work offers them opportunity to apply and develop their expertise and experience (Gardner 1986; Garner and Cummings 1988; Janssen 2001; Scott 1996). After all, people in leadership positions usually reach their status from seeking and succeeding in situations others may avoid. However, researchers have also discovered that overly taxing job demands can entail grea<sup>t</sup> mental strain and stress (Karasek 1979; Van Yperen and Snijders 2000; Wall et al. 1996; Xie and Johns 1995) and incur physical health problems (Fox et al. 1993; Theorell and Karasek 1996; Warr 1990). The nature of whether a job demand is stimulating or taxing is dependent on three factors: task challenges,

performance challenges, and personal performance aspirations (Hambrick et al. 2005). The degree of stress a manager finds in addressing their tasks, organizational expectations, and personal aspirations can also impact the quality of their decision-making (Ganster 2005). Therefore, overly demanding jobs can lead to poor decisions by managers. This negative consequence is multiplied when made by leaders who supervise outcomes with grea<sup>t</sup> impact on their organization and/or society. Few professionals in society make more important decisions than nurse managers. They routinely are faced with "life or death" situations requiring decisions of how their frontline nurses are to proceed. Better practices for assisting nurse managers with the demands they face in their work will improve their decision making and, ultimately, will better serve their patients with quality care as well as address patient safety.

The job of the nurse is filled with much stress and chaos given the challenging demands within today's medical environment (Goldsby et al. 2020; Greggs-McQuilkin 2004). One of the major stressors confronting nurses is perceived time pressure (Teng et al. 2010). Time pressure impairs the decision making of nurses (Hahn et al. 1992), reduces their emotional well-being (Gärling et al. 2016), and leads to nurse exhaustion Gelsema et al. (2006). Furthermore, recent research in the psychological sciences suggests that increased time pressure can lead to more dishonesty (Protzko et al. 2019). Given such potential negative outcomes on nurses due to perceived time pressures, it seems logical that a nurse manager's ability to help nurses manage this time pressure and become better decision makers (that is, become better time managers) could enhance nurse well-being and performance. Research in the organizational time managemen<sup>t</sup> literature shows a positive relationship between time managemen<sup>t</sup> and job satisfaction, health, and performance outcomes (Claessens et al. 2007). Paralleling research in the nursing literature suggests that in order to improve the perception patients have of the quality of care they receive, nurse managers should embrace ways to lower perceived time pressure (Teng et al. 2010). However, while time pressure on nurse managers has been studied as a common problem in hospitals, a theory-based framework for better performance within those constraints has not been provided in the literature. We seek to address that literature gap by answering the following research question in the upcoming sections: How can nurse managers and nurses provide quality patient care by making better decisions under time pressure? This conceptual paper provides a step in that direction; that is, to help nurse managers reduce perceived time pressure by nurses and improve the decision making of nurse managers and nurses. In this article, we sugges<sup>t</sup> how evidence-based time managemen<sup>t</sup> practices (Garbugly 2013; Saunders 2014) and self-leadership theory (e.g., Neck et al. 2019) can help nurse managers to reduce perceived time pressure by the nurses that they manage. We capture these insights in a framework we call *The Time Pressure Mitigation Model for Nurse Managers* (see Figure 1). We propose that guidelines inherent in this model will also serve other managers who find themselves making decisions under time pressure constraints.

**Figure 1.** The time pressure mitigation model for nurse managers.

Our proposed model mitigates the time pressure nurse managers face based on three areas of research: psychosocial care, time management, and self-leadership. Based on the conceptual methodology of metatriangulation (Lewis and Grimes 1999; Saunders et al. 2003; Cristofaro, Matteo 2020. Unfolding Irrationality: How do Meaningful Coincidences Influence Management Decisions? forthcoming), we provide three metaconjectures for further consideration by organizational and psychological researchers. Metaconjectures are "propositions that can be interpreted from multiple paradigms" (Saunders et al. 2003, p. 251). Saunders et al. (2003), for example, applied the approach to examining power and information technology. The context of nurse managers is included in the title of the framework because the professional outcome pertinent to their roles is psychosocial care. Based on the research on nurse managemen<sup>t</sup> studies, we conjecture that time pressure will impede good decision making and detract from providing quality psychosocial care. However, the research in time managemen<sup>t</sup> and self-leadership warrant us to also conjecture that when practices from these two areas are successfully implemented, the negative effect of time pressure on decisions related to psychosocial care can be lessened. In other words, proper application of time managemen<sup>t</sup> and self-leadership practices moderates the relationship between time pressure and psychosocial care by nurse managers.

In this conceptual paper, we first describe the context nurse managers face that affects their decision making. We then provide the model and its constituent parts. An example is then given that demonstrates how the model may work in a healthcare setting. We conclude with considerations for future development of the model.

### **2. The Context of Healthcare Settings**

Time is a major issue in healthcare today. The emphasis on quality of care, safety, standardization, and efficiency has to be managed within the constraints of an increase in the amount of patients being treated and a condensed length of stay (Bundgaard et al. 2016). Nurses are often in a continuous struggle to perform an increasing number of complex tasks under time-crunched conditions (Chan et al. 2013). Further complicating the nurse's job are the many decisions that must be made within that limited time (Saintsing et al. 2011). In a study of a medical admissions unit, it was found that a nurse confronts up to 50 important clinical decisions in a single 8-hour shift (Thompson et al. 2004). Other researchers have discovered similar patterns of clinical judgements and choices in controlled time frames. Thompson et al. (2008), for example, discovered that nurses in intensive therapy units encountered a clinical judgment or decision every 30 seconds. Along with that, in a study by Saintsing et al. (2011), nurses reported time constraints that limited their patient assessments with approximately 80% of the novice nurses acknowledging making mistakes due to time pressure. In this study, it was reported that each nurse made better decisions when there was no time pressure confronting their interactions. Additionally, Gonzalez (2004) demonstrated that people making decisions under limited time conditions performed worse than others faced with the same situations but with more time.

Accelerated information processing (Maule and Edland 1997) has been recognized as a natural response to time pressure when implementing a desired strategy (Payne et al. 1993). Furthermore, novice nurses described that peer-pressure is an indirect basis of time constraint (Ebright et al. 2004). Specifically, they feel pressure to leave no unfinished tasks for the incoming nurses that start the next shift, pressured to complete their allotted tasks so that incoming nurses start their shifts without leftover work. This self-inflicted time constraint is pervasive in healthcare, especially for new nurses who want to avoid being seen as incapable of thoroughly completing their responsibilities. The "must-do work" supersedes the "should-do work" (Bowers et al. 2001), thereby causing nurses to perform in a reactive fashion rather than being proactive with decision making (Hoffman et al. 2009). Nurses report that pressure to perform, workload, technology, and system issues produce barriers that prevent them from providing compassionate care. The often-chaotic environment weakens their capacity to care for others as well as themselves. This can result in dissatisfaction, burnout, and compassion fatigue (Roussel et al. 2020). Moreover, time pressure bears a high price of energy expenditure as nurses rely on coping mechanisms to bear the increased anxiety that comes with time pressure. In other words, nurses are not able to fully focus on their job, but must engage in self-coping to stand up to the pressure. This unfortunate predicament can drain energy over a work shift (Maule et al. 2000). Given this context of time pressure within a healthcare setting, we next explain the Time Pressure Mitigation Model for Nurse Managers and offer related metaconjectures for future study.

### **3. The Time Pressure Mitigation Model for Nurse Managers**

Time pressure is the perception that scarcity of time exists to finish obligatory tasks (Teng and Huang 2007). Nursing responsibilities have been rising along a range of complexity. This amplified workload can complicate nursing (Gurses et al. 2009). Too much to do without enough help was found to be the top source of stress in a study of Iranian nurses (Mosadeghrad 2013). In the study, occupational stress was found to lessen the quality of care due to having less time to demonstrate compassion for the patients in their care. Additionally, mistakes and practice errors occurred more often when occupational stress increased. Stress is related to time pressure in that it is recognized as inadequate time for accomplishing required tasks that compromises one's ability to cope. Under intense time pressure, it was found that individuals tend to escalate information processing, hinder decision-making quality, and experience information overload (Ben-Zur and Breznitz 1981; Hahn et al. 1992). Concurrently, the stress of time pressure has physical complications, such as increased blood pressure and a rise in human cortisone levels (Wellens and Smith 2006; Greiner et al. 2004). Thompson et al. (2008) found that time pressure reduced the nurses' capacity to assess patient needs in acute care and a ffected nurses' risk assessment decisions. Time pressure also creates negative emotions, increases anxiety, and leads to nurse emotional exhaustion (Gelsema et al. 2006) or burnout (Ilhan et al. 2008). When in a state of high anxiety, one's working memory resources are constrained, significantly diminishing resources for completing tasks and ultimately diminishing individual effectiveness. Patients are aware of this limited cognition, which can diminish client satisfaction and confidence in the hospital. Teng et al. (2010) discovered that nursing-perceived time pressure is negatively related to patient perceptions of dependability, accountability, responsiveness and assurance of the nurse. Thus, to enhance patient perception of care quality, nursing managers must develop means to lessen nurse-perceived time pressure.

### *3.1. Time Pressure and Psychosocial Care*

Psychosocial care, a holistic approach to nursing to meet the psychological and social needs of patients (Kenny and Allenby 2013), is an important healthcare outcome compromised by insu fficient time and heavy workloads (Legg 2011). Barriers, including lack of time, stand in the way of appropriate psychosocial care (Legg 2011). Recent studies reveal that o ffering good psychosocial care may improve patient overall health outcomes (Chen and Raingruber 2014). Additionally, appropriate psychosocial care reduces patient anxiety and stress and alleviates pain, thereby improving quality of life as well as a reduction in hospitalization cost due to a decreased need for medical resources (Kenny and Allenby 2013; Legg 2011). Studies by Legg (2011) and Rodriguez et al. (2010) found that good psychosocial care decreased the duration of hospitalization.

Unfortunately, psychosocial care does not often become an area of focus in hectic acute care settings (Legg 2011; O'Gara and Pattison 2015). In a study by Chen and Raingruber (2014), all the participants stated that, although often limited, positive interactions with patients and their family members were vital for providing psychosocial care. Communication within a time-pressured environment is hard to come by. As one nurse in the study said, "I think in order to know the needs of the patient, you need to communicate with them, and then you will know what they need." (p. 229).

The literature supports that e ffective interactions between nurses and patients result in increased rapport, trust and medical care, thus making therapeutic relationships possible (Belcher and Jones 2009; Josefsson 2012; Mcmillan et al. 2016). Furthermore, although nurses support spiritual care, they commonly said it was not possible when under time constraints (Balboni et al. 2014). Most participants in Legg (2011) study responded that time constraints due to excessive workloads was the top obstacle to o ffering psychosocial care. Time constraints shortened conversations with patients that would better uncover individualized needs. Other studies support this conclusion that most nurses contend with time-related pressures (Legg 2011; Chen and Raingruber 2014; DeCola and Riggins 2010; Lawless et al. 2010). A likely cause for this occurrence are the high patient workloads in hospitals and the distribution of tasks that require a specific schedule that needs completed before the end of one's shift (Lim et al. 2010). An enormous preoccupation with documentation also limits time available for psychosocial needs (Legg 2011). Most nurses in this study expressed that a preoccupation with timely documentation requirements limiting patient interaction was the cause of not attending to psychosocial needs.

Quality decisions within a healthcare context are also a ffected by time pressure. Good decisions are greatly dependent on the information considered by decision makers. However, new findings in the psychological sciences reveal that time pressure can cause nurses to misrepresent actual events and results, in order to appear more favorable to other people (Protzko et al. 2019). This was a ffected, though, by participants' beliefs on whether their true self was virtuous. Bear and Rand (2016) and Rand et al. (2014) proposed that one's automatic responses develop from internalizations of actions commonly agreed to as good to others in social exchanges. With this notion in mind, when time pressure is at hand, an individual might say what would appear to be the right response when indeed it might not be the truthful response. An example of this could be when a nurse reports to the nurse manager that she/he has followed protocol and checked all the necessary patient identifiers before giving medications during a busy shift, while in reality the nurse is telling the nurse manager what she/he thinks she/he wants to hear. This error in judgment could result in a medication error, which is one of the most common—and dangerous—mistakes in healthcare. When people are under time-crunched conditions, they often o ffer socially desirable answers or information as a default. A clash between a person's long-held self-conception and workplace role takes place. Thus, under time pressure, people often operate in opposition to their true self-concept, responding consistently with the internalized social norm of how the unit is supposed to operate from day-to-day (Everett et al. 2017). Positive self-presentation becomes a habitual tendency when time pressure is present (Protzko et al. 2019). When intentions and actual events are in misalignment, cognitive dissonance can place further stress on the nurse's psyche—sometimes lasting well beyond the date of the actual occurrence.

Given this discussion of the e ffect of time pressure on psychosocial care, we o ffer the following metaconjecture based on the literature:

*Metaconjecture 1: In situations where nurse managers face increased time pressure, providing quality psychosocial care will be compromised; i.e., the more time pressure a nurse manager experiences, the less psychosocial care their patients receive.*

### *3.2. Time Management for Nurse Managers*

Nurse managers must create a positive work environment even when they are confronted with ever-changing priorities. They must especially consider time pressure of their sta ff when designing their schedules. Workload should relate to a realistic assessment of individual nurses' capabilities and resources. Adequate sta ff can help in keeping nurses' assignments realistic to su fficiently manage workloads (Waterworth 2003). Nurse managers should initiate strategies to provide substantial support for the nurses to deal with the stresses that are at hand. Numerous studies have considered time pressure and work overload as major contributors to work stress among healthcare professionals. A burdensome workload intensifies job tension and reduces job satisfaction which, in turn, increases the probability of turnover. Although, Efron (2014) identifies poor leadership as the main reason for sta ff to leave and notes that sta ff quit the leader, not the organization. Roussel et al. (2020) report that the highest turnover takes place within one year of employment, with the cost of replacement at USD 75,000 due to recruitment, temporary sta ff, overtime, orientation and replacement. Moreover, the remaining sta ff are a ffected with heavier work assignments and overtime, which also leads to burnout. If the vacancy rate remains high, burnout may lead to more vacancies and, in turn, increase the potential for further burnout among the remaining sta ff leading to a downward spiral. It is as if a unit is unintentionally downsizing itself.

Inadequate sta ffing also impacts quality of care and patient outcomes (Aiken et al. 2002). Conscientious managemen<sup>t</sup> of all these factors is key. Time managemen<sup>t</sup> for nurse managers is an important issue (Mirzaei et al. 2012) because it directly a ffects people's health, availability of critical time, and can cause a decrease in e fficiency (Soleymani et al. 2011). It was found in a study by Ziapour et al. (2015) that training nurse managers according to time managemen<sup>t</sup> practices delivers positive results in healthcare centers.

A main objective for the nurse is to make optimum usage of the time at hand. Nurses keep part of their focus on maintaining the expectations of the greater healthcare system while also providing individualized care in the most e fficient way they can. Thus, instead of developing a relationship with a patient, much of the allotted time is spent on the technical and instrumental responsibilities in nursing. As a result, compassionate nursing becomes harder to provide (Bundgaard et al. 2016). Therefore, productivity, and not compassion, becomes the key objective of the job. Numerous researchers cited Lakein (1973) when studying time management, emphasizing the practices of needs assessment, setting goals to meet these needs, prioritizing, and task planning necessary to meet the set goals. Practices proposed to extend intellectual e fficiency were suggested by Britton and Tesser (1991). Kaufman-Scarborough and Lindquist (1999) provided methods for strategizing activities by prioritizing them by their relative importance to the healthcare mission.

Collections of behaviors that are considered to aid e fficiency and lessen stress were suggested by Lay and Schouwenburg (1993). Based on a review of the time managemen<sup>t</sup> literature, Claessens et al. (2007) sugges<sup>t</sup> the following definition: "behaviors that aim at achieving an e ffective use of time while performing certain goal-directed activities" p. 262. Since the focus is on goal-directed activities that are accomplished in a manner that implies successful use of time, the following behaviors are included in their definition: (1) Time Assessment Behaviors—focusing on mindfulness of the past, present and future with self-awareness of time usage within the boundaries of one's abilities (Kaufman et al. 1991) and self-awareness of time handling by deciding which tasks suitably fit into one's abilities; (2) Planning Behaviors—with the goal of e ffective use of time, that includes goal setting, development, prioritizing, formulating a to-do list, and arranging tasks (Britton and Tesser 1991; Macan 1996); and (3) Monitoring Behaviors—with the objective of attending to how time is allotted, engagemen<sup>t</sup> of planned undertakings, and limiting the impact of disturbances by others in the completion of tasks and goals (Fox and Dwyer 1996; Zijlstra et al. 1999).

Nurses face time managemen<sup>t</sup> problems due to the unpredictability and complexity of their assignments. Accomplishing tasks e ffectively and minimizing interruptions are essential to the nurse. The importance of routines and prioritization is key to time managemen<sup>t</sup> in a healthcare setting (Waterworth 2003). Furthermore, in complex environments, routines allow for a way of maintaining order since actions have already been planned out and can decrease thinking time needed to make decisions. Routines bring about a sense of predictability, awareness of time control, and familiarity of experience that is pertinent to time managemen<sup>t</sup> (Waterworth 2003). Furthermore, prioritization is a prerequisite for e ffective work performance for nurses. Sequencing work and its duration is necessary as well. It is imperative for timing and speed that there is synchronicity with others in the nursing environment. Determining what is urgen<sup>t</sup> and important is a critical step to attaining high returns on time investments. Simply put, more hours worked does not mean more hours of productivity. Therefore, productivity experts o ffer many suggestions for being more deliberate and conscious of where time on activities is allocated. Some of the latest advice for nurses on time managemen<sup>t</sup> includes (Garbugly 2013; Saunders 2014):


minute, but over the course of hours, days, and weeks, significant time can be lost in perceived "multitasking." Thus, it is more e fficient and productive to complete tasks with full attention and then move onto the next one needing accomplished.


Given this extensive review of research on time managemen<sup>t</sup> theory and practices for better performance, we o ffer the following metaconjecture:

*Metaconjecture 2: In situations where nurse managers face increased time pressure, proper application of research-based time management practices can improve psychosocial care; i.e., time management practices positively moderate the negative relationship between time pressure and psychosocial care.*

### *3.3. Self-Leadership for Nurse Managers*

The research in self-leadership suggests that it can be an appropriate training tool for nurse managers in better performing their roles. Based in social cognitive theory, self-leadership can help nurse managers better manage their thoughts, behaviors, and environment to create a better workplace for improved results. Self-leadership (Manz 1986; Manz and Neck 2004) is a process in which people can regulate what they do, how they interact with others, and how they decide to lead themselves and others by using certain behavioral and cognitive strategies. Self-leadership strategies fall into three groups focused on behavior, natural rewards, and positive thought patterns (Manz and Neck 2004; Prussia et al. 1998; Neck and Houghton 2006). Strategies revolving around behavior improve the awareness a person has on what they are trying to accomplish, especially regarding tasks with which one might want to procrastinate (Manz and Neck 2004; Neck and Houghton 2006). Behavior-focused strategies are:


Natural reward strategies are designed to establish conditions that spur correct actions through focusing on the gratifying aspects of a task (Manz and Neck 2004; Neck and Houghton 2006). These strategies encourage a sense of competence and self-determination in the person practicing them, two key drivers of intrinsic motivation (Deci and Ryan 1985). The necessity for competence comprises the need to practice and increase a person's proficiencies, and self-determination implicates one's desire to be independent from pressures such as conditional rewards. When individuals feel negatively controlled by their environment and they associate their expected actions to external pressures, they are likely to be less motivated by the work itself. To avoid this negative perspective of work, two natural rewards strategies that can be practiced are:


Effective thought pattern strategies are devised to enable a positive stream of recurring thoughts and constructive thinking habits that can enhance a person's performance (Manz and Neck 2004; Neck and Manz 1992). Positive thought pattern strategies include:


conducted a meta-analysis of 35 empirical studies and discovered that mental imagery has a significant positive effect on individual performance (Manz and Neck 2004; Manz and Sims 1980, 2001). Mental imagery can be useful when a problem stems from time pressure. In that case, the nurse manager would picture herself in a calm manner listening to the nurses' concerns over the challenges at hand, offering timely encouragement, and providing useful, deliberate direction. Solutions can be created that can ultimately save time in the future.

When time pressure is at hand, having a deliberate strategy with self-leadership skills is key. While many factors in the surrounding environment can cause stress on a nurse manager, her/his state of mind is within her/his power. Dysfunctional thinking, however, often hinders the nurse manager in advancing a unit toward its preferred benchmarks (Goldsby et al. 2020). Fortunately, dysfunctional or self-limiting thinking can be changed to be more constructive with evidence-based self-leadership strategies.

A significant research finding in the past 30 years is that people can decide on the way they wish to think (Seligman 1991). In the book, Talking to Yourself, Dr. Pamela Butler proposes that people participate in "an ever-constant dialogue" with themselves so that they can pilot their behaviors, feelings, and even stress level (Butler 1983). Much of this self-dialogue is centered on where a person places their attention. Nurses often struggle over difficulties that are not within their power to change, such as situations resulting from time pressure. Many are burdened about consequences that they cannot anticipate. Then, when time pressure is at hand with the potential stress that comes with it, self-defeating thinking can be the cause of extra burden. Significant challenges stem from dysfunctional thinking patterns. The most common dysfunctional thinking patterns are (Manz 1992):


Psychologists point to cognitive distortions as sources of these mental states that can undercut personal effectiveness (Neck and Barnard 1996). Even forms of depression can be the result of these mindsets. When nurse managers can recognize their self-defeating self-talk when it is taking

place, they have the opportunity to alter and re-verbalize these personal dialogues. There is always potential for creating a more positive outlook that will enhance their performance and satisfaction (Goldsby et al. 2020).

Once the self-leadership practices of the nurse manager and nurses are improved, the interactions between the two parties can be honed as well. Social cognitive theory (SCT) (Bandura 1986)—the underlying theoretical foundation of self-leadership—explains that performance is the outcome of a three-way relationship between a person's thoughts, actions, and surroundings in which they find themselves. Self-efficacy, which is a self-assessment of a person's ability to achieve specific undertakings, is in particular an important concept of social cognitive theory. Thus, self-efficacy is also significant within the practice of self-leadership (Neck and Houghton 2006). Furthermore, a chief aspiration of self-leadership practices, including thought pattern strategies, is the development of high self-efficacy prior to performing an activity (e.g., Manz 1986; Manz and Neck 2004; Neck and Manz 1992, 1996). Thus, increased task-specific self-efficacy promotes superior performance expectations (Bandura 1991). Backed by empirical research, self-leadership has been found to be a very helpful process for achieving perceptions of high self-efficacy and task performance (Neck and Houghton 2006). According to self-leadership theory—to the degree that an activity or task is selected—a strong belief in self-determination coupled with the application of practiced skills in increasing a sense of proficiency can enhance a person's performance on a task (Neck and Houghton 2006). In other words, once a person truly believes something is within their hands to do and that they have the ability to do it, they have a much better chance of doing so. The aforementioned self-leadership strategies intentionally practiced over time increases that desired self-efficacy.

It should be noted though that self-leadership is not an isolated process. Improving not only the personal habits of thoughts and behavior but the interactions between all parties in the environment is crucial as well. After all, much of time pressure can be due to systematic factors within a unit. Systems improvements require the involvement of the whole team. Once the nurse manager has improved her/his practices of self-leadership, it is time to improve the environment he or she co-exists in with others in the unit. Turning a manager's employees into better self-leaders themselves is a process known as SuperLeadership. The best managers set the example of what a good self-leader does and empowers and coaches the rest of the team to reach that same level of self-performance. When achieved, a team can outperform others who must wait for a manager to inform them how to handle complex situations. In a sense, the SuperLeader has inculcated the values and goals into each team member to exceed what she/he can do alone (Manz and Sims 1989, 1991; Manz 1990, 1991, 1992; Neck and Houghton 2006). The best SuperLeaders of self-managing teams encourage and support their employees to learn and practice the self-leadership process (Neck and Houghton 2006). The nurse manager, after all, cannot find or fix all the factors and issues causing time pressure on the unit.

Given this extensive review of research on self-leadership theory and practices for better performance, we offer the following metaconjecture:

*Metaconjecture 3: In situations where nurse managers face increased time pressure, proper application of self-leadership practices can improve psychosocial care; i.e., self-leadership practices positively moderate the negative relationship between time pressure and psychosocial care.*
