Journal of Nursing Management, 2014, 22, 532–539
Comparing nurse managers and nurses’ perceptions of nurses’ self-leadership during capacity building KARIEN JOOSTE
PhD, MA Nurs, RGN
1
and LINDI CAIRNS
MA Nurs, RGN
2
1
Professor, School of Nursing, Faculty of Community and Health Sciences, University of the Western Cape, Cape Town, and 2Master Student, Department of Nursing, University of Johannesburg, Johannesburg, South Africa
Correspondence Karien Jooste School of Nursing Sciences Faculty of Community and Health Sciences University of the Western Cape Private Bag X17, Bellville 7535 Cape Town Western Cape South Africa E-mail: [email protected]
JOOSTE K. & CAIRNS L.
(2014) Journal of Nursing Management 22, 532–539 Comparing nurse managers and nurses’ perceptions of nurses’ self-leadership during capacity building Aims This paper compares the perceptions of nurse managers and nurses about self-leadership of professional nurses while taking ownership of capacity building during unit management. Background The Nursing Strategy for South Africa states that the competency of nurses is dependent upon factors that lead to capacity building. Method A quantitative design was followed by conducting a survey. The target population included nurse managers and professional nurses working at an academic public hospital in the Gauteng Province of South Africa. Results The findings indicate shortcomings in relation to advising professional nurses about self-direction while taking ownership of their daily pressures and stresses associated with unit management. Conclusion Professional nurses should develop their confidence by focusing on their self-leadership strengths when managing a unit. Implications for nurse managers Recommendations are made to promote selfleadership while taking ownership of nurses during capacity building of unit management.
Keywords: capacity building, nurse managers, ownership, self-leadership, unit management Accepted for publication: 17 February 2014
Introduction Capacity building is a management approach used to develop individuals by enabling them to carry out their tasks to the best of their ability. This is achieved by giving health care professionals access to information, providing opportunities for them to make decisions, and empowering them to act (Hawe et al. 2009). All professional nurses should be equipped with the skills and knowledge of management in order to assume accountability and responsibility within their nursing unit (Muller 2009). The concepts of capacity building include enhanced participation in formulating organisational plans and an 532
increase in the authority given to the nurse (Grobler et al. 2006). The attributes of capacity building include teamwork, the availability of information systems, decision making, support and self-leadership through ownership (Proudfoot et al. 2007). Self-leadership is a process that requires an individual to control personal actions, to be self-aware and to utilise personal strength, which are necessary for performing tasks effectively (Kondradt et al. 2009). While self-ownership depends on a self-awareness of one’s actions, it also contributes to the effectiveness of self-leadership. Therefore, the process of self-leadership involves techniques that enhance one’s self-awareness as a leader. DOI: 10.1111/jonm.12235 ª 2014 John Wiley & Sons Ltd
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In a study conducted in 2012, capacity building refers to managerial structures, staff development, professional networking, interpersonal relations, and selfleadership through ownership as essential components of the process (Cairns 2011). This paper focuses on self-leadership through ownership. There is a need for self-ownership (also called professional identity) of nurses in order to facilitate: (1) accountability, (2) selfregulation, (3) self-motivation and (4) self-awareness. Autonomous practice implies accountability and professional responsibility (Holden 2007). The attributes of autonomy are defined as control over practice, autonomous decision-making, independence, interdependence, and self-regulation (Gagnon et al. 2010). Self-regulation is defined as a person’s ability to guide disruptive moods or impulses and the impartiality to postpone judgement by thinking before acting. Nurse managers should build the professional nurses’ capacity by expecting them to demonstrate that they are self-regulated professionals within their nursing unit (De Ridder & De Wit 2006). Self-motivation is the amount of effort a person applies to their work, how that effort is distributed across actions and tasks, and the continuous persistence of that effort allocation (De Nisi & Pritchard 2006). Signs of low motivation include role ambiguity, unwillingness to perform additional work, unwillingness to change because of work inefficiency, avoidance of work and not trying hard enough (effort) (De Nisi & Pritchard 2006). According to Thompson (2008), nurse managers can determine the motivational needs of professional nurses based on positive beliefs that motivate individuals to perform better at work. Morreale et al. (2007) state that every situation has a different reward appeal. Von Bonsdorff (2011) concurs that both financial and non-financial rewarding elements are highly appreciated by nurses. Self-awareness goes hand-in-hand with emotional self-management and control (Hamilton 2007). A person who lacks self-awareness will find it difficult to regulate their emotional expressions, their fears and avoidance of impulsive behaviour when threatened or rejected (George 2007). Jack and Smith (2007) explored self-awareness and concluded that methods that enhance the nurses’ levels of self-awareness are beneficial for personal and professional growth.
Research problem Although made known to nurse managers in hospitals, it seemed that little was done to promote capacity ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2014, 22, 532–539
building among nurses at an academic hospital in Gauteng. Nurses expressed their dissatisfaction during a monthly meeting with the lack of delegation of managerial tasks by nurse managers. Being delegated certain tasks could provide nursing staff with selfownership of their responsibilities with the purpose of achieving patient outcomes which, in turn, could reward them with the accountability they need. The lack of self-ownership also caused nurses to experience an underdevelopment of their capacity in their daily working environment. It was therefore unclear how nurse managers enhance self-leadership of professional nurses by taking ownership of capacity building in unit management. The general research question was: What are the perceptions of nurse managers and professional nurses about capacity building of professional nurses during nursing unit management? The subquestion addressed in this paper is: What are the perceptions of nurse managers and professional nurses about self-leadership of professional nurses in taking ownership of capacity building during unit management? The underlying assumption was that professional nurses had to take ownership of leading themselves during unit management.
Purpose of the study The general purpose of the study was to compare the perceptions of nurse managers and professional nurses about capacity building during nursing unit management.
Design and method A comparative design was followed. The accessible population consisted of permanently employed nurse managers (n = 100) and professional nurses (n = 150) at a Johannesburg academic hospital in Gauteng. The accessible population served as the total sample. Survey questionnaires were used to gather information (Burns & Grove 2009). Of the accessible sample, 183 (73.2% response rate) returned fully completed questionnaires. The survey was conducted in November 2011 by using two similar self-administered questionnaires. Questionnaire A was designed for nurse managers and Questionnaire B for professional nurses. The questionnaires addressed the implementation of five key capacity-building areas within the nursing units: managerial structures and processes; staff development; professional networking; self-leadership and ownership; and 533
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interpersonal relations. A seven-point Likert scale represented the professional nurses’ perceptions of the extent to which the different components of capacity building were being encouraged by the nurse manager or themselves in the nursing unit (see the Supporting Information, Table S1). Five experts in nursing management were asked to remark about the relevance and clarity of the capacity-building items for professional nurses in unit management. The questionnaire was designed to measure the phenomenon (capacity building) and its components. All the components of capacity building were relevant to the research questions (Burns & Grove 2009). In order to establish content validity, an exhaustive literature study based on the research questions was performed. The reliability of this questionnaire was increased by the use of items that strongly correlated to the variable being measured. The questionnaire reduced the chances of the respondents becoming tired or confused while answering the questionnaire. This ensured consistency of answers and a higher rate of participation. Inter-rater reliability was maintained by distributing similar questionnaires to all the respondents (Burns & Grove 2009). The only difference between questionnaires for Group A and Group B was the target group: Internal consistency was obtained by using Cronbach’s alpha coefficient. With a value above 0.70, this coefficient was sufficient evidence to support internal consistency of all sections of the questionnaire (LoBiondo-Wood & Haber 2006). It took about 30 minutes to complete the questionnaire during a prearranged meeting.
Data analysis With the assistance of a statistician, IBM PASW STATISTICS 18 (IBM Cooperation, Somers, NY, USA) was used to analyse the data.
Findings and discussion A total of 73 nurse managers and 110 professional nurses chose to participate in the study (n = 183). Almost half of the nurse managers (n = 33, 45.2%) and professional nurses (n = 49, 44.5%) were older than 40 years of age. Currently, in South Africa, it is an imperative for the health care institution to retain older nurses because fewer young people are entering the system. Only 14 (19.1%) nurse managers and 20 (18.2%) professional nurses held the rank of chief professional nurse on the nursing organogram. Almost half (n = 36, 49.3%) of the nurse managers and 50 534
(45.5%) of the professional nurses held post basic diplomas/degrees. More than one-third (n = 24, 32.9%) of the nurse managers and professional nurses (n = 39, 35.5%) had clinical experience of 11– 20 years. Professional nurses had slightly a greater number of years clinical experience than the nurse managers. The findings indicated a need for self-leadership by taking ownership in capacity building by unit managers. This was also supported in a previous study that indicated the need for professional identity of professional nurses in order to facilitate their development as effective nurse managers (Kooker et al. 2007). The factor analysis of the items in relation to self-leadership extracted two factors (see the Supporting Information, Table S2), namely own professional identity and self-accountability during unit management.
Professional identity as a leader Self-awareness Allowing professional nurses to demonstrate their selfawareness by understanding their moods and how they affect the nursing team provides them with the capacity to understand their personal characteristics and to gain insight into their basic behavioural inclinations, and the way in which they interact with other people (Robbins & Hunsaker 2003). Just under onequarter (n = 42, 23.6%) of the 178 of 183 respondents ‘always’ agreed that they had an understanding of their own self-awareness (x 4.66, SD 2.126). A minority (n = 28; 15.7%) of these respondents stated that they ‘never’ demonstrated their self-awareness. Responses were negatively skewed. Self-motivation By acknowledging that one is self-motivated, Morreale et al. (2007) suggest that the nurses who actively motivate themselves, who consciously search for goals to aim for, and who develop plans that can satisfy those motives will accomplish more in their lives than those nurses who do not analyse their motivations and work towards realising them. More than one-third (n = 64, 36.2%) of the 177 of 183 respondents responded that they were ‘always’ self-motivated (x 5.10, SD 2.030), indicating that they had the capacity for self-leadership. Coping skills The lowest average mean value was indicated by respondents about coping skills of nurses. A minority (n = 35; 19.6%) of the 179 of 183 respondents ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2014, 22, 532–539
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indicated that they could not cope with the daily pressures and stress associated with unit management (x 4.39; SD 2.201). Similarly, less than one-quarter (n = 39, 21.8%) of these respondents pointed out that they ‘always’ felt that they could handle the stress associated with unit management. This revealed an equal and wide distribution of responses around the mean value. Healy & McKay (2008) describe the common use of avoidance coping among nurses in order to reduce stress. Self-regulation Nearly one-third (n = 57, 32.0%) of the 178 of 183 respondents replied that they ‘always’ acted as selfregulated professionals in practice (x 5.18, SD 1.823). Two-thirds (n = 121; 66.8%) of these respondents suggested a positive agreement by indicating mean values between 5 and 7 (‘always’). The nurse manager mentored the professional nurses in self-regulation by developing their moral integrity that influenced their moral values and ethical roles (Kelly 2002). Self-confidence Less than one-quarter (n = 36, 20.2%) of the 178 of 183 respondents stated that the nurse manager built their confidence in unit management. Similarly, a minority (n = 31; 17.4%) of these respondents indicated that the nurse manager ‘never’ built their confidence (x 4.45, SD 2.181). The responses about selfconfidence signified an equal distribution around the mean value. Self-planning Less than half (n = 77; 43.3%) of the 178 of 183 respondents pointed out that they ‘always’ planned their time effectively in order to complete their daily duties (x 5.65, SD 1.868). More than three-quarters (n = 139, 76.5%) of these respondents had a positive agreement by indicating mean values between 5 and 7 (‘always’). The importance of effective time management within the nursing unit lies in the ability of the professional nurse to establish routines and prioritisation (Waterworth 2003). Acting as advocate The highest mean value appeared when respondents responded to being asked to act as a patient advocate. Nearly half (n = 85, 47.5%) of the 179 of 183 respondents stated that they would ‘always’ act as a patient advocate. The majority (n = 148, 81.0%) of these 179 respondents exhibited a positive agreement ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2014, 22, 532–539
by indicating mean values between 5 and 7 (‘always’) when they had acted as a patient advocate, for example by respecting patient rights (x 5.79; SD 1.578). Sorensen and Severinsson (2008) describe professional advocacy skills as essential to overcome barriers and to develop new nursing knowledge and standards when nurses are to perform a self-leadership role that contributes to the health care organisation and management.
Accountability in taking the lead Accountability is usually created through delegation. Kivimaki et al. (2008) describe job enrichment and how accountability for one’s actions is directly linked to work motivation, job satisfaction and taking the lead. Self-acknowledgement The statement was related to acknowledging that the professional nurse was competent to be in charge of the unit during the nurse manager’s absence (x 5.40; SD 1.994). There was a positive agreement from nearly three-quarters (n = 131, 71.8%) of the 181 of 183 respondents with less than half (n = 78, 43.1%) of these responses being ‘always’. Shuttleworth (2008) stated that delegation was more than simply asking another person to take on a task; it involved considering a number of factors, such as assessing that the delegated nurse was competent to undertake the task and that the specific nurse fully understood the direction to be taken. Being motivated Being motivated to perform at your very best on a daily basis was viewed as a valuable part of self-motivation necessary for self-leadership. Jooste (2009) emphasises the need for determining the motivational needs of the nursing staff within the unit in order to effectively implement self-motivation methods. Just under half (n = 84; 46.4%) of the 181 of 183 respondents mentioned that they ‘always’ felt motivated (x 5.66, SD 1.717); more than three-quarters (n = 142, 78.4%) of these respondents exhibited a positive agreement by indicating mean values between 5 and 7 (‘always’). Authority to delegate More than three-quarters (n = 142, 79.3%) of the 179 of 183 respondents had a positive agreement, with mean values between 5 and 7 (‘always’), by stating that they assumed the authority to delegate the 535
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daily tasks among the nursing staff (x 5.74, SD 1.690). Nearly half (n = 87; 48.6%) of these respondents indicated that they ‘always’ took authority. Muller (2009) states that once professional nurses have the legal authority to practice, they are then accountable for their actions. Self-accountability More than three-quarters (n = 142, 78.2%) of the 179 of 183 relevant respondents had a positive agreement, indicating mean values between 5 and 7 (‘always’), by stating that they were accountable for managerial responsibilities, for example ordering of supplies allocated to them during the shift (x 5.65, SD 1.868). Half (n = 90, 50.3%) of these respondents stated that they were ‘always’ accountable. Autonomous practice entails accountability that encompasses both personal and professional responsibility (Holden 2007) and the participant’s capacity for taking ownership to lead the way for followers. Taking responsibility Almost two-thirds (n = 112, 61.7%) of the 180 of 183 respondents had a positive agreement that they took responsibility for their daily managerial tasks such, as arranging agency nurses (x 4.77; SD 2.331). More than one-third (n = 66, 36.7%) of these respondents pointed out that they ‘always’ took personal responsibility for tasks. The attributes of a nurse manager’s work include responsibility and accountability activities (Surakka 2008), with more than half of the group in agreement that they were able to take responsibility and that the professional nurse was being capacitated by taking ownership of activities.
Significant differences between the two groups about self-leadership The 71 (100.0%) nurse managers had a higher average median (5.7) than the 110 professional nurses (5.1) (see the Supporting Information, Figure S1). Of the nurse managers, 50.0% had mean value responses that were distributed from above 5.0–6.5 (total range from 2.8 to 7.0), revealing a positive group agreement that the items of self-leadership were perceived to be practiced. The 110 (100.0%) professional nurses had a wider range of mean value responses (between 1.5 and 7.0), with 50.0% of the responses being between the mean values of 4.0 and 6.0. The nurse managers perceived greater levels of self-leadership within the nursing unit than the professional nurses, maybe 536
owing to the experience of practising nursing from a leadership perspective that requires the nurse manager to practise being responsible, accountable, and autonomous on a daily basis. The Kolmogorov–Smirnov test revealed that there was an abnormal distribution (P < 0.05) between the responses of the nurse managers (P = 0.001) and professional nurses’ (P = 0.001) responses with regard to self-leadership (see the Supporting Information, Table S3). Although not normally distributed, a t-test was performed. The variances were assumed equal (P > 0.05). Professional nurses had a lower agreement on self-leadership than the nurse managers, although both groups gave higher than average mean value responses. An independent samples t-test revealed that the nurse managers (n = 71; x 5.51, SD 1.297) differed significantly in their opinion about self-leadership from the professional nurses (n = 110; x 4.99, SD 1.461), as predicted [t(179) = 2.403 P = 0.017], therefore, the null hypothesis was rejected (Table S3). Johansson et al. (2010) mention that leadership traits of nurse managers are important for enhancing effectively self-knowledge and awareness of followers and to raise the awareness of their limitations. Nurse managers advising the professional nurse how to handle the daily pressures and stress associated with the unit According to the Mann–Whitney test, the responses of the nurse managers (n = 71; x 4.92, SD 2.116; mean rank 100.35) and the professional nurses (n = 107; x 4.14, SD 2.178; mean rank 82.30) were significantly different (z = 2.329; sig 0.020; P < 0.05). Nurse managers responded (range 1.0–7.0, median = 6.0) with higher values in comparison with the professional nurses (range of 1.0–7.0, median = 4.0) (see the Supporting Information, Figure S2). Three-quarters (75.0%) of the 71 nurse managers responded with mean values of between 4.0 and 7.0. The distribution of responses for the professional nurses was lower with 50.0% of the 107 professional nurses responding between 1.5 and 6.0. From the data, it could be assumed that the nurse managers perceived that they had been assisting the professional nurses in dealing with stress whereas the professional nurses agreed to a lesser extent. A study performed by Vanaki and Vagharseyyedin (2009) also discovered that nurses had remarkably higher stress levels than nurse managers. This could be because of low levels of self-confidence in relation to their clinical skills and a lack of managerial support. ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2014, 22, 532–539
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Building the professional nurses’ confidence by focusing on their strengths in unit management The responses from nurse managers (n = 71; x 5.08, SD 2.005; mean rank 105.85) and professional nurses (n = 108; x 3.94, SD 2.214; mean rank 79.58) were significantly different (z = 3.369; sig 0.001; P = < 0.05) (see the Supporting Information, Figure S3). The median of the responses for the 71 (100.0%) nurse managers was 6.0 vs. the 108 (100.0%) professional nurses with a lower median of 4.0. Fifty per cent of the 71 nurse managers responded between 3.5 and 6.0 and 50.0% of the 108 professional nurses responded between 2.0 and 6.0. Therefore, the nurse managers perceived that they built the professional nurses’ confidence whereas the professional nurses indicated that the nurse managers did not build their confidence. These findings concur with those findings of Lavoie-Tremblay et al. (2011). Acting as a self-regulated professional in practice The mean ranks between nurse managers (n = 69; x 5.55, SD 1.614; mean rank 99.28) and professional nurses (n = 109; x 4.94; SD 1.914; mean rank 83.31) were significantly different (z = 2.068; sig 0.039; P < 0.05). The mean of responses of the 69 (100.0%) nurse managers was 6.0 vs. the 109 (100.0%) professional nurses with a lower mean of 5.0 (Figure S4). Seventy-five per cent of the 69 nurse managers and 75.0% of 109 professional nurses responded between 4.0 and 7.0. The higher median of the nurse managers indicated that they acted as self-regulated professionals in practice, as supported by findings of Seago et al. (2011). Nurse managers allowing the professional nurses to demonstrate their self-awareness by understanding their/your moods and how these moods affect the nursing team The mean ranks between nurse managers (n = 70; x 5.19, SD 1.852; mean rank 101.46) and professional nurses (n = 108; x 4.31, SD 2.228; mean rank 81.75) were significantly different (namely z = 2.536; sig 0.01; P < 0.05). The nurse managers had a mean value of 6.0 (range 1–7) vs. 50 (range 1–7) of the professional nurses (see the Supporting Information, Figure S5). Seventy-five per cent of the nurse managers responded with mean values of between 4.0 and 7.0 and 50.0% of the professional nurses responded between 2.0 and 6.0. This is a far greater distribution of responses than the nurse managers with lower mean values. This revealed that nurse managers perceived their compliance with allowing the professional nurses ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2014, 22, 532–539
to demonstrate their self-awareness whereas the professional nurses perceived that nurse managers did not give them the opportunity to demonstrate their selfawareness (Vanaki & Vagharseyyedin 2009).
Limitations of the study Owing to the novelty of the topic of capacity building in nursing, it was challenging to find data on the ideas that were generated from the study. Therefore, further studies about capacity building in self-leadership should be encouraged. Another limitation was the use of respondents who only worked in an academic environment.
Conclusion Professional nurses should develop their confidence by focusing on their self-leadership strengths when managing a unit. Self-ownership could provide the professional nurse with a professional identity whereby he/she will be self-regulated, be self-motivated and self-aware. Only once the professional nurse has a professional identity can he/she have accountability for his/her actions within the nursing unit.
Implications for nursing management The responses showed shortcomings in terms of advising the professional nurse about taking ownership of their daily pressures and stress associated with unit management. An abnormal distribution (P < 0.05) between the responses of the nurse managers (P = 0.001) and professional nurses’ (P = 0.001) with regard to self-leadership was obtained. Only twothirds (n = 112, 61.7%) of the 180 (100.0%) respondents had a positive agreement that they took responsibility for their daily managerial tasks. It is essential for professional nurses to develop their ownership of responsibilities, as it will define them as nurse managers in future. Self-ownership provides the professional nurse with a professional identity that enables them to self-regulate, to self-motivate and to be self-aware. Only once a professional nurse has a professional identity can they assume accountability for their actions in the nursing unit. The nurse manager should encourage nurses to develop a professional identity. In today’s health care environment, nursing roles are shifting dramatically in response to changes in the health care system. It is essential for nurses to sustain themselves by means of 537
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their nursing roles, professional autonomy and supportive communication. A majority of 131 (71.8%) participants agreed on the importance of self-acknowledgement and professional identification. Professional identification could enable the professional nurse to remain self-aware of their nursing roles, self-motivation, self-regulation and maintain a clear vision. Certain actions could be taken by the nurse manager to promote self-leadership of nurses: Advising the professional nurse about ways in which to handle the daily pressures and stress associated with unit management. Supportive communication and social support from the nurse manager in the nursing unit are vital in assisting the professional nurses to be capable of using their own authority when handling stressful circumstances; Building the professional nurses’ self-confidence by focusing on their strong points in unit management; Allowing professional nurses to demonstrate their self-awareness by understanding their moods and how these moods affect the nursing team. Nurses who have a greater understanding of their professional roles in the nursing unit demonstrate greater job satisfaction and higher levels of motivation; and Encouraging the professional nurse to act as a selfregulated professional in practice by adhering to the corporate governance of the professional regulator. The nurse manager should encourage the professional nurse to embrace accountability. Scottish Government Framework for Nursing in General Practice (2004) describes accountability as regarding patient needs of the greatest importance, keeping up to date with regard to knowledge, skills and competence. Recognising personal limits with regard to knowledge skills and competence. Ensuring that nursing care is never compromised. Acknowledging personal accountability and avoiding inappropriate delegation.
Sources of funding The authors did not receive any funding for this paper.
Ethical approval The researcher obtained permission from hospital management to conduct the research at a public hospital, as well as permission from the Academic Ethics Committee and Higher Degree Committee of the Faculty of Health Sciences at a university in Johannesburg 538
(AEC55/09). All respondents were asked to sign an informed consent document before the completion of the questionnaire, which stated that their names would remain anonymous and that the information they provided would be treated confidentially. The respondents were informed about their option to withdraw (Burns & Grove 2009).
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Supporting information Additional Supporting Information may be found in the online version of this article: Figure S1. Occupational group distribution of responses on self-leadership (n = 181). Figure S2. Occupational group distribution of responses on self-leadership (n = 181). Figure S3. Nurses’ confidence by focusing on their strengths (n = 178). Figure S4. Building confidence by focusing on strengths (n = 179). Figure S5. Distribution of responses about acting as a self-regulated professional (n = 178). Figure S6. Self-awareness of moods (n = 178). Table S1. Descriptive statistics: ownership in selfleadership. Table S2. Factor analysis: self-leadership. Table S3. Inferential statistics on self-leadership in a unit: two groups.
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Comparing nurse managers and nurses’ perceptions of nurses’ self-leadership during capacity building KARIEN JOOSTE
PhD, MA Nurs, RGN
1
and LINDI CAIRNS
MA Nurs, RGN
2
1
Professor, School of Nursing, Faculty of Community and Health Sciences, University of the Western Cape, Cape Town, and 2Master Student, Department of Nursing, University of Johannesburg, Johannesburg, South Africa
Correspondence Karien Jooste School of Nursing Sciences Faculty of Community and Health Sciences University of the Western Cape Private Bag X17, Bellville 7535 Cape Town Western Cape South Africa E-mail: [email protected]
JOOSTE K. & CAIRNS L.
(2014) Journal of Nursing Management 22, 532–539 Comparing nurse managers and nurses’ perceptions of nurses’ self-leadership during capacity building Aims This paper compares the perceptions of nurse managers and nurses about self-leadership of professional nurses while taking ownership of capacity building during unit management. Background The Nursing Strategy for South Africa states that the competency of nurses is dependent upon factors that lead to capacity building. Method A quantitative design was followed by conducting a survey. The target population included nurse managers and professional nurses working at an academic public hospital in the Gauteng Province of South Africa. Results The findings indicate shortcomings in relation to advising professional nurses about self-direction while taking ownership of their daily pressures and stresses associated with unit management. Conclusion Professional nurses should develop their confidence by focusing on their self-leadership strengths when managing a unit. Implications for nurse managers Recommendations are made to promote selfleadership while taking ownership of nurses during capacity building of unit management.
Keywords: capacity building, nurse managers, ownership, self-leadership, unit management Accepted for publication: 17 February 2014
Introduction Capacity building is a management approach used to develop individuals by enabling them to carry out their tasks to the best of their ability. This is achieved by giving health care professionals access to information, providing opportunities for them to make decisions, and empowering them to act (Hawe et al. 2009). All professional nurses should be equipped with the skills and knowledge of management in order to assume accountability and responsibility within their nursing unit (Muller 2009). The concepts of capacity building include enhanced participation in formulating organisational plans and an 532
increase in the authority given to the nurse (Grobler et al. 2006). The attributes of capacity building include teamwork, the availability of information systems, decision making, support and self-leadership through ownership (Proudfoot et al. 2007). Self-leadership is a process that requires an individual to control personal actions, to be self-aware and to utilise personal strength, which are necessary for performing tasks effectively (Kondradt et al. 2009). While self-ownership depends on a self-awareness of one’s actions, it also contributes to the effectiveness of self-leadership. Therefore, the process of self-leadership involves techniques that enhance one’s self-awareness as a leader. DOI: 10.1111/jonm.12235 ª 2014 John Wiley & Sons Ltd
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In a study conducted in 2012, capacity building refers to managerial structures, staff development, professional networking, interpersonal relations, and selfleadership through ownership as essential components of the process (Cairns 2011). This paper focuses on self-leadership through ownership. There is a need for self-ownership (also called professional identity) of nurses in order to facilitate: (1) accountability, (2) selfregulation, (3) self-motivation and (4) self-awareness. Autonomous practice implies accountability and professional responsibility (Holden 2007). The attributes of autonomy are defined as control over practice, autonomous decision-making, independence, interdependence, and self-regulation (Gagnon et al. 2010). Self-regulation is defined as a person’s ability to guide disruptive moods or impulses and the impartiality to postpone judgement by thinking before acting. Nurse managers should build the professional nurses’ capacity by expecting them to demonstrate that they are self-regulated professionals within their nursing unit (De Ridder & De Wit 2006). Self-motivation is the amount of effort a person applies to their work, how that effort is distributed across actions and tasks, and the continuous persistence of that effort allocation (De Nisi & Pritchard 2006). Signs of low motivation include role ambiguity, unwillingness to perform additional work, unwillingness to change because of work inefficiency, avoidance of work and not trying hard enough (effort) (De Nisi & Pritchard 2006). According to Thompson (2008), nurse managers can determine the motivational needs of professional nurses based on positive beliefs that motivate individuals to perform better at work. Morreale et al. (2007) state that every situation has a different reward appeal. Von Bonsdorff (2011) concurs that both financial and non-financial rewarding elements are highly appreciated by nurses. Self-awareness goes hand-in-hand with emotional self-management and control (Hamilton 2007). A person who lacks self-awareness will find it difficult to regulate their emotional expressions, their fears and avoidance of impulsive behaviour when threatened or rejected (George 2007). Jack and Smith (2007) explored self-awareness and concluded that methods that enhance the nurses’ levels of self-awareness are beneficial for personal and professional growth.
Research problem Although made known to nurse managers in hospitals, it seemed that little was done to promote capacity ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2014, 22, 532–539
building among nurses at an academic hospital in Gauteng. Nurses expressed their dissatisfaction during a monthly meeting with the lack of delegation of managerial tasks by nurse managers. Being delegated certain tasks could provide nursing staff with selfownership of their responsibilities with the purpose of achieving patient outcomes which, in turn, could reward them with the accountability they need. The lack of self-ownership also caused nurses to experience an underdevelopment of their capacity in their daily working environment. It was therefore unclear how nurse managers enhance self-leadership of professional nurses by taking ownership of capacity building in unit management. The general research question was: What are the perceptions of nurse managers and professional nurses about capacity building of professional nurses during nursing unit management? The subquestion addressed in this paper is: What are the perceptions of nurse managers and professional nurses about self-leadership of professional nurses in taking ownership of capacity building during unit management? The underlying assumption was that professional nurses had to take ownership of leading themselves during unit management.
Purpose of the study The general purpose of the study was to compare the perceptions of nurse managers and professional nurses about capacity building during nursing unit management.
Design and method A comparative design was followed. The accessible population consisted of permanently employed nurse managers (n = 100) and professional nurses (n = 150) at a Johannesburg academic hospital in Gauteng. The accessible population served as the total sample. Survey questionnaires were used to gather information (Burns & Grove 2009). Of the accessible sample, 183 (73.2% response rate) returned fully completed questionnaires. The survey was conducted in November 2011 by using two similar self-administered questionnaires. Questionnaire A was designed for nurse managers and Questionnaire B for professional nurses. The questionnaires addressed the implementation of five key capacity-building areas within the nursing units: managerial structures and processes; staff development; professional networking; self-leadership and ownership; and 533
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interpersonal relations. A seven-point Likert scale represented the professional nurses’ perceptions of the extent to which the different components of capacity building were being encouraged by the nurse manager or themselves in the nursing unit (see the Supporting Information, Table S1). Five experts in nursing management were asked to remark about the relevance and clarity of the capacity-building items for professional nurses in unit management. The questionnaire was designed to measure the phenomenon (capacity building) and its components. All the components of capacity building were relevant to the research questions (Burns & Grove 2009). In order to establish content validity, an exhaustive literature study based on the research questions was performed. The reliability of this questionnaire was increased by the use of items that strongly correlated to the variable being measured. The questionnaire reduced the chances of the respondents becoming tired or confused while answering the questionnaire. This ensured consistency of answers and a higher rate of participation. Inter-rater reliability was maintained by distributing similar questionnaires to all the respondents (Burns & Grove 2009). The only difference between questionnaires for Group A and Group B was the target group: Internal consistency was obtained by using Cronbach’s alpha coefficient. With a value above 0.70, this coefficient was sufficient evidence to support internal consistency of all sections of the questionnaire (LoBiondo-Wood & Haber 2006). It took about 30 minutes to complete the questionnaire during a prearranged meeting.
Data analysis With the assistance of a statistician, IBM PASW STATISTICS 18 (IBM Cooperation, Somers, NY, USA) was used to analyse the data.
Findings and discussion A total of 73 nurse managers and 110 professional nurses chose to participate in the study (n = 183). Almost half of the nurse managers (n = 33, 45.2%) and professional nurses (n = 49, 44.5%) were older than 40 years of age. Currently, in South Africa, it is an imperative for the health care institution to retain older nurses because fewer young people are entering the system. Only 14 (19.1%) nurse managers and 20 (18.2%) professional nurses held the rank of chief professional nurse on the nursing organogram. Almost half (n = 36, 49.3%) of the nurse managers and 50 534
(45.5%) of the professional nurses held post basic diplomas/degrees. More than one-third (n = 24, 32.9%) of the nurse managers and professional nurses (n = 39, 35.5%) had clinical experience of 11– 20 years. Professional nurses had slightly a greater number of years clinical experience than the nurse managers. The findings indicated a need for self-leadership by taking ownership in capacity building by unit managers. This was also supported in a previous study that indicated the need for professional identity of professional nurses in order to facilitate their development as effective nurse managers (Kooker et al. 2007). The factor analysis of the items in relation to self-leadership extracted two factors (see the Supporting Information, Table S2), namely own professional identity and self-accountability during unit management.
Professional identity as a leader Self-awareness Allowing professional nurses to demonstrate their selfawareness by understanding their moods and how they affect the nursing team provides them with the capacity to understand their personal characteristics and to gain insight into their basic behavioural inclinations, and the way in which they interact with other people (Robbins & Hunsaker 2003). Just under onequarter (n = 42, 23.6%) of the 178 of 183 respondents ‘always’ agreed that they had an understanding of their own self-awareness (x 4.66, SD 2.126). A minority (n = 28; 15.7%) of these respondents stated that they ‘never’ demonstrated their self-awareness. Responses were negatively skewed. Self-motivation By acknowledging that one is self-motivated, Morreale et al. (2007) suggest that the nurses who actively motivate themselves, who consciously search for goals to aim for, and who develop plans that can satisfy those motives will accomplish more in their lives than those nurses who do not analyse their motivations and work towards realising them. More than one-third (n = 64, 36.2%) of the 177 of 183 respondents responded that they were ‘always’ self-motivated (x 5.10, SD 2.030), indicating that they had the capacity for self-leadership. Coping skills The lowest average mean value was indicated by respondents about coping skills of nurses. A minority (n = 35; 19.6%) of the 179 of 183 respondents ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2014, 22, 532–539
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indicated that they could not cope with the daily pressures and stress associated with unit management (x 4.39; SD 2.201). Similarly, less than one-quarter (n = 39, 21.8%) of these respondents pointed out that they ‘always’ felt that they could handle the stress associated with unit management. This revealed an equal and wide distribution of responses around the mean value. Healy & McKay (2008) describe the common use of avoidance coping among nurses in order to reduce stress. Self-regulation Nearly one-third (n = 57, 32.0%) of the 178 of 183 respondents replied that they ‘always’ acted as selfregulated professionals in practice (x 5.18, SD 1.823). Two-thirds (n = 121; 66.8%) of these respondents suggested a positive agreement by indicating mean values between 5 and 7 (‘always’). The nurse manager mentored the professional nurses in self-regulation by developing their moral integrity that influenced their moral values and ethical roles (Kelly 2002). Self-confidence Less than one-quarter (n = 36, 20.2%) of the 178 of 183 respondents stated that the nurse manager built their confidence in unit management. Similarly, a minority (n = 31; 17.4%) of these respondents indicated that the nurse manager ‘never’ built their confidence (x 4.45, SD 2.181). The responses about selfconfidence signified an equal distribution around the mean value. Self-planning Less than half (n = 77; 43.3%) of the 178 of 183 respondents pointed out that they ‘always’ planned their time effectively in order to complete their daily duties (x 5.65, SD 1.868). More than three-quarters (n = 139, 76.5%) of these respondents had a positive agreement by indicating mean values between 5 and 7 (‘always’). The importance of effective time management within the nursing unit lies in the ability of the professional nurse to establish routines and prioritisation (Waterworth 2003). Acting as advocate The highest mean value appeared when respondents responded to being asked to act as a patient advocate. Nearly half (n = 85, 47.5%) of the 179 of 183 respondents stated that they would ‘always’ act as a patient advocate. The majority (n = 148, 81.0%) of these 179 respondents exhibited a positive agreement ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2014, 22, 532–539
by indicating mean values between 5 and 7 (‘always’) when they had acted as a patient advocate, for example by respecting patient rights (x 5.79; SD 1.578). Sorensen and Severinsson (2008) describe professional advocacy skills as essential to overcome barriers and to develop new nursing knowledge and standards when nurses are to perform a self-leadership role that contributes to the health care organisation and management.
Accountability in taking the lead Accountability is usually created through delegation. Kivimaki et al. (2008) describe job enrichment and how accountability for one’s actions is directly linked to work motivation, job satisfaction and taking the lead. Self-acknowledgement The statement was related to acknowledging that the professional nurse was competent to be in charge of the unit during the nurse manager’s absence (x 5.40; SD 1.994). There was a positive agreement from nearly three-quarters (n = 131, 71.8%) of the 181 of 183 respondents with less than half (n = 78, 43.1%) of these responses being ‘always’. Shuttleworth (2008) stated that delegation was more than simply asking another person to take on a task; it involved considering a number of factors, such as assessing that the delegated nurse was competent to undertake the task and that the specific nurse fully understood the direction to be taken. Being motivated Being motivated to perform at your very best on a daily basis was viewed as a valuable part of self-motivation necessary for self-leadership. Jooste (2009) emphasises the need for determining the motivational needs of the nursing staff within the unit in order to effectively implement self-motivation methods. Just under half (n = 84; 46.4%) of the 181 of 183 respondents mentioned that they ‘always’ felt motivated (x 5.66, SD 1.717); more than three-quarters (n = 142, 78.4%) of these respondents exhibited a positive agreement by indicating mean values between 5 and 7 (‘always’). Authority to delegate More than three-quarters (n = 142, 79.3%) of the 179 of 183 respondents had a positive agreement, with mean values between 5 and 7 (‘always’), by stating that they assumed the authority to delegate the 535
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daily tasks among the nursing staff (x 5.74, SD 1.690). Nearly half (n = 87; 48.6%) of these respondents indicated that they ‘always’ took authority. Muller (2009) states that once professional nurses have the legal authority to practice, they are then accountable for their actions. Self-accountability More than three-quarters (n = 142, 78.2%) of the 179 of 183 relevant respondents had a positive agreement, indicating mean values between 5 and 7 (‘always’), by stating that they were accountable for managerial responsibilities, for example ordering of supplies allocated to them during the shift (x 5.65, SD 1.868). Half (n = 90, 50.3%) of these respondents stated that they were ‘always’ accountable. Autonomous practice entails accountability that encompasses both personal and professional responsibility (Holden 2007) and the participant’s capacity for taking ownership to lead the way for followers. Taking responsibility Almost two-thirds (n = 112, 61.7%) of the 180 of 183 respondents had a positive agreement that they took responsibility for their daily managerial tasks such, as arranging agency nurses (x 4.77; SD 2.331). More than one-third (n = 66, 36.7%) of these respondents pointed out that they ‘always’ took personal responsibility for tasks. The attributes of a nurse manager’s work include responsibility and accountability activities (Surakka 2008), with more than half of the group in agreement that they were able to take responsibility and that the professional nurse was being capacitated by taking ownership of activities.
Significant differences between the two groups about self-leadership The 71 (100.0%) nurse managers had a higher average median (5.7) than the 110 professional nurses (5.1) (see the Supporting Information, Figure S1). Of the nurse managers, 50.0% had mean value responses that were distributed from above 5.0–6.5 (total range from 2.8 to 7.0), revealing a positive group agreement that the items of self-leadership were perceived to be practiced. The 110 (100.0%) professional nurses had a wider range of mean value responses (between 1.5 and 7.0), with 50.0% of the responses being between the mean values of 4.0 and 6.0. The nurse managers perceived greater levels of self-leadership within the nursing unit than the professional nurses, maybe 536
owing to the experience of practising nursing from a leadership perspective that requires the nurse manager to practise being responsible, accountable, and autonomous on a daily basis. The Kolmogorov–Smirnov test revealed that there was an abnormal distribution (P < 0.05) between the responses of the nurse managers (P = 0.001) and professional nurses’ (P = 0.001) responses with regard to self-leadership (see the Supporting Information, Table S3). Although not normally distributed, a t-test was performed. The variances were assumed equal (P > 0.05). Professional nurses had a lower agreement on self-leadership than the nurse managers, although both groups gave higher than average mean value responses. An independent samples t-test revealed that the nurse managers (n = 71; x 5.51, SD 1.297) differed significantly in their opinion about self-leadership from the professional nurses (n = 110; x 4.99, SD 1.461), as predicted [t(179) = 2.403 P = 0.017], therefore, the null hypothesis was rejected (Table S3). Johansson et al. (2010) mention that leadership traits of nurse managers are important for enhancing effectively self-knowledge and awareness of followers and to raise the awareness of their limitations. Nurse managers advising the professional nurse how to handle the daily pressures and stress associated with the unit According to the Mann–Whitney test, the responses of the nurse managers (n = 71; x 4.92, SD 2.116; mean rank 100.35) and the professional nurses (n = 107; x 4.14, SD 2.178; mean rank 82.30) were significantly different (z = 2.329; sig 0.020; P < 0.05). Nurse managers responded (range 1.0–7.0, median = 6.0) with higher values in comparison with the professional nurses (range of 1.0–7.0, median = 4.0) (see the Supporting Information, Figure S2). Three-quarters (75.0%) of the 71 nurse managers responded with mean values of between 4.0 and 7.0. The distribution of responses for the professional nurses was lower with 50.0% of the 107 professional nurses responding between 1.5 and 6.0. From the data, it could be assumed that the nurse managers perceived that they had been assisting the professional nurses in dealing with stress whereas the professional nurses agreed to a lesser extent. A study performed by Vanaki and Vagharseyyedin (2009) also discovered that nurses had remarkably higher stress levels than nurse managers. This could be because of low levels of self-confidence in relation to their clinical skills and a lack of managerial support. ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2014, 22, 532–539
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Building the professional nurses’ confidence by focusing on their strengths in unit management The responses from nurse managers (n = 71; x 5.08, SD 2.005; mean rank 105.85) and professional nurses (n = 108; x 3.94, SD 2.214; mean rank 79.58) were significantly different (z = 3.369; sig 0.001; P = < 0.05) (see the Supporting Information, Figure S3). The median of the responses for the 71 (100.0%) nurse managers was 6.0 vs. the 108 (100.0%) professional nurses with a lower median of 4.0. Fifty per cent of the 71 nurse managers responded between 3.5 and 6.0 and 50.0% of the 108 professional nurses responded between 2.0 and 6.0. Therefore, the nurse managers perceived that they built the professional nurses’ confidence whereas the professional nurses indicated that the nurse managers did not build their confidence. These findings concur with those findings of Lavoie-Tremblay et al. (2011). Acting as a self-regulated professional in practice The mean ranks between nurse managers (n = 69; x 5.55, SD 1.614; mean rank 99.28) and professional nurses (n = 109; x 4.94; SD 1.914; mean rank 83.31) were significantly different (z = 2.068; sig 0.039; P < 0.05). The mean of responses of the 69 (100.0%) nurse managers was 6.0 vs. the 109 (100.0%) professional nurses with a lower mean of 5.0 (Figure S4). Seventy-five per cent of the 69 nurse managers and 75.0% of 109 professional nurses responded between 4.0 and 7.0. The higher median of the nurse managers indicated that they acted as self-regulated professionals in practice, as supported by findings of Seago et al. (2011). Nurse managers allowing the professional nurses to demonstrate their self-awareness by understanding their/your moods and how these moods affect the nursing team The mean ranks between nurse managers (n = 70; x 5.19, SD 1.852; mean rank 101.46) and professional nurses (n = 108; x 4.31, SD 2.228; mean rank 81.75) were significantly different (namely z = 2.536; sig 0.01; P < 0.05). The nurse managers had a mean value of 6.0 (range 1–7) vs. 50 (range 1–7) of the professional nurses (see the Supporting Information, Figure S5). Seventy-five per cent of the nurse managers responded with mean values of between 4.0 and 7.0 and 50.0% of the professional nurses responded between 2.0 and 6.0. This is a far greater distribution of responses than the nurse managers with lower mean values. This revealed that nurse managers perceived their compliance with allowing the professional nurses ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2014, 22, 532–539
to demonstrate their self-awareness whereas the professional nurses perceived that nurse managers did not give them the opportunity to demonstrate their selfawareness (Vanaki & Vagharseyyedin 2009).
Limitations of the study Owing to the novelty of the topic of capacity building in nursing, it was challenging to find data on the ideas that were generated from the study. Therefore, further studies about capacity building in self-leadership should be encouraged. Another limitation was the use of respondents who only worked in an academic environment.
Conclusion Professional nurses should develop their confidence by focusing on their self-leadership strengths when managing a unit. Self-ownership could provide the professional nurse with a professional identity whereby he/she will be self-regulated, be self-motivated and self-aware. Only once the professional nurse has a professional identity can he/she have accountability for his/her actions within the nursing unit.
Implications for nursing management The responses showed shortcomings in terms of advising the professional nurse about taking ownership of their daily pressures and stress associated with unit management. An abnormal distribution (P < 0.05) between the responses of the nurse managers (P = 0.001) and professional nurses’ (P = 0.001) with regard to self-leadership was obtained. Only twothirds (n = 112, 61.7%) of the 180 (100.0%) respondents had a positive agreement that they took responsibility for their daily managerial tasks. It is essential for professional nurses to develop their ownership of responsibilities, as it will define them as nurse managers in future. Self-ownership provides the professional nurse with a professional identity that enables them to self-regulate, to self-motivate and to be self-aware. Only once a professional nurse has a professional identity can they assume accountability for their actions in the nursing unit. The nurse manager should encourage nurses to develop a professional identity. In today’s health care environment, nursing roles are shifting dramatically in response to changes in the health care system. It is essential for nurses to sustain themselves by means of 537
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their nursing roles, professional autonomy and supportive communication. A majority of 131 (71.8%) participants agreed on the importance of self-acknowledgement and professional identification. Professional identification could enable the professional nurse to remain self-aware of their nursing roles, self-motivation, self-regulation and maintain a clear vision. Certain actions could be taken by the nurse manager to promote self-leadership of nurses: Advising the professional nurse about ways in which to handle the daily pressures and stress associated with unit management. Supportive communication and social support from the nurse manager in the nursing unit are vital in assisting the professional nurses to be capable of using their own authority when handling stressful circumstances; Building the professional nurses’ self-confidence by focusing on their strong points in unit management; Allowing professional nurses to demonstrate their self-awareness by understanding their moods and how these moods affect the nursing team. Nurses who have a greater understanding of their professional roles in the nursing unit demonstrate greater job satisfaction and higher levels of motivation; and Encouraging the professional nurse to act as a selfregulated professional in practice by adhering to the corporate governance of the professional regulator. The nurse manager should encourage the professional nurse to embrace accountability. Scottish Government Framework for Nursing in General Practice (2004) describes accountability as regarding patient needs of the greatest importance, keeping up to date with regard to knowledge, skills and competence. Recognising personal limits with regard to knowledge skills and competence. Ensuring that nursing care is never compromised. Acknowledging personal accountability and avoiding inappropriate delegation.
Sources of funding The authors did not receive any funding for this paper.
Ethical approval The researcher obtained permission from hospital management to conduct the research at a public hospital, as well as permission from the Academic Ethics Committee and Higher Degree Committee of the Faculty of Health Sciences at a university in Johannesburg 538
(AEC55/09). All respondents were asked to sign an informed consent document before the completion of the questionnaire, which stated that their names would remain anonymous and that the information they provided would be treated confidentially. The respondents were informed about their option to withdraw (Burns & Grove 2009).
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Supporting information Additional Supporting Information may be found in the online version of this article: Figure S1. Occupational group distribution of responses on self-leadership (n = 181). Figure S2. Occupational group distribution of responses on self-leadership (n = 181). Figure S3. Nurses’ confidence by focusing on their strengths (n = 178). Figure S4. Building confidence by focusing on strengths (n = 179). Figure S5. Distribution of responses about acting as a self-regulated professional (n = 178). Figure S6. Self-awareness of moods (n = 178). Table S1. Descriptive statistics: ownership in selfleadership. Table S2. Factor analysis: self-leadership. Table S3. Inferential statistics on self-leadership in a unit: two groups.
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