Journal of Nursing Management, 2015
Exploring competencies: a qualitative study of Chinese nurse managers WEN-YI LUO R N , M S N 1, NAN-PING SHEN and JI-WEN SUN B S N 4
RN, MSN
2
, JIAN-HUA LOU
RN, BSN
3
, PING-PING HE
RN, BSN
1
1
Nurse Manager, Cardiovascular Intensive Care Unit, 2Associated Professor, Vice Director, 3Professor, Nursing Department, Shanghai Children’s Medical Centre and 4Student, School of Nursing, Shanghai Jiao Tong University, Shanghai, China
Correspondence Nan-Ping Shen Nursing Department Shanghai Children’s Medical Centre 1678 Dongfang Road Pudong New District Shanghai 200127 China E-mail: [email protected]
LUO W.-Y., SHEN N.-P., LOU J.-H., HE P.-P. & SUN J.-W.
(2015) Journal of Nursing Management Exploring competencies: a qualitative study of Chinese nurse managers Aim To identify core competencies needed in the transition of nurse managers on the way to excellence. Background There is growing recognition of the importance of nurse managers in hospitals. Most managers still learn through their failures and few studies have described the perceptions of nurse managers in China. It is vital to understand what competencies Chinese nurse managers should have in order to establish suitable training programmes and improve their management skills. Method A phenomenological approach that included in-depth interviews with 12 nurse managers in six Chinese hospitals was conducted. Results The transition to management included four phases: the adaptive phase, the running-in and stable phase, the stagnation phase and the maturation phase. Conclusion In order to fulfil their clinical responsibilities, nurse managers need to develop multifaceted competencies, specifically in communication and stress management. Ideally, nurse managers should progress through the four phases mentioned above to achieve excellence. Implications There is a requirement for utilising various methods for nurse managers in adapting new roles, improving communication and relieving stress.
Keywords: competency, management skills, nurse manager, phenomenological approach, qualitative research Accepted for publication: 2 February 2015
Introduction Modern society is focused on the growing demand for nursing. To meet diverse demands and address public concerns, nursing development is inevitable. Nurse managers, directors and operators involved in nursing development have a responsibility to introduce hospitals’ goals and objectives to nursing practice. The responsibilities of the people involved in nursing development influence nursing quality, patient safety and satisfaction, nurses’ working satisfaction and retention and the working environment DOI: 10.1111/jonm.12295 ª 2015 John Wiley & Sons Ltd
(Kirby & DeCampli 2008, Fennimore & Wolf 2011,). There is, therefore, a growing recognition of nurse managers in hospitals to have multifaceted abilities. Jennings et al. (2007) reviewed 140 articles and identified 878 competencies required for nursing management. These days every element in the clinical working environment inclusive of patients, staff, medical insurance and national sanitary regulations is undergoing tremendous change in China. As a result, Chinese nurse managers are facing huge new challenges. In the current situation, many nurse managers 1
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(aged 40–55 years) have low levels of academic preparation and qualifications as a result of the country’s historical background (Wong 2010). The need to be better prepared for information technology, quality assurance, outcome management and evidence-based practice creates a great deal of stress. Additionally, there are the common issues of insufficient training including unclear definitions of management (maintaining order, planning, organising, coordinating resources and attending to rules) and leadership (helping people move towards achieving a vision) (Jennings et al. 2007) and lack of systematic management training (Liu & Wang 2012). The majority of Chinese managers continue to learn through their failures or work in response to their emotional experiences. This response is called ‘sense making’ (Noordegraaf 2000) and leaves nurse managers more likely to feel stress and experience feelings of defeat and failure while attempting to achieve mastery (Kirby & DeCampli 2008, Govero 2012).
Background Since McClelland (1973) observed that competency is task- and organisation-specific, his classic concept has continued to be a popular topic in various fields of research. Studies related to competencies have been built on the basis of the iceberg model, along with other alternative models. Spencer’s iceberg model (Spencer & Spencer 1993) includes hidden characteristics (self-concept, traits and motives) and surface characteristics (knowledge and skills) and is widely used in management owing to the scientific method that it employs to distinguish excellent staff. More recently, Supamanee et al. (2011), guided by the iceberg model, listed and expanded the hidden and surface characteristics of Thai nurse managers. Beyond the iceberg model, some alternative models of nursing manager’s competency have been developed using individual qualitative or quantitative approaches. Two groundedtheory projects have been conducted (Stanley 2006, Sherman et al. 2007), from which competency categories have emerged, including interpersonal effectiveness, caring and systems thinking; personal mastery, financial management and human resource management; and empowerment and motivation. Burns (2009) proposed the competencies of political astuteness and strategic influencing through a phenomenology approach. Kang et al. (2012) indicated the importance of research capability, time management and executive power, showing significant correlations across all managerial competencies. The competencies 2
of nurse managers that have emerged from these alternative models are more detailed and more suitable for the clinic and subspecialty field than those of the iceberg model; however, the content of these models vary across different geographical areas and political systems (Stanley 2006, Sherman et al. 2007, Burns 2009, Kang et al. 2012, ). In light of this, the competencies of nurse managers need to be explored separately. Because they are usually divided into three levels – front-line, mid-level and director-level – with different levels appointed to different missions (Rush et al. 2000). In China, some quantitative research has found firstline nurse managers to be incompetent because of heavy workloads, a nursing shortage and lower education levels (Xianyu et al. 2006, Wu et al. 2010). Based on this situation, the State Council has issued an Outline Program for Chinese Nursing Development (2011–2015) (NHFPCC 2011), which provides concretely stipulated goals and measures for the development of Chinese nurse managers until 2015. It is vital to understand which competencies Chinese first-line nurse managers need so that suitable training programmes can be established to help nurse managers improve their abilities to manage effectively and fulfil the new governmental requirements. Few studies have described the perceptions of firstline nurse managers in China. Therefore, the aim of this study was to identify core competencies needed in the transition of nurse managers on the way to excellence.
Method Design The descriptive phenomenology methodology was used to acquire the intersubjective knowledge of Chinese first-line nurse managers’ experience, that is, the life world as it is known in Husserlian phenomenology, in terms of the meaning of experience and the essence of the experience (Husserl 1965). For Husserl, phenomena of an experience can be consciously expressed and can be understood by people who live it. The experience exists in the consciousness in a pure form without presupposition and can be described through pure subjectivity through bracketing (Husserl 1965).
Participants This study was conducted in 2013. Purposeful sampling was used to recruit a sample of 12 individuals ª 2015 John Wiley & Sons Ltd Journal of Nursing Management
Exploring Chinese nurse managers’ competencies
Four participants wanted to discuss clinical problems with their chief physicians. The benefit of cooperating with the chief physician was clear.
‘People are lazy. Now my management is on the right track. I have no more motivation to pro(NM7) gress’.
‘He gives the nurses a sense of belonging, increases our welfare, educates his physicians to be friendly to nurses and organizes activities’. (NM10)
‘My annual evaluation from nursing department is just passed, not distinguished. But no one force me to change anything, so do I’. (NM4)
Four other informants never communicated with their chief physicians in their daily management. ‘My chief always plays hardball; you know, it is too difficult to talk with him. In his mind, the only requirement of a nurse manager is to avoid (NM2) clinical accidents’. In this phase, the nurse managers aimed to round out the development of their management competencies to meet the basic requirements of their supervisors. As they gained experience, they began to reflect on themselves to discover their strengths and weaknesses. ‘I notice the behavior, expression and attitudes of everybody I meet, and I also get the results of my annual assessment. These are the forces that (NM3) motivate my development’.
The maturation phase When nurse managers scale the learning ‘hump’ of their career lives, most of them improve steadily and rethink their management competencies. Eight participants began to develop their professional identity, and made an effort to learn a second language so that they could engage in outside exchanges and diminish disparities between nursing practices domestically and abroad. ‘I prepared myself all the time. As a result, I had opportunities to be selected to visit famous hospitals in Singapore, France, Australia and the U.S.A. To some extent, I really have benefited a lot from advanced concepts and prac(NM11) tice’.
Once original goals or requirements are met, nurse managers enter the stagnation phase. Three participants could not adjust their emotions and became easily depressed.
During this phase, the nurse managers did not focus on routine duties, they developed the ability to synthesize concept thinking and analytical thinking in risk management. Four participants indicated they could identify key elements of risk events, analyse relevant relationships and solve problems through scientific methods.
‘Most problems resulted from my failure to adjust my emotions and resulted in an easy slide into depression. I must be responsible for everything. I don’t like being ordered about by anyone, you know, but frequently I have to receive their round criticism or rebukes’. (NM2)
‘First, I thought about my education [about pressure ulcers], and then I turned to the standards to find out how to analyze and improve the reasons for the condition. After that, I searched high-level, evidence-based articles and organized relevant staff members to conduct a quality-con(NM5) trol circle’.
When talking about how to balance work and daily life, 10 nurse managers became emotional and cried. They were weighed down with work.
Most participants focused on building their own talent team. Four participants had planned different roles for nurse specialists according to their goals and expectations, and they were all rewarded as excellent nurse managers.
The stagnation phase
‘Sometimes I have to rush to the ward at midnight; I could not care, and even nearly gave up my entire family, especially my sick son [Crying.] ’. (NM9) Three older informants felt they were losing motivation and lacked career planning.
ª 2015 John Wiley & Sons Ltd Journal of Nursing Management
‘Now, all nurses have their own roles and goals. I feel that my unit is gradually moving (NM9) up’.
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‘My unit was short one nurse, so as a manager, I had to fill that position. I had to manage patients, nurses and the unit at the same time’. (NM11) During this phase, all of the participants lacked management experience. They learned and built basic competencies by trial and error, according to clinical primary needs. The adaptive phase helped them build work-awareness. ‘At first I got it all screwed up. I prayed that no more accidents would happen. It took me two or three months to straighten out the mess’. (NM3)
The running-in and stable phase Once the nurse managers worked through the initial phase, they began to develop abilities in the areas of task organisation and time management. ‘I check my schedule every week, plan everything to ensure that nothing is left, and make some marks on my schedule table when I reach my (NM3) goals’. ‘I’ll report all of the key points on the card in my pocket and finish them in order of priority’. (NM7) Occasionally, the full weight of decision-making at the unit level falls on the nurse managers, especially with regards to revising policies and workflow. Six informants preferred taking action immediately, based on what they perceived to be the best approach. ‘I do what I think is right. I am principled and make policies according to rules and regula(NM8) tions’.
specialists help me manage resources and materials, and the nurse educators maintain and moni(NM3) tor clinical quality’. One of the main tasks of nurse managers is clinical quality management, which requires managers to provide the best quality of patient care of greatest benefit. ‘Once there was a patient who needed an enema before surgery, but it was hard to perform due to the existence of a recto-vaginal fistula. Therefore, I tried my best to dilute the mannitol injection, and I tested it myself first until the patient (NM7) could bear the taste’. Fairness was regarded as the most important principle for the 12 participants when evaluating their nursing staff. ‘You must use the same criteria to assess all staff members and be fair in evaluating their perfor(NM5) mance’. The 12 informants agreed on the importance of motivating nurses’ enthusiasm. ‘I assess every nurse’s performance in my unit, praise her contribution and encourage her. Frankly, I would like to offer excellent nurses more chances to learn outside or take part in (NM11) international conferences’. Effective communication was regarded as a significant competency for clinical nurse managers. They must liaise with many people on the health care team and other providers. Five participants also mentioned the existence of a barrier in communicating with younger nurses.
Four participants preferred to use negotiation skills to obtain agreement and support from the nurses they were managing.
‘Traditional education seems to be ineffective. He must quit the job once you have scolded him. You have to encourage and treat him as a (NM5) child. This is a really hard job for me’.
‘First, we argued whether all of us preferred one shift of twelve hours [previously, shifts were 8 hours long]. So we tried it for a while and then discussed it again. Now, everyone is happy (NM11) with twelve-hour shifts’.
Chinese first-line nurse managers have two direct supervisors. One is the chief physician and the other is the chief nursing officer. Most of the nurse managers had built good relationship skills with their chief nursing officers.
Some participants realised the importance empowerment to increase work efficiency.
of
‘At first, I did all of the work by myself and I realized that I was dead tired. Now, I have the backbone to run my unit effectively. The nurse
4
‘My chief nursing officer helps me a lot; she would like to share her experience in nursing management and support you when you have trouble with human resources or clinical quality (NM1) management’.
ª 2015 John Wiley & Sons Ltd Journal of Nursing Management
Exploring Chinese nurse managers’ competencies
Four participants wanted to discuss clinical problems with their chief physicians. The benefit of cooperating with the chief physician was clear.
‘People are lazy. Now my management is on the right track. I have no more motivation to pro(NM7) gress’.
‘He gives the nurses a sense of belonging, increases our welfare, educates his physicians to be friendly to nurses and organizes activities’. (NM10)
‘My annual evaluation from nursing department is just passed, not distinguished. But no one force me to change anything, so do I’. (NM4)
Four other informants never communicated with their chief physicians in their daily management. ‘My chief always plays hardball; you know, it is too difficult to talk with him. In his mind, the only requirement of a nurse manager is to avoid (NM2) clinical accidents’. In this phase, the nurse managers aimed to round out the development of their management competencies to meet the basic requirements of their supervisors. As they gained experience, they began to reflect on themselves to discover their strengths and weaknesses. ‘I notice the behavior, expression and attitudes of everybody I meet, and I also get the results of my annual assessment. These are the forces that (NM3) motivate my development’.
The maturation phase When nurse managers scale the learning ‘hump’ of their career lives, most of them improve steadily and rethink their management competencies. Eight participants began to develop their professional identity, and made an effort to learn a second language so that they could engage in outside exchanges and diminish disparities between nursing practices domestically and abroad. ‘I prepared myself all the time. As a result, I had opportunities to be selected to visit famous hospitals in Singapore, France, Australia and the U.S.A. To some extent, I really have benefited a lot from advanced concepts and prac(NM11) tice’.
Once original goals or requirements are met, nurse managers enter the stagnation phase. Three participants could not adjust their emotions and became easily depressed.
During this phase, the nurse managers did not focus on routine duties, they developed the ability to synthesize concept thinking and analytical thinking in risk management. Four participants indicated they could identify key elements of risk events, analyse relevant relationships and solve problems through scientific methods.
‘Most problems resulted from my failure to adjust my emotions and resulted in an easy slide into depression. I must be responsible for everything. I don’t like being ordered about by anyone, you know, but frequently I have to receive their round criticism or rebukes’. (NM2)
‘First, I thought about my education [about pressure ulcers], and then I turned to the standards to find out how to analyze and improve the reasons for the condition. After that, I searched high-level, evidence-based articles and organized relevant staff members to conduct a quality-con(NM5) trol circle’.
When talking about how to balance work and daily life, 10 nurse managers became emotional and cried. They were weighed down with work.
Most participants focused on building their own talent team. Four participants had planned different roles for nurse specialists according to their goals and expectations, and they were all rewarded as excellent nurse managers.
The stagnation phase
‘Sometimes I have to rush to the ward at midnight; I could not care, and even nearly gave up my entire family, especially my sick son [Crying.] ’. (NM9) Three older informants felt they were losing motivation and lacked career planning.
ª 2015 John Wiley & Sons Ltd Journal of Nursing Management
‘Now, all nurses have their own roles and goals. I feel that my unit is gradually moving (NM9) up’.
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Discussion This study describes the perspectives of Chinese nurse managers and the competencies that they have developed to meet clinical needs. In the first phase, nurse managers built and improved their initial management competencies in order to support their daily work routines. Entering into management positions required a need to embrace significant differences from usual clinical work, where tasks and routines are usually standardised compared with dynamic tasks inherent in a management role (Ham et al. 2011). Informants in this study were unprepared for the challenges in their new role and struggled with increasing workloads and a lack of organisational direction. The second phase is the most vital phase in the nurse managers’ careers as most required competencies have been mastered. The management skills (e.g. task and time management, decision-making, negotiation, empowerment, clinical quality management and communication) found in this phase are similar to those identified in other studies (AONE 2005, Garman & Johnson 2006). Although Eastern and Western countries have different social structures, historical backgrounds and working cultures, the attributes or traits of nurses and their skills are similar as nurses worldwide have ideologies that reinforce the positive beliefs and values of patient-centred care (Talor 1997). Effective communication was regarded as the most challenging competency to achieve in this study. Although nurse managers communicate with their nurses every day, staffing continues to present a challenge (Sullivan et al. 2003). In China, the hiring of large numbers of younger nurses for the sake of alleviating the nurse shortage troubles nurse managers. Younger nurses have tended to grow up in doting families owing to the Chinese one-child policy and are perceived to be narrow-minded, self-centred and more likely to quit when receiving criticism from their managers (Feng 2006). Additionally, chief physicians have the overall responsibility for their units, including nurse managers, and they were perceived by the nurse managers as posing another barrier to effective communication. The statement ‘physicians are from Mars and nurses are from Venus’ (Puntillo & McAdam 2006) effectively summarises the differences between these two disciplines in terms of culture, educational background and socio-economic status. Accordingly, it has been difficult to engage chief physicians to understand the details of nursing and nursing management (Storch & Kenny 2007). Guo (2003) indicates
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that a lack of skills in communication, listening and conflict management will lead managers to fail in their duties. Aside from the outer competencies in the second phase, nurse managers have also developed inner competencies that focus on self-awareness, fairness and principles. Outstanding managers are cognisant of their own values, strengths and limitations and can effectively manage their emotions and behaviours. These competencies are generally denoted as ‘personal mastery’ in the nursing leadership competency model (Sherman et al. 2007). In the Sherman study, nurse managers gradually improved and established their outer management skills through nurturing their inner competencies; thus, all of their competencies produced acceptable outcomes. The stagnation phase indicates that Chinese nurse managers have stressful roles in hospitals. According to the Role Stress Theory (Kath et al. 2013), there are three major work environment stressors: role ambiguity (lack of clarity about roles, responsibilities or expectations), role overload (perceptions of excessive tasks, responsibilities or demands in a given time) and role conflict (competing demands or priorities within one or more roles). All three of these stressors have been identified in our participating nurses, which induced negative emotional reactions and diminished job satisfaction in management. The nurse managers with little or no stress management strategies have resigned themselves to huge workloads leading to feelings of depression. Some have expressed a loss of motivation in developing further. Not all nurse managers overcome the stagnation phase with some lingering between the second and third phases indefinitely. Some nurse managers with strong professional identities seek breakthroughs in their careers and seek to enhance it further. Miskelly and Duncan (2014) note that responsibility is considered to be an intrinsic component in the evolution of an individual’s professional maturity and is also a cornerstone in the formation of a person’s professional identity. Enhancing Chinese nurse managers’ competencies are critical as some of their responsibilities include learning foreign languages, engaging in exchanges both domestically and abroad for the purpose of updating current nursing concepts and clinical practices, strengthening and synthesising different thinking skills to create a more positive work and practice environment (Zori et al. 2010) and building talented teams to accomplish goals or outcomes within their organisations (McKenna et al. 2004). ª 2015 John Wiley & Sons Ltd Journal of Nursing Management
Exploring Chinese nurse managers’ competencies
Methodological considerations To mitigate any potential bias, two authors analysed the data independently and compared the emerging themes together. Whenever there was a disagreement, discussions and clarifications were continued until a consensus was reached. A summary of the interviews was sent to the informants to confirm their perspectives. The plausibility of the findings through an audit trail determined whether the analytical comments or claims made by the researchers were justifiable (Horsburgh 2003). This study was limited to one province in China, Shanghai, and the results could be different in other areas. Although the number of informants was limited, their descriptions were rich, detailed and concise.
Conclusion The results of this study demonstrated that a substantial period of time is required for nurse managers to progress through the four phases of their career trajectory and acquire practice excellence. Nurse managers need to strengthen and nurture their management skills and abilities in order to adapt to the current complex healthcare system. In addition, Chinese nurse managers face unprecedented challenges related to their lack of competencies in communication and stress management. Nurse managers’ responsibilities and obligations need to be clearly defined in such a way that required education and skills can be acquired either before or early in their careers.
Implications First, there needs to be a more formalised and structured curricula towards management where nurse managers are offered the necessary training and preparation in advance. Nurse managers would benefit from early guidance on how to work more effectively. O’Neil et al. (2008) noted that active succession planning, formal education programmes and mentorship were all necessary ways to ensure future growth and development of nurse managers. Second, we found that communicating with chief physicians and younger nurses posed a barrier for nurse managers. It is the responsibility of nurse managers to build a supportive and communicative work environment with an emphasis on active listening, team collaboration and the avoidance of discrimination or favoritism (Rouse & Al-Maqbali 2014). Nursing directors and other administrators need to provide ª 2015 John Wiley & Sons Ltd Journal of Nursing Management
support in learning how to communicate effectively with other colleagues. Creating social arenas and networks for collective sharing of experiences between nurse managers might also prove beneficial. Finally, even although the amount of work required of nurse managers might be reduced and warranted (Meyer et al. 2011), they continued to feel stress in the management role. It is suggested that they should have the autonomy to refuse additional work when they are already overworked (Lewis et al. 2010). Hospitals could support the managers by supporting their efforts in learning how to work more efficiently and how to manage responses to the demands placed on them.
Ethical approval Participation in the study was voluntary. All research participants received a study covering letter and an information sheet. Participants who were interviewed also received a consent form to sign. Research ethics permission was obtained from Shanghai Children’s Medical Center Ethics Committee, China (SCMCIRBK2013035).
Sources of funding This study was supported financially by Science and Technology Fund Project, Shanghai Jiao Tong University School of Medicine, China.
Acknowledgements We would like to extend our appreciation to Ms Hong Xu, who paid more attention on the first-phase preparation of this study while she was alive.
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Govero E. (2012) New nurse manager checklist for foundational success. Nurse Leader 16 (6), 54–56. Guo K. (2003) A study of the skills and roles of senior level health care managers. Health Care Manager 22 (2), 152–158. Ham C., Clark J., Spurgeon P., Dickinson H. & Armit K. (2011) Doctors who become chief executives in the NHS: from keen amateurs to skilled professionals. Journal of the Royal Society of Medicine 104 (3), 113–119. Horsburgh D. (2003) Evaluation of qualitative research. Journal of Clinical Nursing 12, 307–312. Husserl E. (1965) Phenomenology and the Crisis of Philosophy: Philosophy as Rigorous Science and Philosophy and the Crisis of European Man (Q. Lauer, trans.). Harper & Row Publisher, New York, NY. Jennings B.M., Scalzi C.C., Rodgers J.D. & Keane A. (2007) Differentiating nursing leadership and management competencies. Nursing Outlook 55 (4), 169–175. Kang C.M., Chiu H.T., Hu Y.C., Chen H.L., Lee P.H. & Chang W.Y. (2012) Comparisons of self-ratings on managerial competencies, research capability, time management, executive power, workload and work stress among nurse administrators. Journal of Nursing Management 20 (7), 938–947. Kath L.M., Stichler J.F., Ehrhart M.G. & Sievers A. (2013) Predictors of nurse manager stress: a dominance analysis of potential work environment stressors. International Journal of Nursing Studies 50 (11), 1474–1480. Kirby K.K. & DeCampli P. (2008) Nurse manager development beyond the classroom. Nurse Leader 12 (4), 44–47. Lewis R., Yarker J., Donaldson-Feilder E., Flaxman P. & Munir F. (2010) Using a competency-based approach to identify the management behaviors required to manage workplace stress in nursing: a critical incident study. International Journal of Nursing Studies 47 (3), 307–313. Liu W. & Wang X. (2012) A correlative study of head nurses’ core competency and training needs. Nursing Journal of Chinese People’s Liberation Army 29 (14), 28–30 [in Chinese]. McClelland D.C. (1973) Testing for competence rather than for “intelligence”. American Psychologist 28 (1), 1–14. McKenna H., Kenny S. & Bradley M. (2004) Nurse leadership within primary care: the perceptions of community nurses, GPs, policy makers and members of the public. Journal of Nursing Management 12 (1), 69–76. Meyer R.M., O’Brien-Pallas L., Doran D., Streiner D., Ferguson-Pare M. & Duffield C.M. (2011) Front-line managers as boundary spanners: effects of span and time on nurse supervision satisfaction. Journal of Nursing Management 19 (5), 611–622. Miskelly P. & Duncan L. (2014) ‘I’m actually being the grown-up now’: leadership, maturity and professional identity development. Journal of Nursing Management 22 (1), 38–48. National Health and Family Planning Commission of China (2011) An outline program for Chinese nursing development (2011–2015). Chinese Nursing Management 12 (2), 5–8.
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Noordegraaf M. (2000) Professional sense-makers: managerial competencies amidst ambiguity. The International Journal of Public Sector Management 13 (4), 319–332. O’Neil E., Morjikian R.L., Cherner D., Hirschkorn C. & West T. (2008) Developing nursing leaders. An overview of trends and programs. Journal of Nursing Administration 38 (4), 178–183. Puntillo K.A. & McAdam J.L. (2006) Communication between physicians and nurses as a target for improving end-of-life care in the intensive care unit: challenges and opportunities for moving forward. Critical Care Medicine 34 (11), S332– S340. Rouse R.A. & Al-Maqbali M. (2014) Identifying nurse managers’ essential communication skills: an analysis of nurses’ perceptions in Oman. Journal of Nursing Management 22 (2), 192–200. Rush D., McCarthy G. & Cronin C. (2000) Report on Nursing Management Competencies. Office of Health Management, Government of Ireland Publication, Dublin. Sherman R.O., Bishop M., Eggenberger T. & Karden R. (2007) Development of a leadership competency model. Journal of Nursing Administration 37 (2), 85–94. Spencer L.M. &Spencer S.M., Spencer L.M & Spencer S.M. (1993) Competence at Work. John Wiley & Sons Ltd, New York, NY. Speziale H.S. & Carpenter D.R. (2007) Qualitative Research in Nursing: Advancing the Humanistic Imperative, 4th edn. Lippincott Williams & Wilkins, Philadelphia, PA. Stanley D. (2006) Recognizing and defining clinical nurse leaders. British Journal of Nursing 15 (2), 108–118. Storch J.L. & Kenny N. (2007) Shared moral work of nurses and physicians. Nursing Ethics 14 (4), 478–491. Sullivan J., Bretschneider J. & McCausland M. (2003) Designing a leadership development program for nurse managers. Journal of Nursing Administration 33 (10), 544–549. Supamanee T., Krairiksh M., Singhakhumfu L. & Turale S. (2011) Preliminary clinical nursing leadership competency model: a qualitative study from Thailand. Nursing and Health Sciences 13 (4), 433–439. Talor J.S. (1997) Nursing ideology: identification and legitimation. Journal of Advanced Nursing 25 (3), 442–446. Wong F.K.Y. (2010) Challenges for nurse managers in China. Journal of Nursing Management 18, 526–530. Wu C., Du X. & Yang H. (2010) Study of job status and its correlation factors among head nurses. Journal of Nursing Administration 10 (3), 172–174 [in Chinese]. Xianyu Y., He X. & Fan X. (2006) A study on the relationships among job stressors, ways of coping and mental health of head nurses. Chinese Journal of Nursing 41 (9), 849–851 [in Chinese]. Zori S., Nosek L.J. & Musil C.M. (2010) Critical thinking of nurse managers related to staff RNs’ perceptions of the practice environment. Journal of Nursing Scholarship 42 (3), 305–313.
ª 2015 John Wiley & Sons Ltd Journal of Nursing Management
Exploring competencies: a qualitative study of Chinese nurse managers WEN-YI LUO R N , M S N 1, NAN-PING SHEN and JI-WEN SUN B S N 4
RN, MSN
2
, JIAN-HUA LOU
RN, BSN
3
, PING-PING HE
RN, BSN
1
1
Nurse Manager, Cardiovascular Intensive Care Unit, 2Associated Professor, Vice Director, 3Professor, Nursing Department, Shanghai Children’s Medical Centre and 4Student, School of Nursing, Shanghai Jiao Tong University, Shanghai, China
Correspondence Nan-Ping Shen Nursing Department Shanghai Children’s Medical Centre 1678 Dongfang Road Pudong New District Shanghai 200127 China E-mail: [email protected]
LUO W.-Y., SHEN N.-P., LOU J.-H., HE P.-P. & SUN J.-W.
(2015) Journal of Nursing Management Exploring competencies: a qualitative study of Chinese nurse managers Aim To identify core competencies needed in the transition of nurse managers on the way to excellence. Background There is growing recognition of the importance of nurse managers in hospitals. Most managers still learn through their failures and few studies have described the perceptions of nurse managers in China. It is vital to understand what competencies Chinese nurse managers should have in order to establish suitable training programmes and improve their management skills. Method A phenomenological approach that included in-depth interviews with 12 nurse managers in six Chinese hospitals was conducted. Results The transition to management included four phases: the adaptive phase, the running-in and stable phase, the stagnation phase and the maturation phase. Conclusion In order to fulfil their clinical responsibilities, nurse managers need to develop multifaceted competencies, specifically in communication and stress management. Ideally, nurse managers should progress through the four phases mentioned above to achieve excellence. Implications There is a requirement for utilising various methods for nurse managers in adapting new roles, improving communication and relieving stress.
Keywords: competency, management skills, nurse manager, phenomenological approach, qualitative research Accepted for publication: 2 February 2015
Introduction Modern society is focused on the growing demand for nursing. To meet diverse demands and address public concerns, nursing development is inevitable. Nurse managers, directors and operators involved in nursing development have a responsibility to introduce hospitals’ goals and objectives to nursing practice. The responsibilities of the people involved in nursing development influence nursing quality, patient safety and satisfaction, nurses’ working satisfaction and retention and the working environment DOI: 10.1111/jonm.12295 ª 2015 John Wiley & Sons Ltd
(Kirby & DeCampli 2008, Fennimore & Wolf 2011,). There is, therefore, a growing recognition of nurse managers in hospitals to have multifaceted abilities. Jennings et al. (2007) reviewed 140 articles and identified 878 competencies required for nursing management. These days every element in the clinical working environment inclusive of patients, staff, medical insurance and national sanitary regulations is undergoing tremendous change in China. As a result, Chinese nurse managers are facing huge new challenges. In the current situation, many nurse managers 1
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(aged 40–55 years) have low levels of academic preparation and qualifications as a result of the country’s historical background (Wong 2010). The need to be better prepared for information technology, quality assurance, outcome management and evidence-based practice creates a great deal of stress. Additionally, there are the common issues of insufficient training including unclear definitions of management (maintaining order, planning, organising, coordinating resources and attending to rules) and leadership (helping people move towards achieving a vision) (Jennings et al. 2007) and lack of systematic management training (Liu & Wang 2012). The majority of Chinese managers continue to learn through their failures or work in response to their emotional experiences. This response is called ‘sense making’ (Noordegraaf 2000) and leaves nurse managers more likely to feel stress and experience feelings of defeat and failure while attempting to achieve mastery (Kirby & DeCampli 2008, Govero 2012).
Background Since McClelland (1973) observed that competency is task- and organisation-specific, his classic concept has continued to be a popular topic in various fields of research. Studies related to competencies have been built on the basis of the iceberg model, along with other alternative models. Spencer’s iceberg model (Spencer & Spencer 1993) includes hidden characteristics (self-concept, traits and motives) and surface characteristics (knowledge and skills) and is widely used in management owing to the scientific method that it employs to distinguish excellent staff. More recently, Supamanee et al. (2011), guided by the iceberg model, listed and expanded the hidden and surface characteristics of Thai nurse managers. Beyond the iceberg model, some alternative models of nursing manager’s competency have been developed using individual qualitative or quantitative approaches. Two groundedtheory projects have been conducted (Stanley 2006, Sherman et al. 2007), from which competency categories have emerged, including interpersonal effectiveness, caring and systems thinking; personal mastery, financial management and human resource management; and empowerment and motivation. Burns (2009) proposed the competencies of political astuteness and strategic influencing through a phenomenology approach. Kang et al. (2012) indicated the importance of research capability, time management and executive power, showing significant correlations across all managerial competencies. The competencies 2
of nurse managers that have emerged from these alternative models are more detailed and more suitable for the clinic and subspecialty field than those of the iceberg model; however, the content of these models vary across different geographical areas and political systems (Stanley 2006, Sherman et al. 2007, Burns 2009, Kang et al. 2012, ). In light of this, the competencies of nurse managers need to be explored separately. Because they are usually divided into three levels – front-line, mid-level and director-level – with different levels appointed to different missions (Rush et al. 2000). In China, some quantitative research has found firstline nurse managers to be incompetent because of heavy workloads, a nursing shortage and lower education levels (Xianyu et al. 2006, Wu et al. 2010). Based on this situation, the State Council has issued an Outline Program for Chinese Nursing Development (2011–2015) (NHFPCC 2011), which provides concretely stipulated goals and measures for the development of Chinese nurse managers until 2015. It is vital to understand which competencies Chinese first-line nurse managers need so that suitable training programmes can be established to help nurse managers improve their abilities to manage effectively and fulfil the new governmental requirements. Few studies have described the perceptions of firstline nurse managers in China. Therefore, the aim of this study was to identify core competencies needed in the transition of nurse managers on the way to excellence.
Method Design The descriptive phenomenology methodology was used to acquire the intersubjective knowledge of Chinese first-line nurse managers’ experience, that is, the life world as it is known in Husserlian phenomenology, in terms of the meaning of experience and the essence of the experience (Husserl 1965). For Husserl, phenomena of an experience can be consciously expressed and can be understood by people who live it. The experience exists in the consciousness in a pure form without presupposition and can be described through pure subjectivity through bracketing (Husserl 1965).
Participants This study was conducted in 2013. Purposeful sampling was used to recruit a sample of 12 individuals ª 2015 John Wiley & Sons Ltd Journal of Nursing Management
Exploring Chinese nurse managers’ competencies
Four participants wanted to discuss clinical problems with their chief physicians. The benefit of cooperating with the chief physician was clear.
‘People are lazy. Now my management is on the right track. I have no more motivation to pro(NM7) gress’.
‘He gives the nurses a sense of belonging, increases our welfare, educates his physicians to be friendly to nurses and organizes activities’. (NM10)
‘My annual evaluation from nursing department is just passed, not distinguished. But no one force me to change anything, so do I’. (NM4)
Four other informants never communicated with their chief physicians in their daily management. ‘My chief always plays hardball; you know, it is too difficult to talk with him. In his mind, the only requirement of a nurse manager is to avoid (NM2) clinical accidents’. In this phase, the nurse managers aimed to round out the development of their management competencies to meet the basic requirements of their supervisors. As they gained experience, they began to reflect on themselves to discover their strengths and weaknesses. ‘I notice the behavior, expression and attitudes of everybody I meet, and I also get the results of my annual assessment. These are the forces that (NM3) motivate my development’.
The maturation phase When nurse managers scale the learning ‘hump’ of their career lives, most of them improve steadily and rethink their management competencies. Eight participants began to develop their professional identity, and made an effort to learn a second language so that they could engage in outside exchanges and diminish disparities between nursing practices domestically and abroad. ‘I prepared myself all the time. As a result, I had opportunities to be selected to visit famous hospitals in Singapore, France, Australia and the U.S.A. To some extent, I really have benefited a lot from advanced concepts and prac(NM11) tice’.
Once original goals or requirements are met, nurse managers enter the stagnation phase. Three participants could not adjust their emotions and became easily depressed.
During this phase, the nurse managers did not focus on routine duties, they developed the ability to synthesize concept thinking and analytical thinking in risk management. Four participants indicated they could identify key elements of risk events, analyse relevant relationships and solve problems through scientific methods.
‘Most problems resulted from my failure to adjust my emotions and resulted in an easy slide into depression. I must be responsible for everything. I don’t like being ordered about by anyone, you know, but frequently I have to receive their round criticism or rebukes’. (NM2)
‘First, I thought about my education [about pressure ulcers], and then I turned to the standards to find out how to analyze and improve the reasons for the condition. After that, I searched high-level, evidence-based articles and organized relevant staff members to conduct a quality-con(NM5) trol circle’.
When talking about how to balance work and daily life, 10 nurse managers became emotional and cried. They were weighed down with work.
Most participants focused on building their own talent team. Four participants had planned different roles for nurse specialists according to their goals and expectations, and they were all rewarded as excellent nurse managers.
The stagnation phase
‘Sometimes I have to rush to the ward at midnight; I could not care, and even nearly gave up my entire family, especially my sick son [Crying.] ’. (NM9) Three older informants felt they were losing motivation and lacked career planning.
ª 2015 John Wiley & Sons Ltd Journal of Nursing Management
‘Now, all nurses have their own roles and goals. I feel that my unit is gradually moving (NM9) up’.
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‘My unit was short one nurse, so as a manager, I had to fill that position. I had to manage patients, nurses and the unit at the same time’. (NM11) During this phase, all of the participants lacked management experience. They learned and built basic competencies by trial and error, according to clinical primary needs. The adaptive phase helped them build work-awareness. ‘At first I got it all screwed up. I prayed that no more accidents would happen. It took me two or three months to straighten out the mess’. (NM3)
The running-in and stable phase Once the nurse managers worked through the initial phase, they began to develop abilities in the areas of task organisation and time management. ‘I check my schedule every week, plan everything to ensure that nothing is left, and make some marks on my schedule table when I reach my (NM3) goals’. ‘I’ll report all of the key points on the card in my pocket and finish them in order of priority’. (NM7) Occasionally, the full weight of decision-making at the unit level falls on the nurse managers, especially with regards to revising policies and workflow. Six informants preferred taking action immediately, based on what they perceived to be the best approach. ‘I do what I think is right. I am principled and make policies according to rules and regula(NM8) tions’.
specialists help me manage resources and materials, and the nurse educators maintain and moni(NM3) tor clinical quality’. One of the main tasks of nurse managers is clinical quality management, which requires managers to provide the best quality of patient care of greatest benefit. ‘Once there was a patient who needed an enema before surgery, but it was hard to perform due to the existence of a recto-vaginal fistula. Therefore, I tried my best to dilute the mannitol injection, and I tested it myself first until the patient (NM7) could bear the taste’. Fairness was regarded as the most important principle for the 12 participants when evaluating their nursing staff. ‘You must use the same criteria to assess all staff members and be fair in evaluating their perfor(NM5) mance’. The 12 informants agreed on the importance of motivating nurses’ enthusiasm. ‘I assess every nurse’s performance in my unit, praise her contribution and encourage her. Frankly, I would like to offer excellent nurses more chances to learn outside or take part in (NM11) international conferences’. Effective communication was regarded as a significant competency for clinical nurse managers. They must liaise with many people on the health care team and other providers. Five participants also mentioned the existence of a barrier in communicating with younger nurses.
Four participants preferred to use negotiation skills to obtain agreement and support from the nurses they were managing.
‘Traditional education seems to be ineffective. He must quit the job once you have scolded him. You have to encourage and treat him as a (NM5) child. This is a really hard job for me’.
‘First, we argued whether all of us preferred one shift of twelve hours [previously, shifts were 8 hours long]. So we tried it for a while and then discussed it again. Now, everyone is happy (NM11) with twelve-hour shifts’.
Chinese first-line nurse managers have two direct supervisors. One is the chief physician and the other is the chief nursing officer. Most of the nurse managers had built good relationship skills with their chief nursing officers.
Some participants realised the importance empowerment to increase work efficiency.
of
‘At first, I did all of the work by myself and I realized that I was dead tired. Now, I have the backbone to run my unit effectively. The nurse
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‘My chief nursing officer helps me a lot; she would like to share her experience in nursing management and support you when you have trouble with human resources or clinical quality (NM1) management’.
ª 2015 John Wiley & Sons Ltd Journal of Nursing Management
Exploring Chinese nurse managers’ competencies
Four participants wanted to discuss clinical problems with their chief physicians. The benefit of cooperating with the chief physician was clear.
‘People are lazy. Now my management is on the right track. I have no more motivation to pro(NM7) gress’.
‘He gives the nurses a sense of belonging, increases our welfare, educates his physicians to be friendly to nurses and organizes activities’. (NM10)
‘My annual evaluation from nursing department is just passed, not distinguished. But no one force me to change anything, so do I’. (NM4)
Four other informants never communicated with their chief physicians in their daily management. ‘My chief always plays hardball; you know, it is too difficult to talk with him. In his mind, the only requirement of a nurse manager is to avoid (NM2) clinical accidents’. In this phase, the nurse managers aimed to round out the development of their management competencies to meet the basic requirements of their supervisors. As they gained experience, they began to reflect on themselves to discover their strengths and weaknesses. ‘I notice the behavior, expression and attitudes of everybody I meet, and I also get the results of my annual assessment. These are the forces that (NM3) motivate my development’.
The maturation phase When nurse managers scale the learning ‘hump’ of their career lives, most of them improve steadily and rethink their management competencies. Eight participants began to develop their professional identity, and made an effort to learn a second language so that they could engage in outside exchanges and diminish disparities between nursing practices domestically and abroad. ‘I prepared myself all the time. As a result, I had opportunities to be selected to visit famous hospitals in Singapore, France, Australia and the U.S.A. To some extent, I really have benefited a lot from advanced concepts and prac(NM11) tice’.
Once original goals or requirements are met, nurse managers enter the stagnation phase. Three participants could not adjust their emotions and became easily depressed.
During this phase, the nurse managers did not focus on routine duties, they developed the ability to synthesize concept thinking and analytical thinking in risk management. Four participants indicated they could identify key elements of risk events, analyse relevant relationships and solve problems through scientific methods.
‘Most problems resulted from my failure to adjust my emotions and resulted in an easy slide into depression. I must be responsible for everything. I don’t like being ordered about by anyone, you know, but frequently I have to receive their round criticism or rebukes’. (NM2)
‘First, I thought about my education [about pressure ulcers], and then I turned to the standards to find out how to analyze and improve the reasons for the condition. After that, I searched high-level, evidence-based articles and organized relevant staff members to conduct a quality-con(NM5) trol circle’.
When talking about how to balance work and daily life, 10 nurse managers became emotional and cried. They were weighed down with work.
Most participants focused on building their own talent team. Four participants had planned different roles for nurse specialists according to their goals and expectations, and they were all rewarded as excellent nurse managers.
The stagnation phase
‘Sometimes I have to rush to the ward at midnight; I could not care, and even nearly gave up my entire family, especially my sick son [Crying.] ’. (NM9) Three older informants felt they were losing motivation and lacked career planning.
ª 2015 John Wiley & Sons Ltd Journal of Nursing Management
‘Now, all nurses have their own roles and goals. I feel that my unit is gradually moving (NM9) up’.
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Discussion This study describes the perspectives of Chinese nurse managers and the competencies that they have developed to meet clinical needs. In the first phase, nurse managers built and improved their initial management competencies in order to support their daily work routines. Entering into management positions required a need to embrace significant differences from usual clinical work, where tasks and routines are usually standardised compared with dynamic tasks inherent in a management role (Ham et al. 2011). Informants in this study were unprepared for the challenges in their new role and struggled with increasing workloads and a lack of organisational direction. The second phase is the most vital phase in the nurse managers’ careers as most required competencies have been mastered. The management skills (e.g. task and time management, decision-making, negotiation, empowerment, clinical quality management and communication) found in this phase are similar to those identified in other studies (AONE 2005, Garman & Johnson 2006). Although Eastern and Western countries have different social structures, historical backgrounds and working cultures, the attributes or traits of nurses and their skills are similar as nurses worldwide have ideologies that reinforce the positive beliefs and values of patient-centred care (Talor 1997). Effective communication was regarded as the most challenging competency to achieve in this study. Although nurse managers communicate with their nurses every day, staffing continues to present a challenge (Sullivan et al. 2003). In China, the hiring of large numbers of younger nurses for the sake of alleviating the nurse shortage troubles nurse managers. Younger nurses have tended to grow up in doting families owing to the Chinese one-child policy and are perceived to be narrow-minded, self-centred and more likely to quit when receiving criticism from their managers (Feng 2006). Additionally, chief physicians have the overall responsibility for their units, including nurse managers, and they were perceived by the nurse managers as posing another barrier to effective communication. The statement ‘physicians are from Mars and nurses are from Venus’ (Puntillo & McAdam 2006) effectively summarises the differences between these two disciplines in terms of culture, educational background and socio-economic status. Accordingly, it has been difficult to engage chief physicians to understand the details of nursing and nursing management (Storch & Kenny 2007). Guo (2003) indicates
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that a lack of skills in communication, listening and conflict management will lead managers to fail in their duties. Aside from the outer competencies in the second phase, nurse managers have also developed inner competencies that focus on self-awareness, fairness and principles. Outstanding managers are cognisant of their own values, strengths and limitations and can effectively manage their emotions and behaviours. These competencies are generally denoted as ‘personal mastery’ in the nursing leadership competency model (Sherman et al. 2007). In the Sherman study, nurse managers gradually improved and established their outer management skills through nurturing their inner competencies; thus, all of their competencies produced acceptable outcomes. The stagnation phase indicates that Chinese nurse managers have stressful roles in hospitals. According to the Role Stress Theory (Kath et al. 2013), there are three major work environment stressors: role ambiguity (lack of clarity about roles, responsibilities or expectations), role overload (perceptions of excessive tasks, responsibilities or demands in a given time) and role conflict (competing demands or priorities within one or more roles). All three of these stressors have been identified in our participating nurses, which induced negative emotional reactions and diminished job satisfaction in management. The nurse managers with little or no stress management strategies have resigned themselves to huge workloads leading to feelings of depression. Some have expressed a loss of motivation in developing further. Not all nurse managers overcome the stagnation phase with some lingering between the second and third phases indefinitely. Some nurse managers with strong professional identities seek breakthroughs in their careers and seek to enhance it further. Miskelly and Duncan (2014) note that responsibility is considered to be an intrinsic component in the evolution of an individual’s professional maturity and is also a cornerstone in the formation of a person’s professional identity. Enhancing Chinese nurse managers’ competencies are critical as some of their responsibilities include learning foreign languages, engaging in exchanges both domestically and abroad for the purpose of updating current nursing concepts and clinical practices, strengthening and synthesising different thinking skills to create a more positive work and practice environment (Zori et al. 2010) and building talented teams to accomplish goals or outcomes within their organisations (McKenna et al. 2004). ª 2015 John Wiley & Sons Ltd Journal of Nursing Management
Exploring Chinese nurse managers’ competencies
Methodological considerations To mitigate any potential bias, two authors analysed the data independently and compared the emerging themes together. Whenever there was a disagreement, discussions and clarifications were continued until a consensus was reached. A summary of the interviews was sent to the informants to confirm their perspectives. The plausibility of the findings through an audit trail determined whether the analytical comments or claims made by the researchers were justifiable (Horsburgh 2003). This study was limited to one province in China, Shanghai, and the results could be different in other areas. Although the number of informants was limited, their descriptions were rich, detailed and concise.
Conclusion The results of this study demonstrated that a substantial period of time is required for nurse managers to progress through the four phases of their career trajectory and acquire practice excellence. Nurse managers need to strengthen and nurture their management skills and abilities in order to adapt to the current complex healthcare system. In addition, Chinese nurse managers face unprecedented challenges related to their lack of competencies in communication and stress management. Nurse managers’ responsibilities and obligations need to be clearly defined in such a way that required education and skills can be acquired either before or early in their careers.
Implications First, there needs to be a more formalised and structured curricula towards management where nurse managers are offered the necessary training and preparation in advance. Nurse managers would benefit from early guidance on how to work more effectively. O’Neil et al. (2008) noted that active succession planning, formal education programmes and mentorship were all necessary ways to ensure future growth and development of nurse managers. Second, we found that communicating with chief physicians and younger nurses posed a barrier for nurse managers. It is the responsibility of nurse managers to build a supportive and communicative work environment with an emphasis on active listening, team collaboration and the avoidance of discrimination or favoritism (Rouse & Al-Maqbali 2014). Nursing directors and other administrators need to provide ª 2015 John Wiley & Sons Ltd Journal of Nursing Management
support in learning how to communicate effectively with other colleagues. Creating social arenas and networks for collective sharing of experiences between nurse managers might also prove beneficial. Finally, even although the amount of work required of nurse managers might be reduced and warranted (Meyer et al. 2011), they continued to feel stress in the management role. It is suggested that they should have the autonomy to refuse additional work when they are already overworked (Lewis et al. 2010). Hospitals could support the managers by supporting their efforts in learning how to work more efficiently and how to manage responses to the demands placed on them.
Ethical approval Participation in the study was voluntary. All research participants received a study covering letter and an information sheet. Participants who were interviewed also received a consent form to sign. Research ethics permission was obtained from Shanghai Children’s Medical Center Ethics Committee, China (SCMCIRBK2013035).
Sources of funding This study was supported financially by Science and Technology Fund Project, Shanghai Jiao Tong University School of Medicine, China.
Acknowledgements We would like to extend our appreciation to Ms Hong Xu, who paid more attention on the first-phase preparation of this study while she was alive.
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