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Managerial competencies of head nurses: A model and assessment tool

Article  in  British journal of nursing (Mark Allen Publishing) · January 2019


DOI: 10.12968/bjon.2019.28.1.30

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Managerial competencies of head
nurses: a model and assessment tool
Nader Markazi Moghaddama, Sanaz Zargar Balaye Jamea, Sima Rafieib, Ali Asghari
Saremc, Ashraf Ghamchilid and Milad Shafiie

T
he existence of an efficient and effective evaluation
ABSTRACT system for recognition of personnel competencies
Head nurses’ performance plays an important role in the successful operation and capabilities can play a significant role in reducing
of hospitals. Identification and prioritisation of managerial competencies organisations’ costs and providing services with higher
required for these supervisors and evaluation of their performance on this levels of quality (Meretoja and Leino-Kilpi, 2003;
basis are necessary. This study aimed to provide a valid tool for assessing Shafii et al, 2016). Improvement in management performance
managerial competencies of hospital department head nurses. First, through may not be achieved unless there is an appropriate model
literature review, Delphi technique and expert panel a competency model was for performance evaluation based on accurate and applicable
developed. Then using the analytic hierarchy process, competencies were indicators. Such a model provides an opportunity for proper and
weighted and prioritised. Finally, based on the model, an instrument was principled selection and training of managers who are capable of
designed to measure the competencies of head nurses. Validity and reliability organising healthcare provision processes to be efficient, effective
of the instrument was also checked. The proposed framework included and responsive (Pillay, 2010; Liang et al, 2013).
27 competencies categorised by four main managerial tasks: planning, Although there are different assessment methods, several
organising, leadership and control. Findings revealed that the highest priority studies have focused on competence-based approaches for
was given to strategic thinking (0.1221) and the lowest priority was given to evaluating the performance of healthcare managers, particularly
evidence-based decision making (0.007). Based on impact score and content head nurses—that is, the lead nurse for each particular clinical
validity ratio results, the content validity of all questions has been proved. department (Arcand and Neumann, 2005; Cowan et al, 2005;
Furthermore through the use of a content validity index, 11 questions were Liu et al, 2007; Cummings et al, 2010; Pillay, 2010; Dadgar et
omitted or modified. The study presents a valid and comprehensive model for al, 2012; Wongprasit, 2014).
assessing managerial competencies of hospital department head nurses in In the last few years the significant role of head nurses in
order to take an important step towards improving their performance. directing patient care affairs and provision of a healthy work
Key words: Management ■ Assessment ■ Competencies  ■ Leadership environment for nursing staff has been emphasised more
than ever (Hu, 2010). In fact, hospital-based head nurses, or
nurse managers, not only need to accomplish their clinical
practices, they are also required to carry out the administrative
tasks that are entrusted to them due to their management
Nader Markazi Moghaddam, Assistant Professor, Department responsibility. To fulfill the task effectively, they should be
of Health Management and Economics, School of Medicine, AJA equipped with essential competencies to guide them in this
University of Medical Sciences, Tehran, Iran direction. Furthermore as nurse managers constitute a significant
Sanaz Zargar Balaye Jame, Assistant Professor, Department of number of healthcare managers in the health market also
Health Management and Economics, School of Medicine, AJA their performance improvement potentially result in hospital
University of Medical Sciences, Tehran, Iran excellence, developing a logical model for evaluating managerial
Sima Rafiei, Assistant Professor, Social Determinants of Health competencies would be substantially beneficial (Liu et al, 2007)
Research Center, Qazvin University of Medical Sciences, Qazvin, Despite the importance, a valid and comprehensive measurement
Iran tool has not been developed in the authors’ country to evaluate
Ali Asghari Sarem, Assistant Professor, Faculty of Management the managerial competencies of this occupational group (Parry,
and Accounting, Bu-Ali Sina University of Medical Sciences, 1997; Meretoja and Leino-Kilpi, 2003; Khomeiran et al, 2006).
Hamedan, Iran Thus in the current study the aim was to provide a valid tool
Ashraf Ghamchili, MSc in nursing management (Master’s for assessing managerial competencies of hospital department
graduate), AJA University of Medical Sciences, Tehran, Iran head nurses.
© 2018 MA Healthcare Ltd

Milad Shafii, Assistant Professor, Health Policy and Management


Research Center, School of Public Health, Shahid Sadoughi Material and methods
University of Medical Sciences, Yazd, Iran, Milad.shafii@ssu.ac.ir This descriptive-analytical study was conducted in 2017 in six
Accepted for publication: March 2018 main phases. First a literature review was carried out using the
scientific databases of Web of Science, PubMed, Science Direct,

2 British Journal of Nursing, 2018, Vol 27, No 21


RESEARCH

Scopus, Emerald and Proquest using the following keywords: experts familiar with the job were given the questionnaire and
head nurse, nurse, competency, performance evaluation, asked to score each item from 0 to 2 with a 3-degree range of
competency assessment and managerial competency.As a result, ‘not necessary’, ‘not necessary but helpful’ or ‘necessary’. The
a list of managerial competencies required for hospital head formula for content validity ratio is CVR= (Ne - N/2)/(N/2),
nurses was drafted to run the first Delphi round of the study in in which Ne represents number of experts who mentioned
the second phase. In this stage, the developed list was verified by the item necessary and N is the total number of experts in
the research team and sent to 16 experts including 5 academic the panel. In this study if the average score for CVR was 0.62
members in the field of nursing and healthcare management or more, or calculated CVR was in the range 0-0.75 and the
and 11 nurses with at least 5 years’ experience of nursing. In the average score of responses was more than 1.5, the item in the
third step, the arranged list was reviewed by a five-member panel questionnaire would be accepted with an acceptable level of
of experts to be integrated, categorised and finalised through significance (Najafi and Kheiry, 2013).
omitting any pointless or duplicate issues. Then the second Regarding CVI, panel members were asked to rate questions
Delphi round was conducted so that verified competencies in terms of relevancy, simplicity and transparency in a four-point
(with mode equal to 4 and 5) and dimensions needing to be re- scale. If the CVI was higher than 0.79, the item was deemed
examined (mode equal to 3) were sent to experts for the second appropriate. If it was between 0.7 and 0.79 it would require
time to be weighted based on an analytic hierarchy process modification and if it was less than 0.7 it was removed (Lawshe,
(AHP). Collected data were analysed in Excel and competencies 1975; Waltz, 1981).
prioritised. In the fifth step, these competencies were discussed
in a seven-member panel made up of the research team and two Results
other experts in the field of healthcare management and nursing Overall, 27 managerial competencies required for head nurses
to finalise a model for evaluating head nurses’ competencies. were identified and categorised in 4 main categories relating
Finally a questionnaire with the purpose of evaluating head to management functions: planning, organising, leadership and
nurses’ managerial competencies was designed and checked for control. These competencies are shown in Table 1.
its validity and reliability. Results obtained from weighting identified competencies
To analyse reliability, two methods were applied. First a pilot through a hierarchy analysis technique (Table 2) revealed that
study was conducted among 30 participants selected from a the study population gave the highest priority to strategic
research population including head nurses, matrons and nursing thinking (0.1221) and the lowest to evidence-based decision
staff. Cronbach’s alpha was calculated to show the internal making (0.007). Within the three defined competencies for
consistency of developed assessment tool and its reproducibility planning function, strategic thinking was mentioned as the most
was checked through applying the test re-test method and important qualification (0.4885) while intelligence in planning
calculation of intra-class correlation coefficient (ICC) (Alison ranked the least important (0.2299). Of the competencies that
Evans Consulting, 2008).Values greater than than 0.8 affirmed fell under the organising function, managerial competency and
the reproducibility of the questionnaire. resource allocation had the highest priority (0.4091). Among
To qualitatively test face validity of the questionnaire, a competencies relating to the leadership function, professionalism
10-member panel of experts including 7 university academic was mentioned as the most important prerequisite (0.1610)
members and 3 experts with sufficient experience in nursing and of the competencies required for the control function,
reviewed all questions to ensure their proportionality, performance evaluation was seen as the most significant (0.4877).
transparency, proper layout and ease of understanding. A Considering management roles, the study population regarded
quantitative method was also used to evaluate the instrument’s critical thinking as the most important competency (0.2101).
face validity.To do so, 20 individuals from the study population In general, experts involved in the study mostly emphasised
received the questionnaire using a 5-point Likert scale and were the significance of leadership qualifications (0.2638), while
asked to fill it out. Then, the impact score of each question they gave the least priority to those in the field of management
was calculated through item impact method and a formula of roles (0.1035).
(impact score=frequency (%) x importance). Those questions In the final step, a questionnaire with 78 questions and a
with impact score greater than 1.5 were approved and remained 5-point Likert scale was designed. Findings obtained from
in the final questionnaire. the reliability assessment of data collection tool confirmed its
Furthermore to qualitatively evaluate content validity of internal consistency (Cronbach’s alpha = 0.93). In addition the
the questionnaire, a data collection tool was reviewed by a 10- questionnaire’s reproducibility was calculated to be 0.89 based
member expert group and checked for compliance with writing on the value obtained from the stability reliability measurement
rules, inclusion of significant questions and their arrangement (ICC). Furthermore, quantitative assessment of the questionnaire’s
in the right place. Finally content validity ratio (CVR) was used face validity showed all questions had an the impact score
for the quantitative assessment of content validity and ensuring higher than 1.5, which was appropriate for further analysis.
© 2018 MA Healthcare Ltd

the selection of the most appropriate and important questions. The questionnaire’s content validity also showed that among all
Also, to confirm the proper organisation of questions so that questions in the initial version of the data collection tool, seven
they measured content in the best possible manner, content had a CVI lower than 0.7 and correspondingly were omitted
validity index (CVI) was applied. Lawshe (1975) proposed from final version, while four questions achieved CVI values
a method for measuring CVR; according to this approach, in a range of 0.7 to 0.79 and were modified by the research

British Journal of Nursing, 2018, Vol 27, No 213


Table 1. Model developed for head nurses’ managerial competencies
Managerial functions and Competencies
roles

Managerial Planning Planning intelligence (ability to participate in planning and capability to understand action, tactical and strategic plans)
functions
Strategic thinking (defining vision, goals and strategies)

Goal setting (ability to implement approved programmes towards determined goals)

Organising Coordination (ability to coordinate individuals and activities)

Delegating roles and functions (emphasising meritocracy and considering staff's capabilities in distributing job duties)

Resource allocation (ability to use resources effectively and efficiently)

Effective communication (ability to overcome communication barriers through identifying improvement approaches)

Team building (ability to create teamwork and play an effective role as a team member)

Change management (ability to conduct effective activities towards facilitating appropriate modifications in an organisation)

Conflict management (ability to identify and resolve organisational conflicts, deal with opposing viewpoints and guiding
teamwork towards common goals of the organisation)

Negotiation (ability to reach consensus when discussing issues and convince individuals)

Management of organisational climate and culture (ability to identify main factors related to organisational culture and develop
an appropriate working environment that supports organisational goals and values)

Inspiration (ability to promote motivation, professional interest, commitment and responsiveness in oneself or others)

Trust and credibility (ability to gain employees’, customers’ and colleagues' trust)

Professionalism (adherence to principles, values, beliefs, regulations, continuous training and development)

Commitment towards customers (valuing patients, ability to identify and meet their needs and respecting their rights)

Control Self-management (ability to identify and control emotions, dominate behaviour and guide it towards a positive manner)

Performance evaluation (ability to determine key criteria for evaluating actual performance on their basis)

Feedback (ability to deliver and get useful feedback and reform job affairs on their basis)

Managerial Problem solving (ability to identify and resolve organisational problems)


roles
Critical thinking (ability to think logically about different issues and make correct judgments about them)

Systematic thinking (ability to think about different organisational issues systematically through recognising inter-relationships between them)

Analytical competency (ability to analyse and interpret available data)

Information literacy (ability to collect and analyse valid information in an appropriate time)

Evidence-based decision making (ability to make decisions and find appropriate solutions based on valid evidence)

Creativity and innovation (ability to use novel thinking in managerial planning)

Attitude towards continuous improvement (believing in implementing improvement activities gradually over time)

team. Similarly values obtained from CVR calculation revealed of management professional competencies for successful nurse
that all questions were appropriate to be included in the final managers to fulfill their tasks in an effective manner. Although
questionnaire. Table 3 lists the elements of the final questionnaire application of the Delphi method is somewhat restricted in
for evaluating the managerial competencies of head nurses. practice as it is time-consuming and there may be skepticism
about its reliability and validity, it is widely used in the field of
Discussion nursing; the authors chose to use it as there are several benefits
This study was conducted to develop a valid model for evaluating in terms of expanding knowledge and reaching consensus from
head nurses’ managerial competencies and apply the evaluation a wide range of comments provided by different individuals
© 2018 MA Healthcare Ltd

tool in practice to identify and prioritise required qualifications. (Munro, 2005).


Through the study, 27 managerial competencies categorised Although several studies have been conducted to identify
in four main functions (including planning, organising, competencies required for head nurses, consensus has not been
leadership and control) were identified. These qualifications reached yet, perhaps for the reason that competency evaluation
were similarly emphasised by Wood (2011) who mentioned a list is a multi-dimensional issue (Cummings et al, 2010; Jasper and

4 British Journal of Nursing, 2018, Vol 27, No 21


RESEARCH

Table 2. Competencies’ weights obtained from AHP method


Managerial Competencies Competency's Weight for Total Ranking of Overall
functions and roles weight in relative managerial weight of competency ranking of
function/ role functions/ roles competency in relative competencies
function/ role

Planning Planning intelligence 0.2299 0.2501 0.0574 3 7

Strategic thinking 0.4885 0.1221 1 1

Goal setting 0.2816 0.0704 2 4

Organising Coordination 0.3375 0.2480 0.0837 2 3

Delegating roles and functions 0.2534 0.0628 3 6

Resource allocation 0.4091 0.1014 1 2

Leadership Effective communication 0.1412 0.2638 0.0372 3 11

Team building 0.1219 0.0321 4 12

Change management 0.0838 0.0221 6 15

Conflict management 0.0644 0.0169 8 19

Negotiation 0.0604 0.0159 9 20

Management of organisational 0.0979 0.0258 5 14


climate and culture

Inspiration 0.0465 0.0122 10 23

Trust and credibility 0.1583 0.0417 2 9

Professionalism 0.1610 0.0424 1 8

Commitment toward customers 0.0646 0.0170 7 18

Control Self-management 0.2293 0.1346 0.0308 3 13

Performance evaluation 0.4877 0.0656 1 5

Feedback 0.2830 0.0380 2 10

Managerial roles Problem solving 0.0773 0.1035 0.0080 6 25

Critical thinking 0.2101 0.0217 1 16

Systematic thinking 0.1802 0.0186 2 17

Analytical competency 0.0979 0.0101 5 24

Information literacy 0.0720 0.0074 7 26

Evidence-based decision making 0.0678 0.0070 8 27

Creativity and innovation 0.1509 0.0156 3 21

Attitude towards continuous 0.1438 0.0148 4 22


improvement

Crossan, 2012; Westphal, 2012). However, most of the studies empower themselves in leadership. Focusing on non-clinical
found agreed that evaluating managers’ performance according aspects of head nurses’ performance and having professional
to identified competencies adds accuracy and transparency input into evaluating a set of managerial competencies were
to the evaluation process, and a transparent and responsive among the main considerations for the study presented here.
evaluation system in turn increases job responsibility among In this regard, Munyewende et al (2016) mentioned six main
nurses. In a study conducted by Kantanen et al (2017) the areas for competency assessment of primary healthcare clinic
© 2018 MA Healthcare Ltd

importance of considering a list of managerial competencies for nursing managers including communication, leadership
head nurses and the necessity for evaluating their performance and management, staff management, financial management,
have been emphasised.The researchers concluded that although planning and priority setting, and problem-solving—and argued
head nurses were trustworthy and had proficiency in both that financial management competency needed to be more
general and professional competence areas, they still needed to emphasised in training programmes.

British Journal of Nursing, 2018, Vol 27, No 215


Table 3. Questions included in final assessment tool for head nurses’ managerial competencies
Competencies Questions
 5-point scale for responses:
 very poor, poor, moderate, good, very good

Planning intelligence Participation in action, tactical and strategic planning

Understanding hospital's plans and policies

Regular updating of programmes based on environmental change

Strategic thinking Perception of hospital's vision, goal and strategies

Determining the division's objectives based on vision and determined goals

Goal setting Implementing programmes based on determined goals

Coordination Awareness of the nursing organisational chart

Effective participation in various meetings held about the issue of nursing staff coordination

Inter-sectoral coordination

Intra-sectoral coordination

Create understanding between working departments

Develop cooperation and coordination between nursing staff and hospital departments

Delegating roles and functions Meritocracy (selecting appropriate individuals to undertake various activities)

Division of work based on individual's capabilities

Determining key competencies needed for organisational role playing

Succession planning (including the development of leadership and managerial skills among staff)

Resource allocation Efficient and effective use of resources

Estimating the department's needs in terms of resources and facilities

Effective communication Effective verbal and non-verbal communication

Resolving communication barriers

The art of oratory (having the power of speech and ability to present well)

Transferring attitudes and beliefs clearly

Art of effective listening

Team building Creating effective teamwork

Working as an effective team member

Leading and motivating team members to visualise their highest level of performance

Change management Mentioning change as an opportunity

Evaluating internal and external work environment

Making effective changes to solve organisational challenges

Involving key stakeholders in designing and implementing change

Managing employees' resistance toward change

Conflict management Identifying organisational conflicts

Resolving conflicts and leading them toward organizational objectives


© 2018 MA Healthcare Ltd

Negotiation Ability to reach consensus about discussing issues and convince individuals

Managing meeting effectively and efficiently

Management of organisational Ability to effectively work with individuals of diverse race, gender and culture
climate and culture
Creating a fair work environment

6 British Journal of Nursing, 2018, Vol 27, No 21


RESEARCH

Inspiration Creating interest in one’s own role (raising awareness of and motivation in the role)

Creating motivation, commitment and responsiveness among employees to achieve determined goals

Acting as a mentor and role model for staff

Trust and credibility Ability to gain employees, customers and colleagues' trust

Ability to gain credit among employees, customers and colleagues through developing organisational trust

Building trust and an environment of respect among employees

Professionalism Dedication to continuous learning

Perceiving principles, values, beliefs and regulations

Considering ethical issues in decision making and organisational communication

Providing opportunities for employees' professional development

Time management

Stress management

Commitment to customers Respecting patients' rights

Self-management Ability to control emotions and regulate behaviour

Ability to identify one's own strengths and weaknesses and make effort toward improvement

Learning from mistakes and making effort to correct them in an appropriate time

Performance evaluation Identifying key criteria for performance evaluation

Evaluating one's own activities based on standards for professional performance

Implementing corrective actions in case of malfunctioning

Feedback Giving and receiving effective feedback

Problem solving Identifying organisational problems in an effective manner

Identifying root causes for organisational problems

Prioritising problems and identified causes

Making prompt decisions to resolve organisational problems

Critical thinking Ability to think logically and critically

Providing correct inferences from collected data

Systemic thinking Having a systemic attitude

Holism in playing institutional roles

Analytical competency Analysing a difficult issue carefully and simplifying it to find appropriate solutions

Information literacy Looking for information

Collecting correct and accurate data in an appropriate timeframe

Evaluating the validity of collected data

Analysing collected data in an appropriate and timely manner

Appropriate and timely use of data to prepare valid reports

Using computer for information management

Evidence based decision Decision making in complicated and ambiguous conditions through use of valid information
making
Use of scientific valid evidence in organisational decision making
© 2018 MA Healthcare Ltd

Creativity and innovation Ability to create novel thoughts

Ability to use novel thoughts in practice

Attitude towards continuous Believing in implementing improvement activities gradually over time
improvement

British Journal of Nursing, 2018, Vol 27, No 217


Similarly Tongmuangtunyatep et al (2015) developed a Conclusion
competency assessment scale for head nurses in community Nursing management plays a key role in today’s healthcare
hospitals composed of five factors including leadership, organisations, thus there is a need for further discussion of
healthcare environment management, communication, nurse managers’ leadership and management competencies.
management and professional ethics. Results obtained from In fact head nurses in hospitals not only need to accomplish
the AHP analysis in the study here revealed that among their clinical practices but they are also required to carry out
managerial roles and functions, leadership was given the most administrative tasks that are entrusted to them as part of their
importance emphasising the obligation to apply leadership management responsibilities.To fulfill the task effectively, they
principles in encouraging subordinates in moving toward should be equipped with essential competencies that guide
determined goals. The literature also supported the findings them in this direction.
and focused on the significant role of leadership in persuading This study provides a valid and comprehensive instrument
employees to provide high-quality services and making their to ensure the quality of head nurses’ performance.The capacity
best effort to keep working to maximum standards (Afandi, for identifying managerial weaknesses is an important feature
2014; Ghamari-Zare, 2011; Pillay, 2011). The importance of of the instrument, and offers an interesting starting point for
nursing leadership for nurses has also been emphasised in further analysis to establish training courses and empowerment
a study conducted by Curtis et al (2011). They mentioned programmes for head nurses.
that leadership skills include supporting staff in achieving This study was cross-sectional, so conducting longitudinal
organisational goals also creating an encouraging vision and research will help to improve the strength of research information.
objectives for nursing personnel to follow through resource Despite this limitation, the study could have beneficial results
management, policy making and monitoring. . In agreement for healthcare managers and policy makers in the health system.
with the study presented here, all these researchers focused Developing such an assessment tool and applying it to evaluate
on leadership comprising strategic thinking, looking to managerial competencies of head nurses highlights the existing
the future, having flexibility and a positive attitude toward gaps in their managerial skills and reveals related competency
change, negotiation and effective communication as significant areas where work is needed. Such information would be useful
competency factors and agreed on the important role that across a wide range of healthcare organisations and types of
head nurses should play in hospitals regarding influencing hospitals worldwide. BJN
healthcare team members to strive for achieving goals (Curtis,
2011; Pillay, 2011; Ghamari-Zare et al, 2011). Declaration of interest: none
Researchers also mentioned planning, organising and control
as managerial competencies which help managers do their duties Acknowledgements
in a more effective manner. Consistent with the findings of this The researchers would like to thank all study participants and
study, previous studes conducted by Pillay (2011) and Asamani experts who contributed in the study and helped us in collecting
et al (2013) mentioned management as another contributing necessary data.
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CPD reflective questions


■■ What can be done to enhance the performance of head nurses?
■■ Reflect on the process needed to develop a valid assessment tool for managerial competencies
■■ Considering the 11 themes derived from both managerial functions and roles, which do you think has the most
influential effect on head nurses’ performance and thus should be regarded in the assessment tool?
© 2018 MA Healthcare Ltd

British Journal of Nursing, 2018, Vol 27, No 219

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