The existence of an efficient and effective evaluation system for recognition of personnel competencies and capabilities can play a significant role in reducing organisations' costs and providing services with higher levels of quality (Meretoja and Leino-Kilpi, 2003; Shafii et al, 2016). Improvement in management performance may not be achieved unless there is an appropriate model for performance evaluation based on accurate and applicable indicators. Such a model provides an opportunity for proper and principled selection and training of managers who are capable of organising healthcare provision processes to be efficient, effective and responsive (Pillay, 2010; Liang et al, 2013).
Although there are different assessment methods, several studies have focused on competence-based approaches for evaluating the performance of healthcare managers, particularly head nurses—that is, the lead nurse for each particular clinical department (Arcand and Neumann, 2005; Cowan et al, 2005; Liu et al, 2007; Cummings et al, 2010; Pillay, 2010; Dadgar et al, 2012; Wongprasit, 2014).
In the last few years the significant role of head nurses in directing patient care affairs and provision of a healthy work 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 responsibility. To fulfil the tasks effectively, they should be equipped with essential competencies to guide them in this direction. Furthermore, as nurse managers constitute a significant number of healthcare managers in the health market and their performance improvements potentially result in hospital excellence, developing a logical model for evaluating managerial competencies would be substantially beneficial (Liu et al, 2007). Despite this, a valid and comprehensive measurement tool has not been developed in the authors' country to evaluate the managerial competencies of this occupational group (Parry, 1997; Meretoja and Leino-Kilpi, 2003; Khomeiran et al, 2006). Thus in the current study the aim was to provide a valid tool for assessing managerial competencies of hospital department head nurses.
Material and methods
This descriptive-analytical study was conducted in 2017 in six main phases. First a literature review was carried out using the scientific databases of Web of Science, PubMed, Science Direct, Scopus, Emerald and Proquest using the following key words: head nurse, nurse, competency, performance evaluation, competency assessment and managerial competency. As a result, a list of managerial competencies required for hospital head nurses was drafted to run the first Delphi round of the study in the second phase. In this stage, the developed list was verified by the research team and sent to 16 experts, including 5 academic members in the field of nursing and healthcare management and 11 nurses with at least 5 years' experience of nursing. In the third step, the arranged list was reviewed by a five-member panel of experts to be integrated, categorised and finalised through omitting any pointless or duplicate issues. Then the second Delphi round was conducted so that verified competencies (with mode equal to 4 and 5) and dimensions needing to be re-examined (mode equal to 3) were sent to experts for the second time to be weighted based on an analytic hierarchy process (AHP). Collected data were analysed in Excel and competencies prioritised. In the fifth step, these competencies were discussed in a seven-member panel made up of the research team and two other experts in the field of healthcare management and nursing to finalise a model for evaluating head nurses' competencies. Finally a questionnaire with the purpose of evaluating head nurses' managerial competencies was designed and checked for its validity and reliability.
To analyse reliability, two methods were applied. First a pilot study was conducted among 30 participants selected from a research population including head nurses, matrons and nursing staff. Cronbach's alpha was calculated to show the internal consistency of developed assessment tool and its reproducibility was checked through applying the test re-test method and calculation of intra-class correlation coefficient (ICC) (Alison Evans Consulting, 2008). Values greater than 0.8 affirmed the reproducibility of the questionnaire.
To qualitatively test face validity of the questionnaire, a 10-member panel of experts including 7 university academic members and 3 experts with sufficient experience in nursing reviewed all questions to ensure their proportionality, transparency, proper layout and ease of understanding. A quantitative method was also used to evaluate the instrument's face validity. To do so, 20 individuals from the study population received the questionnaire using a 5-point Likert scale and were asked to fill it out. Then, the impact score of each question was calculated through item impact method and a formula of (impact score=frequency (%) x importance). Those questions with impact score greater than 1.5 were approved and remained in the final questionnaire.
Furthermore, to qualitatively evaluate content validity of the questionnaire, a data collection tool was reviewed by a 10-member expert group and checked for compliance with writing rules, inclusion of significant questions and their arrangement in the right place. Finally, content validity ratio (CVR) was used for the quantitative assessment of content validity and ensuring the selection of the most appropriate and important questions. Also, to confirm the proper organisation of questions so that they measured content in the best possible manner, content validity index (CVI) was applied. Lawshe (1975) proposed a method for measuring CVR; according to this approach, experts familiar with the job were given the questionnaire and asked to score each item from 0 to 2 with a 3-degree range of ‘not necessary’, ‘not necessary but helpful’ or ‘necessary’. The formula for content validity ratio is CVR= (Ne - N/2)/(N/2), in which Ne represents the number of experts who mentioned the item necessary and N is the total number of experts in the panel. In this study if the average score for CVR was 0.62 or more, or calculated CVR was in the range 0-0.75 and the average score of responses was more than 1.5, the item in the questionnaire would be accepted with an acceptable level of significance (Najafi and Kheiry, 2013).
Regarding CVI, panel members were asked to rate questions in terms of relevancy, simplicity and transparency in a four-point scale. If the CVI was higher than 0.79, the item was deemed appropriate. If it was between 0.7 and 0.79 it would require modification and if it was less than 0.7 it was removed (Lawshe, 1975; Waltz and Baussell, 1981).
Results
Overall, 27 managerial competencies required for head nurses were identified and categorised in 4 main categories relating to management functions: planning, organising, leadership and control. These competencies are shown in Table 1.
| Managerial functions and roles | Competencies | |
|---|---|---|
| Managerial functions | Planning | Planning intelligence (ability to participate in planning and capability to understand action, tactical and strategic plans) |
| 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 roles | Problem solving (ability to identify and resolve organisational problems) | |
| Critical thinking (ability to think logically about different issues and make correct judgements 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) | ||
Results obtained from weighting identified competencies through a hierarchy analysis technique (Table 2) revealed that the study population gave the highest priority to strategic thinking (0.1221) and the lowest to evidence-based decision making (0.007). Within the three defined competencies for planning function, strategic thinking was mentioned as the most important qualification (0.4885) while intelligence in planning ranked the least important (0.2299). Of the competencies that fell under the organising function, managerial competency and resource allocation had the highest priority (0.4091). Among competencies relating to the leadership function, professionalism was mentioned as the most important prerequisite (0.1610) and of the competencies required for the control function, performance evaluation was seen as the most significant (0.4877).
| Managerial functions and roles | Competencies | Competency's weight in relative function/role | Weight for managerial functions/roles | Total weight of competency | Ranking of competency in relative function/role | Overall ranking of competencies |
|---|---|---|---|---|---|---|
| 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 climate and culture | 0.0979 | 0.0258 | 5 | 14 | ||
| 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 improvement | 0.1438 | 0.0148 | 4 | 22 |
Considering management roles, the study population regarded critical thinking as the most important competency (0.2101). In general, experts involved in the study mostly emphasised the significance of leadership qualifications (0.2638), while they gave the least priority to those in the field of management roles (0.1035).
In the final step, a questionnaire with 78 questions and a 5-point Likert scale was designed. Findings obtained from the reliability assessment of data collection tool confirmed its internal consistency (Cronbach's alpha = 0.93). In addition the questionnaire's reproducibility was calculated to be 0.89 based on the value obtained from the stability reliability measurement (ICC). Furthermore, quantitative assessment of the questionnaire's face validity showed all questions had an impact score higher than 1.5, which was appropriate for further analysis. The questionnaire's content validity also showed that among all questions in the initial version of the data collection tool, seven had a CVI lower than 0.7 and correspondingly were omitted from the final version, while four questions achieved CVI values in a range of 0.7 to 0.79 and were modified by the research team. Similarly values obtained from CVR calculation revealed that all questions were appropriate to be included in the final questionnaire. Table 3 lists the elements of the final questionnaire for evaluating the managerial competencies of head nurses.
| 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 organisational objectives | ||
| Negotiation | Ability to reach consensus about discussing issues and convince individuals | |
| Managing meetings effectively and efficiently | ||
| Management of organisational climate and culture | Ability to effectively work with individuals of diverse race, gender and culture | |
| Creating a fair work environment | ||
| 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 a computer for information management | ||
| Evidence-based decision making | Decision making in complicated and ambiguous conditions through use of valid information | |
| Use of scientific valid evidence in organisational decision making | ||
| Creativity and innovation | Ability to create novel thoughts | |
| Ability to use novel thoughts in practice | ||
| Attitude towards continuous improvement | Believing in implementing improvement activities gradually over time | |
Discussion
This study was conducted to develop a valid model for evaluating head nurses' managerial competencies and apply the evaluation tool in practice to identify and prioritise required qualifications. Through the study, 27 managerial competencies categorised in four main functions (including planning, organising, leadership and control) were identified. These qualifications were similarly emphasised by Wood (2011) who mentioned a list of management professional competencies for successful nurse managers to fulfil their tasks in an effective manner. Although application of the Delphi method is somewhat restricted in practice as it is time-consuming and there may be scepticism about its reliability and validity, it is widely used in the field of nursing; the authors chose to use it as there are several benefits in terms of expanding knowledge and reaching consensus from a wide range of comments provided by different individuals (Munro, 2005).
Although several studies have been conducted to identify competencies required for head nurses, consensus has not been reached yet, perhaps for the reason that competency evaluation is a multi-dimensional issue (Cummings et al, 2010; Jasper and Crossan, 2012; Westphal, 2012). However, most of the studies found agreed that evaluating managers' performance according to identified competencies adds accuracy and transparency to the evaluation process, and a transparent and responsive evaluation system in turn increases job responsibility among nurses. In a study conducted by Kantanen et al (2017) the importance of considering a list of managerial competencies for head nurses and the necessity for evaluating their performance was emphasised. The researchers concluded that, although head nurses were trustworthy and had proficiency in both general and professional competence areas, they still needed to empower themselves in leadership. Focusing on non-clinical aspects of head nurses' performance and having professional input into evaluating a set of managerial competencies were among the main considerations for the study presented here. In this regard, Munyewende et al (2016) mentioned six main areas for competency assessment of primary healthcare clinic nursing managers including communication, leadership and management, staff management, financial management, planning and priority setting, and problem-solving—and argued that financial management competency needed to be more emphasised in training programmes.
Similarly Tongmuangtunyatep et al (2015) developed a competency assessment scale for head nurses in community hospitals composed of five factors including leadership, healthcare environment management, communication, management and professional ethics. Results obtained from the AHP analysis in the study here revealed that among managerial roles and functions, leadership was given the most importance, emphasising the obligation to apply leadership principles in encouraging subordinates in moving toward determined goals. The literature also supported the findings and focused on the significant role of leadership in persuading employees to provide high-quality services and making their best effort to keep working to maximum standards (Afandi, 2014; Ghamari-Zare et al, 2011; Pillay, 2011). The importance of nursing leadership for nurses has also been emphasised in a study conducted by Curtis et al (2011). They mentioned that leadership skills include supporting staff in achieving organisational goals and also creating an encouraging vision and objectives for nursing personnel to follow through resource management, policy making and monitoring. In agreement with the study presented here, all these researchers focused on leadership comprising strategic thinking, looking to the future, having flexibility and a positive attitude toward change, negotiation and effective communication as significant competency factors and agreed on the important role that head nurses should play in hospitals regarding influencing healthcare team members to strive for achieving goals (Curtis et al, 2011; Pillay, 2011; Ghamari-Zare et al, 2011).
Researchers also mentioned planning, organising and control as managerial competencies that help managers do their duties in a more effective manner. Consistent with the findings of this study, previous studies conducted by Pillay (2011) and Asamani et al (2013) mentioned management as another contributing factor for head nurses' competency. In this regard, the literature affirmed that head nurses should have strategic planning skills to set vision, mission, goals, objectives and strategies in an encouraging way. They should also organise organisational affairs and related resources effectively and control work activities in a precise way to attain determined goals (Hutchinson and Purcell, 2010; Asamani et al, 2013).
Conclusion
Nursing management plays a key role in today's healthcare organisations, thus there is a need for further discussion of nurse managers' leadership and management competencies. In fact head nurses in hospitals not only need to accomplish their clinical practices but they are also required to carry out administrative tasks that are entrusted to them as part of their management responsibilities. To fulfil the task effectively, they should be equipped with essential competencies that guide them in this direction.
This study provides a valid and comprehensive instrument to ensure the quality of head nurses' performance. The capacity for identifying managerial weaknesses is an important feature of the instrument, and offers an interesting starting point for further analysis to establish training courses and empowerment programmes for head nurses.
This study was cross-sectional, so conducting longitudinal research will help to improve the strength of research information. Despite this limitation, the study could have beneficial results for healthcare managers and policy makers in the health system. Developing such an assessment tool and applying it to evaluate managerial competencies of head nurses highlights the existing gaps in their managerial skills and reveals related competency areas where work is needed. Such information would be useful across a wide range of healthcare organisations and types of hospitals worldwide.