Managerial competencies of head nurses at central hospitals in Hanoi

Factors from senior leaders of head nurses, doctors and staff: Attention of 7 leaders and the board of directors, heads of department; the dependence on doctors’ indications and medical intructions; staff. Cultural and organizational factors of hospitals and patients: Hospital policies and mechanisms; hospital culture; patient overload. 2.3.3. Factors outside hospital Government mechanisms and policies, nation's culture, cooperation between hospitals; coordination of nursing training between hospital and training facilities; international cooperation; patients’ cooperation are also the factors that affect the managerial competencies of head nurses. 8 CHAPTER 3 RESEARCH METHODOLOGY 3.1. Design and selection of research framework Figure 3.1: The conceptual framework used in this study 3.2. Sample size and method 3.2.1. Sampling method Hospitals deliberately selected include general hospitals, specialized hospitals, large hospitals and small hospitals t at central level that located in Hanoi. Convenience sampling of hospital chiefs and vice chiefs of nursing, head nurses and staff nurses was conducted to find those who are willing to share information. In each hospital, the research was carried out on hospital chiefs and vice chiefs of nursing, head nurses and staff nurses in each unit under convenience sampling method. 3.2.2. Sample size The author included 14 hospital chiefs and vice chiefs of nursing, 60 head nurses and 538 staff nurses in this study. 3.3. Data collection 3.3.1. Secondary data collection Secondary data was collected from management agencies including Administration of Medical Service - Ministry of Health, Department of General Administration at hospitals. The researcher reached out to collect data, collate and 9 compare data, and review data to ensure the data was consistent and reliable. 3.3.2. Primary data collection The researcher interviewed the research subjects with questionnaires designed for head nurses and staff nurses (see appendix 3 for the survey questionnaire and questionnaire design) and then entered and cleaned the data. 3.4. Data management and analysis 3.4.1. Research process The research process of the thesis is implemented through the main stages: (1) Preliminary research, (2) In-depth quantitative research. In particular: Preliminary research: The research focuses on developing research indicators, identifying variables used in the research, making questionnaires and preliminary analysis of questionnaires by qualitative methods. In-depth quantitative research - Piloting on 100 subjects and assess the uniformity of the scale, adjust the scale to eliminate questions that completely reduce the quality of the scales. - Conducting the surveys on research subjects (14 chiefs and vice chiefs of nursing, 60 head nurses and 538 staff nurses in 60 departments of 07 central hospitals in Hanoi), describing characteristics of study population, carrying out basic statistical analysis. 3.4.2. Data cleaning and analysis Quantitative analysis: mainly to test the uniformity of the scale, principal component analysis and logistic regression analysis. Testing the uniformity of the scale is a technical method to check variables in each target group to see if there are similarities in measurement or not. This test will help reshape the structure of these factors more clearly and logically through the identification and elimination of interference factors and increase the reliability of input data. Principal component analysis (PCA) is the second quantitative analysis tool to help organize survey variables from the questionnaire into groups of indicators. Each group of indicators will represent a factor of competence of head nurses. PCA helps determine significant factors and reshape the structure of head nurses’ competencies into main criteria. These criteria will be used to evaluate the importance of each competency indicator and to assess the quality of nursing activities. In addition, component analysis helps to synthesize survey variables into main components and will be the input for the regression analysis to assess the impact on the quality of patient care. 10 Next, logistic regression analysis will evaluate the effects of the above classified components on variables that reflects the quality of nursing activities. The results of logistic regression analysis will clarify the relationship of each factor, compare the relationship between the factors, and orient the improvement of executive quality of head nurses. Finally, although all staff nurses access the same questionnaire, there is still a possibility that differences exist in the evaluation between groups by age, gender, experience, etc. 3.4.3. Methods to identify strengths and weaknesses of managerial competencies - The distance between the expected competencies and the current competencies of the head nurses as assessed by staff nurses was calculated by the difference between the average of expected score (the requirements for head nurses by 2025 set out by chief and vice chief of nursing) and the average score of the current managerial competencies of the head nurses as evaluated by staff nurses. - The distance between the expected competencies and the current competencies of the head nurses as assessed by themselves was calculated by the difference between the average of expected score (the requirements for head nurses by 2025 set out by chief and vice chief of nursing) and averages score of the current managerial competencies of the head nurses as evaluated by themselves. - Each distance was divided into high and low group. The high group included criteria with higher average score than the median, the low group included criteria with lower average score than the median. - Strengths were determined as the criteria had both of these above distance at low group. - Weaknesses were determined as the criteria had both of these above distance at high group and the average of Importance lied above the median. Weaknesses was an important basis for recommending solutions to improve managerial competencies of head nurses in hospitals. 11 CHAPTER 4 ASSESSMENT OF MANAGERIAL COMPETENCIES OF HEAD NURSES AT CENTRAL HOSPITALS IN HANOI 4.1. Head nurses at central hospitals The youngest studied head nurse was 34 years old and the oldest was 60 years old, 49% of them were over 40 years old. In terms of education level, the majority of head nurses (75%) hold a university or higher degree, this confirms the role as well as the importance of technical training for each head nurse to meet. 52 out of 60 head nurses took short-term training on management, yet there were two of them who had not been trained for management. 4.2. The current status of managerial competencies of the (studied) head nurses at central hospitals in Hanoi 4.2.1. Job performance of head nurses 66.7% of departments had less than 30 staff nurses; meanwhile there were only 4 departments (6.7%) that had many staff nurses (over 50 nurses). The head nurses who took part in the questionnaire survey said that they spend a little time on planning, most of them spend less than 15% of their time planning. Whereas the time spent on organizing operation activities and leadership was relatively appropriate, most head nurses responded that they spent between 16-30% of the time on this activity. The majority of head nurses focused on controlling nursing activities. Head nurses encountered difficulty most in planning, 7 of them (accounted for 11.7%) admitted that planning faced many obstacles. However, in general, it can be seen that currently head nurses have been facilitated to practice nursing management fairly well; over 70% of the head nurses said that their management activities were carried out in favourable or very favourable conditions. 4.2.2. Research results on the requirements and importance for managerial competencies of head nurses The technical skills of head nurses were determined based on 11 criteria. These criteria with the highest requirements included evidence-based practice; and comprehensive understanding of patient classification system. Meanwhile, the criteria with the lowest requirements were knowing and good practice of medical records, understanding of nursing care regulations. The most important criteria included understanding of nursing practice standards, nursing care planning, and understanding of nursing care regulations. The least important criteria included practice clinical skills in 12 nursing, comprehensive understanding of patient classification system, good infection control practice, and evidence-based practice. Human resource management skills of head nurses were determined based on 12 criteria. The most demanding criteria included effective communication and effective discipline. Meanwhile, the criteria with the lowest requirements were good sense of humor and optimistic. The most important criteria were constructive performance evaluation and staff development strategies. The least important criteria included having appropriate retention strategies, good recruitment strategies, good clinical examination, good sense of humor. The head nurses’ conceptual skills were determined based on 8 criteria. The most demanding criteria were mastering nursing theories and good knowledge of ethical standards and principles. The criteria with the lowest requirements were having strong political stance and having strategic planning/ goal development. The most important criteria included mastering nursing theories, having knowledge about legal issues related to nursing care. The least important criteria were having good administrative/organizational theories, having knowledge on the overview of quality management process. Leadership skills of head nurses were determined based on 14 criteria. The most demanding criteria were being able to manage time well and knowing how to assign work properly. Criteria with the lowest requirements included subtle and effective in expressing power and empowerment appropriately; research and proposal of process. The most important criteria were having ability to train employees, having good time management, interdisciplinary care coordination. Meanwhile, the least important criteria included having good knowledge of policies and procedures, and ability to make decisions. Financial management skills of head nurses were determined based on 07 criteria. The most demanding criteria were having appropriate measures to increase productivity, having appropriate measures for cost containment and cost avoidance practices. Criteria with the lowest requirements included having ability to develop/find financial resources and having good unit budget control measures. The most important criteria were having appropriate measures for cost containment and cost avoidance practices, having appropriate measures to increase productivity. Meanwhile, the least important criteria included having good unit budget control measures and having ability to develop/find financial resources. 4.2.3. Research results of current managerial competencies of head nurses Technical skills: As seen by staff nurses, head nurses had performed well the 13 evidence-based practice and fluent use of information technology and computers. However, understanding of nursing practice skills and understanding of nursing care regulations of head nurse were rated as less competent. The studied head nurses evaluated themselves to be the most competent at understanding of nursing care regulations and understanding of patient classification system. Meanwhile, fluent use of information technology and computers and nursing care planning were rated as less competent. Human resource management skills: Staff nurses evaluated that head nurses were humorous, optimistic and had reasonable retention strategies, on the other hand they rated head nurses as poorly competent at being able to communicate effectively, and not having good clinical examination. Head nurses perceived their communication skill and group process to be most effective. Meanwhile good sense of humor and team building strategies were assessed to be their worst competence by themselves. Conceptual skills: Staff nurses assessed head nurses’ competence to be best at having strong political stance and mastering nursing knowledge, worst at strategy planning and goals development, teaching/learning theories. Whilst head nurses perceived themselves as good at mastering nursing theories, understanding ethical standards and principles, in contrast they rated themselves poorly competent at strategy planning and goals development having an overview of quality management process. Leadership skills: Staff nurses evaluated that head nurses had the best competence in interdisciplinary care coordination, knowledge of policies and procedures, and worst in problem- solving and organization of unit work. The studied head nurses evaluated themselves to be the most competent at organization of unit work and workflow process and being able to solve problems appropriately and thoroughly. They saw themselves weak at creating sophisticated and effective motivational strategies and demonstrating power and empowerment appropriately. Financial management skills: As seen by staff nurses, head nurses had performed well cost-benefit analysis and capital budget forecasting. However, cost containment and cost avoidance practices, and unit budget control measures of head nurses were rated as less competent. The studied head nurses evaluated themselves to be the most competent at unit budget control measures, cost containment and cost avoidance practices, and worst at having appropriate measures to increase productivity, capital budget forecasting. 4.3. Factors related managerial competencies of head nurses Individual demographics factors such as age, management experience, length of service, educational level, managerial qualification explained 39.1% change of technical competence, 56% change of personnel management competence, 52% of change in conceptual competence, 33% change in leadership competence and 34% change in 14 financial management competence. Length of service was inversely correlated with technical skills (beta = - 0.338, p = 0.019); educational level was positively correlated with personnel management skills (beta = 0.031, p = 0.031) and positively correlated with conceptual skills (beta = 0.094, p = 0.028); length of service had a positive correlation with personnel management skills (beta = 0.222, p = 0.043); managerial qualification was positively correlated with conceptual skills (beta = 0.134, p = 0.031) in the managerial competencies of the head nurses. 4.4. Relationship between managerial competencies of head nurse and patient care outcomes Technical skills had negative correlation with the rate of patients falling (beta = - 0.267, p = 0.012), and was inversely correlated with the rate of pressure ulcers (beta = - 0,216, p = 0.001), There was a negative correlation between technical skills with the rate of medication administration errors (beta = -0,153, p = 0.021). Human resource management skills were inversely correlated with the rate of pressure ulcers (beta = - 0.182, p = 0.035). Leadership skills had a negative correlation with the rate of medication administration errors (beta = -0.94, p = 0.029). Conceptual skills and financial management skills were not correlated with patient care outcomes. 4.5. General assessment of managerial competencies of (studied) head nurses at central hospitals in Hanoi 4.5.1. Strengths in managerial competencies of head nurses Strengths in technical skills of head nurses: The skills that head nurses performed well (strong points) were those of which the two distance were short when compared with the expected competencies. Strengths in nursing technical skills included understanding of nursing care regulations; having knowledge of and good practice records management; understanding nursing practice skills; good practice of nursing clinical skills. Strengths in human resource management skills: Strengths in personnel management skills of head nurses included good clinical examination competence; being optimistic; ability to implement group process; having staff development strategies; having appropriate retention strategies. Strengths in conceptual skills of head nurses: Strengths in head nurses’ conceptual skills included having strong political stance; knowledge of legal issues related to nursing care. Strengths in leadership skills of head nurses: Strengths in leadership skills of head nurse included being able to solve problems appropriately and thoroughly; ability of 15 training staff; understanding policies and procedures; having good stress management skills; research and propose processes. Strengths of financial management skills of head nurses: Strengths in financial management skills of head nurses included ability to develop/find financial resource; ability to implement unit budget control measures; ability to analyse cost- benefit. 4.5.2. Limitations and causes in managerial competencies of head nurses Limitations and causes in technical skills of head nurses: Criteria for technical skills of head nurses were considered weak when there was a difference between the expected and the actual competencies assessed both by staff nurses and themselves plus the score for the importance was high. Weaknesses included nursing care planning, evidence-based practice, and good application and use of new technology. Causes: Head nurses had not been trained in planning nor updated with knowledge about evidence-based practices and new technologies, or maybe they were subjective, got used to following their past experiences, habit and feeling leading to missing out of required steps. In addition, since hospitals had no requirements or regulations on mandatory implementation of the above contents, the implementation was not consistent. Limitations and causes in nursing skills human resource management skills: Weaknesses in human resource management skills of head nurses included the ability of effective communication and effective staffing strategy. Causes: Head nurses had not been trained or well trained on communication skills. They often conducted communication when they felt it necessary or upon requests, they had not had long-term communication strategies. The development of staffing strategies of head nurses was limited due to the specific nature of healthcare service that had divided nurses into specialties and departments. This division had previously been interpreted by default as the possibility of chief or vice chief of nursing or the hospital board of directors. Therefore, head nurses were still passive to carry out this skill. Limitations and causes in head nurses' conceptual skills: Weaknesses in head nurses’ conceptual skills included being able to teach and study well; having strategy planning and goal development. Causes: Head nurses had not been trained in pedagogy. The teaching/coaching process was mainly practical with hands-on instructions, without any long-term and well- planned training strategies. Well planning also needs to improve because they had not yet paid enough attention to it, plans developed was mainly developed similar to the plans of previous years. Limitations and causes in head nurses’ leadership: Weaknesses in leadership skills of head nurses included the ability of problem- 16 solving, time management, organization of work of unit and workflow process, and interdisciplinary care coordination. Causes: Firstly, nursing work was very hard and full of pressure from work processes, patients and patients’ family members. These pressures created conflicts frequently. Head nurses faces difficulties and were even impossible to resolve all these conflicts. Secondly, the above weaknesses were common and required a long time for the head nurses to undergo, learn from experience and overcome. Thirdly, the fact that job description for each position had not been completed lead to the overlapping, unmanageable, not fully assigned coordination of common workloads of their unit. Limitations and causes in financial management skills of head nurses: These weaknesses included the ability to control unit budget and take appropriate measures to increase productivity. The causes for these weaknesses were mainly due to the starting point of head nurses. They were the ones who switched from practicing as an RN in the beginning, and they had not been trained on financial management. Only at hospital had department of finance, there was no team specialized in financing at department level. In addition, little had head nurses been trained on financial management as enterprise managers had. Furthermore, nursing activities were mainly performed following processes. At the time of the study, head nurses paid more attention to safety and proper implementation of procedures than to productivity measurements. This is one of the weaknesses that needs to be improved, especially in public hospital. 17 CHAPTER 5 SOLUTIONS TO IMPROVE MANAGERIAL COMPETENCIES OF HEAD NURSES BY 2025 5.1. Orientation to improve managerial competencies of head nurses 5.1.1. The need for improving managerial competencies of head nurses In order to improve the quality of care, ensure safety for patients and enhance performance of head nurses, in the coming years, the Health sector needs to pay attention to following issues: 1- Transforming nursing policy, nursing management system 2- Increasing both in quantity and quality of human resources for nursing and midwifery 3- Transforming service attitude and style and improving quality of care towards patients’ satisfaction 4- Issuing nursing care process and implementation guidelines 5.1.2. The goals of improving managerial competencies of head nurses from now on to 2025 By 2025, Vietnam needs to achieve the following goals: 1- Enhancing the completion of legal provisions related to the role, position, functions, obligations and responsibilities of head nurses. 2- Developing and standardizing skill sets for head nurses; as a basis for staff nurses to strive for, and a basis for recruiting head nurses with good education level and management qualifications as well. 3- Consolidating training curriculum, syllabus, teaching facilities and standard teaching staff toward practical and effective teaching/coaching about resource management – administration. 4- Enhancing the effectiveness and efficiency of nursing management of the current head nurses. 5.1.3. Viewpoint on improving the competencies of head nurses by 2025 Improving the competencies of head nurses in particular and nurses in general should: - Be implemented scientifically, persistently and aggressively. - Be fully allocated resources on policies, personel, facilities and conditions for practicing theories obtained. - Be supplemented with “work management tools” to ensure feasibility and effectiveness 18 - Adopt appropriate policies to support and encourage skillful staff and acknowledge the contributions of head nurses. - Receive high consensus of head nurses in self-planning, looking for opportunities to improve their own skills. 5.2. Recommendations to head nurses 5.2.1. Recommendations for improving technical skills in managerial competencies of head nurses The relationship between length of service and technical skills is statistically significant and negatively correlated (beta = -0.338, p = 0.019). Therefore, in addition to improving managerial competencies, head nurses still need to update and practice nursing skills regularly so they can participate in the development of technical processes and supportive work for management. Recommendations to management units: It is necessary to supplement the regulations and compulsory requirements for head nurses on updating, supplementing and improving technical skills annually. Criteria that need to be focused on improving include nursing care planning, evidence-based practice, good application and use of new technology. Head nurses need to complete the planning in 5 steps as follows: (1) Assessment; (2) Nursing diagnosis; (3) Care planning; (4) Implementation; (5) Evaluation (Kozier, B. 2004).