Turbulent Atmosphere-Based Dominant Management Behavior of the Head Nurses in Clinical Wards: A Qualitative Study.

BACKGROUND: Nursing management is the most important aspect for providing high-quality nursing care. Therefore, skillful nursing managers, such as head nurses, are required to accomplish this goal. High-quality nursing care is one of the most important principles of health organizations to ensure society's health.
OBJECTIVES: The goal of the conventional content analysis is to explain the dominant experienced-based behavior of the head nurses in clinical wards.
MATERIALS AND METHODS: This study was conducted by applying a quality study approach with a common content analysis model (Granheim and Lundmen). The participants were 25 head nurses who were working in the wards of various hospitals in Zahedan City. They were selected via the purposeful sampling method. The data were collected thoroughly and continued until a saturation stage was reached.
RESULTS: The result of data analysis was the theme "turbulent atmosphere-based management," which consists of five categories as follows: the work culture of the ward, job burnout, negligent evaluation, job conflict, and decision making with limited effects.
CONCLUSIONS: The analysis of the findings of the present study through considering the defined categories demonstrated that, to modify and correct the turbulent atmosphere-based management, several important measures are required and need to be continually monitored.

1. Background

Management has a pivotal role in the growth, development, and even death of organizations (1). Informed and skillful head nurses who are the backbone of hospitals and health institutions are required for the appropriate leadership of nursing staff to provide high-quality nursing care, which is a major goal of health institutions, as its ultimate result is the guaranteed health of society (2). Health institutions cannot be effectively developed unless nursing management or leadership is developed (3). Therefore, with regard to the increasing complexity of the performance role of managers and since the head nurses are the front line in solving the problems of nursing, it is necessary to identify and redesign the factors affecting this field (4). Head nurses constantly face serious challenges in supervising their wards, particularly in their professional performance, and thus one of their important responsibilities is to know how to effectively deal with these challenges (5). One of these challenges is the lack of transparency regarding the importance of their role in their relationship with nurses, supervisors, and superordinate managers (4). Another challenge for head nurses is the different perceptions nurse managers and nurses have of their working environment that, in turn, may cause some adverse effects, such as nurses’ turnover and work abandonment (6). It is clear that the organizational culture influences healthcare performance; hence, it is necessary to identify the effects of culture dimensions on healthcare performance. Recognizing the organizational culture is the key success of head nurses, and it has been proven that a strong organizational culture is a key factor leading to the development of organization performance (7). Moreover, nursing management is constantly faced with serious challenges, such as a shortage of human resources, negative emotions, staff’s concerns, changes in the current rules and regulations, and the increasing complexity of clinical performance. It is believed that strategic thinking, in addition to coping with all these challenges, is required to form a more humane and more responsible health system (5). Thus, new management based on presenting nursing services, technological changes, and societal pressures calls for head nurses with special skills, knowledge, and competence in all management aspects to respond to the present demands (8). Nurse managers have to provide a secure and safe environment, integrate healthcare workflows, and create or develop a sound healthcare climate to facilitate nursing care (9). Common necessary characteristics of qualified head nurses include interest, optimism, an ability to develop good relationships with others, optimal role modeling, mentorship, and crisis management with the consideration of all ethical issues in the nursing profession (10). A simple review reveals that most studies carried out in Iran have primarily been concerned with classifying the required duties and skills of managers. Therefore, with regard to the fact that management is culture based, its full investigation in the existing culture seems necessary to identify the factors affecting management to cope with the challenges and organize head nurse managers’ behaviors and customs. As a result, the present qualitative study was conducted in this environment, by determining the dominant behavior of the head nurses in clinical wards to identify the challenges, present the alternative solutions, promote the head nurses’ performance, increase the professional perception of nursing management, and resolve the challenges, as these can lead to job satisfaction and an increase in the quality of nursing services.

2. Objectives

The goal of the conventional content analysis is to explain the dominant experienced- based behavior of the head nurses in clinical wards.

3. Materials and Methods

To achieve this purpose, the conventional content analysis method was used (Grandheim and Lundman). Qualitative content analysis was employed as the study method for the subjective interpretation of written data to identify the implicit and explicit models in the text via systematic classification process (11). The study has no any exclusion criteria. The study has been approved by the Research Committee of Tarbiat Modares University with ethical approval number D-52/3517 Date: 01/26/2013 and complies with current ethical considerations. Informed consent was obtained from each participant. The study protocol conforms to the ethical guidelines of the 1975 Declaration of Helsinki. There is no conflict of interest related to the material in this study.

3.1. Study Area

This study was conducted in hospitals located in the city of Zahedan, Iran.

3.2. Sampling Method

Typical case purpose-based sampling techniques were used.

The subjects were selected concerning their practical experience in the head nursing field so that sharing of their experience could help the researcher so much to describe the current situation. One limitation of this study is that it is performed with a limited number of the participants in Zahedan, Iran.

3.3. Participant Selection Method

All 25 head nurse participants were interviewed at all hospitals in Zahedan, Iran during 2013. The head nurses were required to have the following criteria to be included in the study: a university degree (at least a BSc), at least one year of managing experience, qualified verbal skills, an ability to expressing their experiences without shyness, an ability to clearly remember the issues and experiences which has happened the problems, an innate interest in expressing their informative experiences and presenting a reliable image of the study phenomenon.

3.4. Data Collection Method

After the proposal was approved in the Research Council of Medical Sciences and Ethic Committee in Tarbiat Modares University, the data were collected via unstructured interviews individually. All ethical issues, such as anonymity, the right to have informed consent, confidentiality, and the right to leave the study, were carefully observed. The interview was conducted by the first author of this study, who has a Ph.D. candidate in nursing, as well as the successful completion of workshops, in addition to all phases of qualitative research, including data collection and data analysis.

Before interviews, participants were told about the purpose of the study, confidentiality, and the recording process of the interviews. Then, in the case of inclusion in the study, the open interviews would start with the following general statement: “Please explain your experience of a working day from the moment you enter the ward until the time you leave.” No repeat interviews were carried out, as all the interviewees were alert and aware of the question. Then the participants were probed with follow-up questions. The interviews, on average, were 70 minutes, ranging from 30 to 120 minutes. All the interviews were conducted by the main researcher and recorded at the same time, and later, they were transcribed and typed verbatim. After listening carefully to the interviews several times to gain an in-depth understanding of the data, the researcher would type the text in transcript form and analyze it.

3.5. Data Analysis Method

The following steps were used to analyze the data (Grandheim and Landman, 2004):

transcription of the interviews verbatim and several revisions to understand the concept as a whole.

breaking down the text into rational units that were condensed.

conceptualization of the compressed significant units and cataloging them with codes.

categorization of the codes into subcategories and categories, depending on their similarities and differences.

devising themes based on the latent content of the text (12). Based on the methods of Granheim and Lundmen, the following steps were taken. A transcription was typed verbatim immediately after each interview and the text was read several times to achieve a general perception of its content. Then it was divided into semantic units and the semantic units were summarized and each was given a code. The initial codes were then categorized into categories and subcategories based on their similarities and differences. Following that, the themes in the data were extracted as the hidden content. Then the data from each interview was used as the guidance for the next interview. Sampling was continued in this way until the data were saturated (Box 1).

Box 1.

Data Analysis Method[a]

Irregular Work Culture of the Ward
Congestion and disturbance in patient care affairs
Too many companions
Too many students
Irregular visits
Staff turn over
Non-specialized intervention
Intervention of the patients’ companions in nursing affairs
The intervention of other healthcare personnel in nursing affairs

aThe patients’ many companions are real barriers for care, as they interfere in nursing affairs and impede the care process. This is the culture of this region, as they love their patients and don’t want to leave them alone for a moment” (P. 12, with 15 years of experience). “One of the problems that impedes the nursing process is the irregular visits by physicians. Although physicians have their own justifications, it has caused some disturbances in the nursing function” (P. 1, with 23 years of experience). “Nurses’ turnover rate is high in the ward; we hire a nurse and train her, but after a while nursing office calls and transfers her to a different ward and we have to hire another one” (P. 15, with 17 years of experience). “Some of the other healthcare professionals, such as physicians, interfere with nursing affairs” (P. 19, with 20 years of experience)

To ensure the validity and reliability of the qualitative data, scientific precision criteria such as credibility, dependability, transferability, and conformability suggested by Guba and Lincoln were employed (13).

Credibility is the long-term involvement of the researcher with the topic of the study and with the data, controlled by the participants themselves (a part of the interview texts with initial codes was presented to the participants and its homogeneity was compared with the participants’ views). Data integration was used in interviews with the head nurses. To observe transferability, some sampling techniques with maximum diversity were employed; that is, the selection of participants in terms of experience, age, gender, job, and education and inclusion criteria was taken into consideration (experience: from 1 to 30 years, gender: male and female, age ranging from 25 to 55 years, education: BScN and higher) (Table 1).

Table 1.

Demographic Variables of Participants

Occupation	Head Nurse
Gender	5 Males and 20 Females
Age	25 – 55
Code Number of Participants	From P1 – P25
Degree and Higher Education	Bachelor and Post Graduate
Experience, y	1 – 30

The confirmation ability of the results was evaluated by experts familiar with qualitative research; that is, some parts of the interviews with the related codes encoded by the first author and confirmed by the research team and emerging categories were assessed and confirmed by two intra-raters familiar with qualitative research. To make it auditable, the researcher clearly recorded and reported the study stages so that the study it could easily be followed up. For the transferability of findings, an attempt was made to present the participants’ views accurately. The demographic features of the participants and the study area were expressed in detail No special software was used for the data analysis of classification; it was done using Microsoft Office Word.

4. Results

Based on the rich and in-depth descriptions of the participants, 2770 initial codes were primarily extracted. After several careful reviews and summarizations, these codes were classified based on their appropriateness and similarity. By analysis and comparison, their internal meaning was recognized in five main categories and 13 subcategories; the categories were named based on their nature conceptually and subjectively. They include “work culture,” “job burnout,” “negligent evaluation,” “job conflict,” and “decision making with a limited effect.” The results of the experience and dimension of the performance of head nurses were presented in the form of the turbulent atmosphere-based management of clinical wards. When head nurses were in this atmosphere, this management process was observed in their environment. Therefore, the themes and each of the categories and sub-subcategories are explained in Box 2.

Box 2.

Subcategories and Categories and Themes

Turbulent atmosphere-based management
Irregular work culture of the ward
Congestion and disturbance in patient care affairs
Non-specialized intervention
Job burnout
Dissatisfaction
Physical and emotional fatigue
Conflict of organizational and personal interests
Shortage of human resources in the ward
Job conflict
Shortage of organizational trust
Demands for non-professional work
Decision making with a limited effect
Self-reliant decision making
High-risk decision making
Inadequate participation of human resources
Negligent evaluation
Decision making with a limited effect
Negligent evaluation

4.1. Irregular Work Culture of the Ward

Head nurses deal with a variety of people, including nurses, physicians, patients, patients’ relatives, and other people with various cultural backgrounds in the clinical environment. Head nurses have a practical role in clinical environments. Thus, recognizing work culture in terms of satisfaction and improving the service quality is quite important. In this category, based on the participants’ experiences, the subcategories of “congestion and irregularity in care issues of patient” and “non-specialized interference” were obtained.

Regarding the sub-category of “congestion and irregularity in care issues of patients,” one of the participants said, “They insist on having even more than one companion next to their patients. Regarding the local culture, they don’t want to leave their patients alone” (p. 15, with 17 years of experience). Another participant said, “Because of the irregular visits, the treatment of the patient is delayed and a sort of irregularity happens in the process of nursing” (p. 16, with 19 years of experience).

Regarding the subcategory of non-specialized interference, one of the participants said, “One of our problems is the interference of the patients’ companions and even some physicians in the professional task of nursing” (p. 19, with 20 years of experience).

4.2. Job Burnout

Job burnout is one of the main factors in reducing efficiency, losing human resources, and creating physical and mental problems for nurses; based on the importance of nurses’ roles in the healthcare system, the identification of the factors leading to job burnout is of great importance. The experiences of the participants demonstrated the subcategories of “dissatisfaction,” “physical and emotional fatigue,” “conflict of organizational and personal interests,” and “a shortage of human resources.”

Regarding the category of “dissatisfaction,” one participant said, “I am looking forward to being retired, and it is not a positive message; it shows my dissatisfaction with the system” (P. 3, with 29 years of experience).

Regarding “physical and emotional fatigue,” one of the participants said, “The increasing number of hospitalized patients and the insufficient number of nurses have imposed mental and physical pressure on the personnel” (P. 14, with 16 years of experience).

Regarding the “conflict of organizational and personal interests,” one of the participants said, “From the very first moment when I arrive at work, I get so involved with work that I forget my family and children; it’s very hard; when I get home, I have no energy for my personal life” (P. 9, with 15 years of experience).

Regarding “the shortage of human resources in workplace,” one participant said, “We are experiencing a shortage of nurses, security guards, and servants” (P. 22, with 18 years of experience).

4.3. Negligent Evaluation

Head nurses pay attention to professional performance and resolve the factors leading to negligent evaluation. This means that they pay significant attention to nursing staff’s productivity and increasing the quality of nursing services. Based on participants’ experiences, “performance evaluation and “negligence in evaluation” were obtained. Regarding performance evaluation, one of the participants said, “I jot down the performance of the nurses daily and tell them their mistakes at the end of the day; also, I provide them with the results of a monthly performance evaluation” (P. 9, with 15 years of experience).

Regarding “negligence in evaluation,” one of the participants said, “Here, the difference in the evaluation score between the most active and the least active person is only a half score. They justify it by claiming that giving low scores will make them angry. I, however, believe it is not fair because there are people who deserve higher evaluation scores” (P. 24, with 8 years of experience).

4.4. Job Conflict

The job conflict issue has been considered a critical issue in the nursing profession. Conflicts may lead to some problems, such as distrust, stress, low productivity, and dissatisfaction. According to participants’ experiences, the subcategories of “organization distrust” and “asking for non-professional work” were obtained.

Regarding “organizational distrust,” one participant said, “When a nurse does his/her job properly, and no one complains about their work, I request a reward for them, but the top managers don’t care about it, which shows a kind of distrust” (p. 16, with 25 years of experience).

Regarding “taking care of non-professional work,” one of the participants said, “I have to be responsive to the things that are not at all related to nursing” (p. 8, with 22 years of experience).

4.5. Decision Making with a Limited Effect

The uncertain conditions of patients require that the head nurses be qualified decision makers based on the complexity of conditions and an open system- a working system which is in constant interaction with the outside environment. Therefore, with regard to the increased costs of care services, making rational decisions can lead to improving health, reducing healthcare costs, and improving the treatment of patients. It also facilitates the appropriate use of material and human resources that can finally result in improving patients’ care. According to participants’ experiences, the two subcategories of “high-risk decision making” and “inadequate participation” were obtained.

Regarding “high-risk decision making,” one of the participants said, “Almost every hour, a new decision is made, and they change it frequently; I am really annoyed” (p. 25, with 15 years of experience).

Regarding “inadequate participation,” one of the participants said, “I make the decisions, and I rarely ask the nurse’s opinion” (p. 16, with 25 years of experience).

5. Discussion

The findings of this study consisted of categories related to head nurses’ experiences in managing clinical wards and showed head nurses’ unique characteristics in the form of a turbulent atmosphere-based theme. The analysis of the experiences revealed that the proper management of clinical wards is an effective step to improve the quality of nursing services because the head nurse has the closest relationship with patients and nursing service providers and nurse managers. Thus, the close relationship among head nurses with nurses, patients, supervisors, nursing service managers, and other staff in a disciplinary team requires continual supervision of the categories of the “work culture of the ward, job burnout, negligent evaluation, job conflict, and decision making with a limited effect.” All of these categories were extracted from the experiences of head nurses’ performance in clinical wards.

Work culture is a part of the nursing profession; in addition, individuals’ cultures may differ, so head nurses should recognize the professional culture, which enables the head nurses to communicate effectively with the patient from different cultutral background to prevent potential misunderstandings, of nurses, patients, and the workplace. This understanding at the workplace enhances communicative behaviors and can lead to an increase in the satisfaction of nurses, physicians, patients, and their companions that in turn result in improvements in healthcare services.

Catherine argued against the belief of not considering patients’ beliefs and customs while presenting nursing services seriously because the impact that society has had on care performance of nurses cannot be denied. In her study, no negative effect of the tradition on nursing performance was observed. However, further careful investigations are required to determine whether the cultural conditions endanger the nursing position (14). The results obtained in the present study, however, were different from the abovementioned study, which can be attributed to cultural differences. Therefore, unlike the previous study, in the present work several factors were identified that had adverse effects on ward management and nursing performance, such as cultural habits, too many visits, and interference of the patients’ companions in nursing affairs or irregular visits of doctors.

Regarding the job burnout category, one of the most important reasons for stress is the kind of job- here nursing. Job stress has an important role in various aspects of working people’s lives. Job pressures resulting from job demands are inevitable. They are tolerable in the short-term, but physical and psychological resistance is reduced in the long term and it leads to job burnout ultimately. The issue of mental and physical weaknesses among employees in service-related jobs is now a prevalent and serious problem. Since job burnout among nursing staff, especially head nurses, causes low efficiency, psychological and physical problems, and nurses’ dissatisfaction of the services, recognizing the contributing factors and eliminating them based on the experiences of head nurses can be effective in improving physical and psychologicl ocial health and the quality of services.

Koivula et al. also reported that approximately half of nursing staff suffer from job burnout, the reasons for which are ambiguity at work, a lack of appropriate respect and feedback, an unsuitable work environment, too many patients, an increased workload, a lack of time, and fatigue. They continued that job burnout leads to low motivation, a reduction in work commitment, negative feelings toward patients, high turnover among staff, the inhibition of creativity and innovation, economic problems, absenteeism, negligence in care, complaints and dissatisfaction of the patients, and a negative effect on the family; this all hinders the planned goals from being achieved. Finally, nurse managers are required to develop and promote the quality of nursing services and to identify and reduce the factors leading to job burnout (15).

The results of the abovementioned study are inconsistency with the present study. Based on the subcategory formation, the higher the job satisfaction, the lower the physical and emotional pressure, the higher the standards in the organizational structure, and the lower job burnout, all of which can be fulfilled with careful planning.

Regarding negligent evaluation, it can be said that of all nurse managers, head nurses as frontline managers have the most and the closest contact with the patients and nursing personnel. To improve personnel performance, hospitals need to revise their methods of nursing staff evaluation. The existing methods are not efficient, and the evaluation forms are inconsistent with the nurses’ job descriptions in different wards. Other problems with the existing method include centralization, the differences in nurses’ performance in different wards, and evaluation errors, which should all be eliminated.

Emamzadehghasemi et al. reported that in Iran, not only are the evaluation principles of nurses ignored, but traditional methods are also used without scientific validation; moreover, the unimportant role of head nurses in staff evaluations has caused nurses’ evaluations to be time-consuming and costly, which has no effect on the quality of care and nurses’ performance. Finally, with regard to the current condition, it is proposed to develop methods for the appraisal performance of nurses that can direct their performance to achieve the required planned goals (16).

It is clear that the results of the abovementioned study are in line with those of the present study. Based on the results and the reasons (e.i. performance evaluation and “negligence in evaluation) in the present work, formulating a local evaluation model based on the conditions of clinical wards is an unavoidable necessity.

Today, due to the complexity of communication in work environments, namely role conflicts and duties of people, job conflict in nursing is a serious issue. If the conflicts are not managed well, they may lead to distrust and even violence and turnover among nurses. Developing trust in the wards, due to its effect on all human interactions, the actualization of human resources’ talent, and delegating authority increase the general trust in organizations. This is the best tool for nurse managers to prove their trust and avoid job conflicts. Nurse managers are required, instead of ignoring the factors leading to job conflict, to identify problems and eliminate them.

Wu et al. argued that there is a negative association between job satisfaction and role ambiguity and job satisfaction and job conflict, and they found that decent work conditions and high education are related to job satisfaction; moreover, the perception of nurses’ experiences in the clinical environment is important for nursing managers, and they can make clinical environment more attractive by creating suitable strategies like designing and applying local evaluation forms based on nurses’ standard professional performances (17).

Payamibousari et al. also reported that job conflict is a dynamic issue influenced by a conflict of interest. Their findings indicated that conflicts in the clinical environment focus mostly on non-duty and marginal aspects of nursing. They also observed that work conditions were responsible for issues such as marginal communication conflicts at the workplace of clinical nurses; thus, nursing managers are supposed to manage these conflicts and to develop solutions to eliminate them and to take measures in accordance to the nurses’ work environment. It was also proposed that by understanding some causal factors in job conflict, the conflicts can be guided to achieve positive results for nurses and health organizations (18). Regarding job conflict, the abovementioned results are consistent with our study. According to our findings, conflicts can be caused by distrust, inadequate collaboration, inadequate participation of top managers and health departments, and relative professional nursing authority; as such, coping with this issue depends highly upon careful planning. Considering decision making with a limited effect, it can be said that uncertain conditions, nurses and patients require that head nurses be qualified decision makers to respond to the needs of nurses and patients and as clinical decisions are based on people’s culture, decision making is the most important duty of head nurses. In many cases, nursing care inadequacy is not related to a nurse shortage, but it is only due to head nurses making inefficient decisions.

According to Nooritajer et al., whose results are in line with our findings, over 40% of head nurses stated their participation in decision making was average. The researchers found that there is a significant association between participation in decision making and satisfaction. Finally, they proposed that to achieve a clear perception of participative decision making in health organizations in Iran, comprehensive research should be conducted on decision-making methods in nursing (19).

In another study in Saudi Arabia, Aboshaiqah indicated that effective decision making, authentic leadership, appropriate staffing, true collaboration, skilled communication, and meaningful recognition were rated as good in nursing (20). The results of the study, however, are in clear disagreement with the present study, the reason for which can be attributed to issues such as culture differences, differences in formal and informal organizational structure, the shortage of human resources, the inadequate participation of managers, relative professional autonomy, and decision making with a limited effect. Thus, based on the results in the present study, required steps, such as developing self-confidence in skills, having appropriate relations with nurses and patients, being relaxed, and having a suitable perception of clinical images via careful planning, are necessary to achieve positive results in relation to decision making with a limited effect. According to the obtained results of our study, in addition to known criteria, other factors, including burnout job, role conflict, neglectful evaluation, restricted decision making, unsuitable structure, and the atmosphere of clinical wards and cultural discrepancies are considered issues obstructing effective management. In the case of cultural differences, three issues stand out: uneven visits by physicians, the intervention of patients’ families in nursing duties, and finally their persistence in continuously accompanying patients, which are mainly based on their attitudes, beliefs, and strong passions that all stem from people’s cultural background. To modify such stated approaches, we need precise planning, continuous feedback, and a practical managerial model to improve the efficiency of nursing management.

5.1. Conclusion

The analysis of the findings of the present study considering the defined categories demonstrated that, to modify and correct the turbulent atmospheric-based management, the following important measures need to be carefully applied: reducing the workload by compensating for the human resources shortage and preventing non-professional affairs, compensating for the facilities shortage, developing informal structures, including welfare establishments like kindergartens for the staff’s children, providing materialistic and spiritual rewards, developing informal communication, enhancing professional qualifications, for example, by holding specialized workshops, carefully supervising the work, creating a trustworthy climate by giving authority appropriate to nurses’ responsibility, developing a participative decision-making condition, conducting real evaluation via checklists in accordance with the structure of each ward, improving nursing positions by increasing the service quality, and continually monitoring the plans.

5.2. Implications for Nursing Management

One of the main tasks of nurse managers in health organizations is to provide safe and effective services that satisfy all patients and stakeholders. Considering the challenges identified in the research that lead to head nurses’ inappropriate performance, the approach of head nurses needs to be changed to include the use of more positive strategies. The findings of the study on nursing education have led to the training of effective managers. In addition, nursing research has led to transparency regarding the referred challenges as well as overcoming these challenges through improving the effective performance of head nurses and so achieving their satisfaction by enhancing the quality of nursing services in general.