Skills Required for Nursing Career Advancement: A Qualitative Study.

BACKGROUND: Nurses require certain skills for progression in their field. Identifying these skills can provide the context for nursing career advancement.
OBJECTIVES: This study aimed to identify the skills needed for nurses' career advancement.
MATERIALS AND METHODS: A qualitative approach using content analysis was adopted to study a purposive sample of eighteen nurses working in teaching hospitals affiliated with the Qazvin, Shahid Beheshti, and Iran Universities of Medical Sciences. The data were collected through semi-structured interviews, and analyzed using conventional content analysis.
RESULTS: The three themes extracted from the data included interpersonal capabilities, competency for career success, and personal capacities. The results showed that acquiring a variety of skills is essential for career advancement.
CONCLUSIONS: The findings showed that personal, interpersonal, and functional skills can facilitate nurses' career advancement. The effects of these skills on career advancement depend on a variety of conditions that require further studies.

1. Background

Nurses need to be promoted to flourish and develop in their profession (1, 2). When working in an organization, nurses usually think about career progression and promotion after gaining experience and professional skills. Staff promotion motivates them, and helps them to develop a sense of value. Following advancement, they feel greater commitment and responsibility toward their jobs (3, 4); therefore, career advancement is a requirement for nurses. They need to reach the level of perfection that they are capable of, and achieving that level depends upon their competence and success. In healthcare settings, nurses require a complex range of skills, from personal to organizational levels, to achieve career advancement (5).

In Iran, nurses are predominantly promoted to managerial positions, which include a charge nurse, head nurse, supervisor, and the senior nurse manager (matron), depending on the organizational needs and professional competencies (6). In 2003, the ministry of health and medical education proposed a road map of nurses’ career advancement, which aimed to improve staff productivity and motivation. According to this model, nurses achieve career promotion in three levels, senior, expert, and excellent, depending on their scores in performance, work experience, research, and personal development indicators (7). Following the notification of civil services legislation in 2011, a revised model was developed which contains five categories, including basic, preliminary, senior, expert, and excellent (6).

The promotion of nurses depends on their technical, interpersonal, and organizational skills (8, 9). Upon entry into the profession, the emphasis is on technical skills; however, it gradually shifts toward interpersonal skills (10). Evidence has shown that more skilled nurses with appropriate performance are more likely to be promoted (6, 9, 11), and performance in a previous position is a predictor of promotion (12). The skills required for promotion depend on several parameters; they vary at each level (13), and have not been clearly defined for nurses (8, 14, 15). In addition, organizational expectations from nurses vary at different professional levels, and change with their promotions (2, 16). This ambiguity leads to confusion and delays in promotions (17). Accordingly, identifying the organizational skills required for a promotion answers the question: “What skills are required to facilitate career advancement?” Since promotions happen in the context of social and interpersonal interactions, different social circumstances might affect this process. Therefore, special attention should be paid to the social context and interactions within it to study such a concept (8, 9). Moreover, identifying the skills required for promotion through the experiences of those who have already been through this process would be quite beneficial (11, 14).

2. Objectives

This study aimed to identify the skills required for nurses’ career advancement.

3. Materials and Methods

This manuscript reports part of a grounded theory study aimed at exploring the process of career advancement in nursing. For the purpose of this paper, a content analysis approach was conducted to clarify the skills needed for nurses’ career advancement. This method is appropriate for answering questions with regard to people’s concerns about an event or a phenomenon, especially when the existing literature on the phenomenon is limited, and researchers have no predetermined framework for explaining or analyzing the data (18, 19).

This study was conducted from June of 2013 until November of 2014, and the participants were recruited from nurses working in hospitals affiliated with the Qazvin, Shahid Beheshti, and Iran Universities of Medical Sciences. A purposive sampling technique with maximum variation was used, and in order to create maximum variation, participants from different levels were involved. The inclusion criteria were more than 5 years of work experience, experiencing career advancement in the last two years, and willingness to participate in the study. The first participant was a nurse manager, and then other participants were invited to the study based on the codes which emerged from the previous interviews. Data saturation occurred after interviewing 16 staff nurses, head-nurses, supervisors, and nurse managers, and analyzing the interviews; but two more interviews were conducted to be sure, and the interviewing stopped after the eighteenth interview (Table 1).

Table 1.

The Characteristics of the Participants[a]

No.	Sex	Age	Education	Occupation Status	Work Experience, y
1	F	45	Bachelor’s degree	Head nurse	26
2	F	41	Master’s degree	Nurse manager	18
3	F	48	Master’s degree	Supervisor	26
4	M	32	Bachelor’s degree	Head nurse	10
5	M	39	Master’s degree	Supervisor	16
6	F	40	Master’s degree	Head nurse	17
7	M	42	Bachelor’s degree	Nurse manager	19
8	F	38	Master’s degree	Head nurse	15
9	F	44	Master’s degree	Supervisor	21
10	F	30	Bachelor’s degree	Staff nurse	8
11	F	45	Master’s degree	Nurse manager	22
12	M	48	Master’s degree	University nurse manager	25
13	M	38	Bachelor’s degree	Supervisor	14
14	F	42	Master’s degree	Nurse manager	20
15	F	45	Master’s degree	University nurse manager	23
16	F	47	Master’s degree	University nurse manager	24
17	F	40	Master’s degree	Nurse manager	17
18	F	32	Bachelor’s degree	Staff nurse	10

aN = 18.

We employed a semi-structured face-to-face interview technique for the data collection. Initially, we used general open-ended questions, such as: How long have you been working in this setting? Would you please explain your advancement in nursing? Which factors affected your advancement? During the interviews, we focused particularly on the skills required for the nurses’ career advancement. Additionally, we used probing questions to obtain more in-depth information about the participants’ career advancement experiences. All of the interviews were conducted by one interviewer (the first author) in a quiet, private room located in each hospital. The interviews ranged in length from 45 to 100 minutes, with an average of 60 minutes, and we recorded the interviews using a digital sound recorder. Each interview was listened to carefully and transcribed verbatim on the same day. The data collection continued until saturation occurred, and a rich description of the nurses’ experiences and perspectives was obtained.

3.1. Ethical Considerations

This study was approved by the ethics committee of the university of social welfare and rehabilitation (IRB No. USWR.REC.1392.48). The participants were provided with adequate information about the ethical considerations of the study before the interview. They were all assured of the data confidentiality, their voluntary participation, and the right to withdraw from the study at any point. All of the participants signed written informed consent before participation, and allowed the researcher to record the interviews. Once the interviews were transcribed, more explanations were requested from the participants through phone calls in those cases of ambiguous statements.

3.2. Data Analysis

In this study, we employed a conventional qualitative content analysis approach for the data analysis (19). The preliminary analysis was carried out by the first author of this manuscript. Each interview was listened to carefully on the same day, and then the transcript of every interview was read repeatedly to achieve immersion and get a sense of the whole. Next, the transcripts were read word by word to find key thoughts and concepts, and these were marked. Then, the texts were reread, and the meaning units or the units of analysis were determined, which are the words or statements that contain a meaning related to the central phenomenon. These units were usually coded using the exact words from the text, or the words or statements the researcher made according to his impression. As this process continued, labels for the codes emerged that were reflective of more than one key thought. These labels often came directly from the text or the researchers’ impressions, and produced the initial coding scheme. For example, one participant commented, “The most important factor contributing to career advancement in our hospital is work experience,” and the code “work experience” emerged from this comment. Codes that were conceptually similar were located in one cluster, and the semantically related clusters were then organized into categories (themes). For instance, the codes “conscientious work,” “cooperation,” and “discipline” were placed in a cluster, and then this cluster was placed in the theme “commitment to professional values.” Next, according to the codes and clusters in each theme, subthemes (subcategories) were identified. In this study, main themes emerged, each with three to four subthemes. Afterward, definitions for the themes, subthemes, and codes were developed, and exemplars for each code and theme were identified from the data in order to report the findings.

3.3. Data Trustworthiness

The data trustworthiness was achieved using the Guba and Lincoln criteria, including credibility, confirmability, dependability, and transferability (20). In order to achieve credibility, we employed a member-checking technique. To this end, all of the coded interviews, along with a summary of the generated meaning units, were passed to the concerned participants, and they were asked to confirm or determine how much our analyses reflected their career advancement experiences. Moreover, some of the coded interviews were checked by the study supervisors and three senior lecturers with PhD degrees in nursing that have conducted and supervised qualitative studies at the university of social welfare and rehabilitation. They read the transcripts, performed the analyses, and approved the data analysis process. The process of member checking also enhanced the dependability of the findings. Moreover, we tried to document and report the process of the data production and analysis precisely, to enhance the confirmability of the findings. In addition, we invited a few nurses who were not among the study participants, but recently experienced career advancement, to read the final themes and subthemes and the first draft of the results section, and they confirmed that the results were similar to their own experiences. We also provided thick descriptions of the study data to improve the transferability of the study findings.

4. Results

Table 1 shows the characteristics of the participants. A total of eighteen nurses participated in this study: two staff nurses, four head nurses, four supervisors, five hospital nurse managers (matrons), and three university nurse managers. Most of the participants (thirteen people) were female, a majority (twelve) had Master’s degrees, and the remaining six held Bachelor’s degrees. The themes and subthemes derived from the participants’ perspectives and experiences are presented in Table 2.

Table 2.

Themes and Subthemes of the Skills Required in Nurses’ Career Advancement

Main Themes and Subthemes
Interpersonal capabilities
Interaction: ladder for progression
Sensitivity to hospital problems
Being a good mentor
Sensitivity to ethical issues
Career Competency for Career Success
Experimenting: key to career progression
Management ability
Clinical skills mastery
Personal Capacities
Attachment of importance to work
Commitment to professional values

4.1. Theme I: Interpersonal Capabilities

According to the participants, interpersonal capabilities are necessary for promotion in nursing, and nurses with such skills are more likely to be promoted. These characteristics were organized into four subthemes, including “interaction: ladder for progression,” “sensitivity to hospital problems,” “being a good mentor,” and “sensitivity toward ethical issues.”

4.1.1. Interaction: Ladder for Progression

According to the participants, a nurse’s ability to establish good interactions with their colleagues and other people in the organization has a great effect on the process of career advancement. Expressions such as appropriate interaction, good communication, and appropriate relationships were frequently articulated by the participants, and were considered to be important professional capabilities in career advancement. One head nurse commented, “A basic criterion for nurses’ career advancement in our hospital is their ability to establish good communications” (P4). She believed that it was a person’s communication skills that paved the road for the emergence of their other capabilities.

The participants believed that nurses with effective communication skills are better accepted by their colleagues and mangers. For example, the senior nurse managers frequently cited the “ability to establish effective communication” as a necessary attribute for promotion in nursing. One of them stated, “When I want to choose a head nurse or a supervisor, one of the important things for me is their communication with fellows and physicians…” (P2). Another matron referred to the nurses’ communication skills as “the ladder for progress” (P5).

4.1.2. Sensitivity to Hospital Problems

Based on the participants’ comments, a sensitivity to hospital problems was defined as responding to the organizational needs and working with nursing managers’ expectations and plans. The majority of the participants considered this attribute to be an influential factor in their promotion. Helping to overcome staff shortages and cooperation with nurse managers were considered to be representative of this sensitivity. One of the supervisors stated, “I have been so flexible with the monthly shift program so that the nursing manager always appreciated me and considered me as a model for other nurses” (P13).

4.1.3. Being a Good Mentor

According to the participants, being able to teach others, and having a desire and ability to guide other colleagues not only empowers the nurses themselves, but also improves others’ attitudes toward them, and paves their pathway for career advancement. One nurse manager cited her experience, and said, “In my department, I always tried to teach newcomer nurses… they often came to me to solve their problems. I even set up training classes for them…” (P14). She believed that when a nurse tries to transfer her professional experiences to a fresh nurse, they would gradually see her as a mentor, and this would consequently facilitate her promotion. A participant recently promoted to a supervisory position commented in this regard, “We needed a training supervisor in this hospital. Since I had been holding training classes for nurses, and I was the training liaison officer of the department and authorities had observed my teaching ability, they recommended the supervisor position to me” (P3). Another training supervisor explained, “Holding several conferences in the hospital, and collaborating with nursing and midwifery schools as a trainer, persuaded hospital authorities to choose me for the vacant position of training supervisor” (P9).

4.1.4. Sensitivity to Ethical Issues

According to the participants, a nurse’s sensitivity toward ethical issues, and conducting colleagues according to the principles of professional and Islamic etiquette, can greatly influence their career advancement in Iran. One of the participants commented, “Nurses who conduct others according to the principles of professional ethics are role models for others” (P16). Emphasizing the importance of observing ethics and professional behaviors in the process of career advancement, a nurse manager stated, “The behaviors and conduct of nurses in the workplace are very important to us. We should score their behaviors and conduct in nurses’ performance evaluation forms and nurses’ career promotion forms. Those scores highly affect the nurses’ career promotion” (P7). The participants also believed that the implementation of ethical principles affects people’s general acceptance by their colleagues, doctors, and managers, and consequently facilitates the process of promotion. One head nurse responded, “I consider work experience, good communication, knowledge, and acceptance among colleagues as the criteria for nurses’ promotion” (P9).

Professional behaviors such as patience and caring for critically ill patients are intended to satisfy God. These form the foundation of professional ethics and work conscientiousness in Iranian nurses, and can affect the formation of sensitivity to ethics. According to one supervisor, “I got to where I am because of devotion, patience, and tolerance, despite hardships at work” (P3). The participants frequently mentioned that nurses are always in contact with patients, and repeatedly make important clinical decisions about them; in such conditions they should not only be proficient in their skills, but also be ethically sensitive. This sensitivity gradually provides the context for their development and promotion. One nurse said in this regard, “The main reason for my promotion was patient satisfaction. I work in such a way that fewer patients are dissatisfied with my department” (P14).

4.2. Theme II: Career Competency for Career Success

In this study, the participants believed that nurses should possess a series of professional characteristics, and do a series of activities in accordance with their organizational job description, to accelerate their career advancement. These characteristics were organized in three subthemes, including: “experimenting: key to career progression,” “management ability,” and “clinical skills mastery.”

4.2.1. Experience: Key to Career Progression

Experience was also considered a key to career progression, and a prerequisite capability needed by nurses. The participants also considered tirelessness and practical commitment to professional duties, work discipline, caring about the profession, and patient care follow-up as indicators of a nurse’s work experience. To them, a high level of work experience was an effective indicator of competency for promotion. As stated by one head nurse, “I was promoted for being highly experienced compared to others” (P4). A high level of experience convinces colleagues that an occupational promotion has been fair; for example, another nurse said, “I cannot accept the promotion of a nurse less experienced than me” (P18). The nurses believed that acquiring experience and knowledge is important, and both of them shape their work experience. All of the participants agreed that they were promoted because of their higher levels of work experience. One head nurse also commented, “A High level of work experience is the foremost criterion when hospital authorities decide about nurses’ promotions” (P6).

4.2.2. Management Ability

According to the participants, nurses who are candidates for career advancement should possess managerial and problem-solving skills compatible with their new positions, and those with such characteristics have more chances of being promoted. These capabilities would present themselves through decisions a nurse makes in different situations; according to one head nurse, “What made my early promotion possible was the ability to handle various duties and tasks left in my care” (P8). Some of the participants considered their lack of managerial skills a reason for not being promoted. In this regard, one nurse commented, “I didn’t have much managerial skills and had no interest in management either. This was probably the reason for not being promoted yet” (P10).

4.2.3. Mastery in Clinical Skills

The study participants considered clinical competencies and skills mastery to be important factors in career advancement. According to them, competent nurses are more likely to be promoted. One university nurse manager emphasized that such competencies are usually manifested through providing quality nursing care, which not only affects the patients’ satisfaction but also the authorities’ periodical evaluations. He said, “Performance evaluation is a vital indicator in nurses’ professional promotion. Those with higher scores are more likely to be promoted” (P12). A training supervisor also confirmed that her clinical competence affected her promotion to a supervisory position; she said, “I had been appointed to intensive care units several times, and every time the managers were satisfied with my work” (P13). She also added that competent nurses are predominantly mentioned in managerial reports, and in this way they become well-known and suitable for promotions (P1).

4.3. Theme III: Personal Capacities

The features of the personal capacities of the nurses formed the subthemes of “reinforcing professional values,” “attachment of importance to work,” and “commitment to professional values.”

4.3.1. Attachment of Importance of Work

The nurses explained that they were promoted because they regarded their work and duties as important, and tried to do their best. One head nurse said, “My job was very important to me, and I tried to do it properly, and this was noticed by managers” (P6). A passion for nursing was another feature of valuing work that was cited by the majority of participants, who considered professional belonging and emotional attachment to the nursing profession a sign of a love for nursing. A university nurse manager commented, “I love my discipline. If I was to choose a profession again, I would opt for nursing, and working in the ward. My interest in nursing made me achieve whatever I wanted” (P15).

4.3.2. Commitment to Professional Values

The majority of the participants asserted that the development of professional values, such as conscientious work, cooperation, and discipline, are part of the commitment to professional values. As one nurse manager stated, “Discipline, care, and conscientiousness at work made my promotion possible” (P17). Work conscientiousness was another characteristic of this category cited by nurses; according to one supervisor, “Work conscientiousness makes you do your job properly, and no one can fault your work, and this will distinguish you from others” (P11). Some of the participants commented that their own performance had been affected by their conscientiousness. The majority explained that these values affect the performance of nurses because of their religious beliefs and values in the Iranian cultural psyche.

5. Discussion

The results show that some skills are essential for a nurse’s promotion, including interpersonal capabilities, career competency for career success, and personal capacities. Skills and their importance in nurses’ promotions are different in the clinical settings than those in the managerial positions. The initial levels of nursing promotion, such as charge nurse and head nurse, are mainly affected by functional determinants in the road map of nursing promotion. Adeniran et al. stated that these skills also vary in promotions with regard to different managerial levels, such that a promotion to head nurse is based on technical and functional skills, while interpersonal skills have greater importance in a promotion to a higher level (9). Based on the expectations, nurses should acquire various skills, for example, interpersonal skills are more important than other skills in promotions to managerial levels. Evidence has shown that nurses should acquire certain skills in order to be promoted to managerial roles (21, 22). Adeniran et al. argue that human resources, interpersonal, and personal determinants are essential in nurses’ promotions (8). In addition, the participants cited these capabilities as key elements in creating conditions conducive to professional promotion. Overall, these results are consistent with what has been reported by Bradbury-Jones et al., who consider nursing skills to be an important part of the nursing profession that can lead to promotions (23).

The results of this study have also indicated that interpersonal capabilities contain certain dimensions and features, such as in interactions: ladder for progression, sensitivity to hospital problems, being a good mentor, and sensitivity to ethical issues. Interpersonal capabilities are developed through effective interactions in a healthcare organization (24), and these skills are necessary for performing professional duties. Moreover, the participants considered effective communication to be an essential requirement for the development of professional competence, and the context for the transfer of experience. Sensitivity to ethical issues is derived from the values of the society, and in the religious society of Iran, providing services for God’s satisfaction can affect the fostering of other capabilities. Patient satisfaction is the dominant manifestation of such beliefs.

Adeniran et al. have considered social capital to be the basis for the professional promotion of nurses, and it consists of elements such as mentoring, networking, interpersonal skills, and interactions (8). Responding to organizational needs is manifested in a sensitivity to hospital problems toward organizational policies. In line with organizational policies, nurses have effective interpersonal capabilities, which pave the way for their promotions. Teaching and learning skills can affect their empowerment in the organization, and these capabilities are primarily realized in continuing education courses buy gaining certificates and points. Access to education in healthcare organizations dramatically affects these capabilities. For example, one study indicated that the role of education is one of the capabilities of nurses that are evaluated in their promotion process (25).

This research suggests that career competency for career success affects nurses’ promotional prospects, such that nurses that score high in formal and informal performance evaluations of functional indicators are more likely to be promoted. The study participants stated the importance of characteristics such as experience being key to career progression, management ability, and mastery in clinical skills, which might also accelerate a nurse’s career advancement. Experience helps nurses to be more capable of proper performance in their duties; although there are different levels of gaining experience in clinical settings. Previous studies have also confirmed the key role of work experience in the process of a nurse’s career advancement (26, 27).

Managerial and problem-solving skills are among the functional indicators cited by the participants in this study. Such abilities are very important in managing the critical situations that are prevalent in healthcare organizations. Gould et al. believed that the art of care requires knowledge, skill, and expertise, and that problem-solving is at the heart of effective performance (28). The mastery of clinical skills is another factor affecting nurses’ career success. More competent and skilled nurses usually obtain higher scores in evaluations for career promotion.

“Personal capacities” was another key theme which emerged in this study. Such capabilities included the attachment of importance to work, and commitment to professional values. Providing quality services and care to satisfy patients can help in the development of other professional capabilities (24). In addition, nurses’ ethical values affect their knowledge, skills, and ultimately, the quality of care they provide (29). In the present study, the participants emphasized the key role of Islamic values in nursing. Their experiences showed that their belief in professional values resulted from their stable professional beliefs, which can be recognized as an effective facilitating factor in the promotional prospects of nurses. According to the participants’ experiences, work discipline, valuing work, nursing duties, and interest in nursing, together with conscientiousness, are skills that nurses acquire during their service. The development of these skills is influential in the promotion of nurses. Shahriari et al. believed that professional values and beliefs in the nursing community are dominant features of nursing (30), and considered to be a unique capability in nursing in Iran.

This study was conducted on a small sample of nurses. Although we tried to encourage the participants to express a full range of their experiences and perspectives, the replication of similar studies in different places and with greater numbers of participants might explore a wider range of experiences, and show us some of the hidden aspects that were not explored in this study.

This research has shown that different personal, interpersonal, and functional skills are required for promotions in nursing. The importance of these skills at various levels of promotion depends upon several factors. Given that these data are derived from the experiences and perceptions of nurses and managers, the results may be used to develop appropriate interventions for the development of nurses’ capabilities and skills, to provide them with promotional prospects. Identifying factors that affect acquiring these skills at various levels of promotion can provide information that nurses need to hasten the process of promotion. Therefore, more studies are needed to support these results. Finally, nursing leaders, healthcare policy-makers, and nurse educators can use the findings of this study to facilitate a nurse’s career advancement, and pave the way for it.