Effects of a learning programme for nurse managers to connect their experience: A quasi-experimental study.

AIM: The present study aimed to examine the effects of a learning programme for nurse managers on connecting learning with their own experiences and fostering competence.
BACKGROUND: In Japan, second-level programmes for certified nurse administrators represent the main opportunity for formal training for nurse managers. However, it is difficult for nurse managers to transfer second-level programme learning to their workplace.
METHODS: This quasi-experimental study used a two-group pretest-posttest design with purposive sampling and non-random assignment of 29 consenting Japanese nurse managers who were participating in a second-level programme through a prefectural nursing association. The programme provided reflection papers and feedback from a researcher, as well as reflective group sessions. The outcome measure was the Japanese First-Line Nurse Managers Competence Inventory (JNMCI) score.
RESULTS: The intervention group showed significant improvement in JNMCI scores after participating in the programme. A significant difference in JNMCI scores was also observed between the intervention and comparison groups.
CONCLUSION: This learning programme led to improved competency among nurse managers. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse manager development programmes should include reflection papers and feedback, as well as reflective group sessions, to improve competency among nurse managers.

BACKGROUND

Nurse managers are vital to the success of health care organisations because they affect staff retention, patient outcomes and profitability (Moore et al., 2016). In addition, they help with organisation, create a suitable environment for the provision of high‐quality nursing care, improve the quality of nursing care, manage resources and ensure an educational setting for nurses (Japanese Nursing Association, 2016a). Furthermore, the results of a conceptual analysis of nurse administrator competency found that they were responsible for ‘improving the quality nursing care by staff nurses’, ‘revitalizing departments and strengthening cooperation among divisions’, ‘improving patient satisfaction’ and ‘improving job satisfaction’ (Beppu, 2019). However, numerous first‐line nurse managers have left their posts because of poor relationships with department heads and a lack of support, suggesting the need for further opportunities for development (Japanese Nursing Association, 2016b).

In Japan, second‐level programmes for certified nurse administrators represent the main opportunity for nurse managers to engage in formal training. Programmes for certified nurse administrators consist of the following: (1) first‐level programmes mainly for assistant nurse managers, (2) second‐level programmes mainly for nurse managers and (3) third‐level programmes mainly for directors and vice‐directors of nursing. These programmes were developed by the Japanese Nursing Association with the aim of developing competency among nurse administrators (Japanese Nursing Association, 2019). Nurse administrators who complete first‐ to third‐level programmes can take an examination to become registered as a certified nurse administrator. As of 2019, a total of 62 institutions in Japan, including prefectural nursing associations and various colleges of nursing, operate second‐level programmes.

The lecture topics of second‐level programmes have included ‘health care systems’, ‘organisational management’, ‘human resource management’, ‘resource management’, ‘quality management’ and ‘integrated practical training’. The total instruction time is 180 h, and nearly, all nurse managers engage in learning for a few months while working. Second‐level programmes can gather many nurse managers in the classroom for lectures at the same time (Kawano, 2014). However, it is often difficult for nurse managers to transfer learning from second‐level programmes to their workplace.

A previous study reported that only 66% of second‐level programme participants could transfer learning to their workplace, and after participation, the self‐evaluation scores regarding competency were low for ‘human resources’, ‘gathering and analysing information’ and ‘decision‐making’ (Kikuchi et al., 2008). These findings suggest the need for a new approach to support the transfer of learning from second‐level programmes to the workplace.

Therefore, in this study, we decided to focus on the International Masters in Practicing Management (IMPM) programme developed by Mintzberg (2004). Mintzberg describes a very different approach to management education that encourages practicing managers to learn from their own experiences. No one can create a manager in the classroom, but existing managers can improve their practice substantially in a thoughtful classroom that makes use of those experiences. The IMPM components include the following: (1) reflection papers, (2) reflective group sessions and (3) feedback from the faculty. Mintzberg introduced reflection papers to encourage the transfer of learning to the workplace and asked participants to revisit all the material in the module and write a paper that linked whatever seemed most relevant to themselves, their job, their organisation and their world. Through the IMPM, the participants (1) share materials, (2) apply methods, (3) change behaviours and (4) provoke new frames of perceptions.

Previous studies have indicated that many nurse manager development programmes involve reflective learning (Frasier, 2019; McGarity et al., 2020). However, to our knowledge, no programmes have connected the classroom learning and personal experiences of nurse managers.

Although the IMPM participants were business managers, we believe that a structured programme that includes the contents of IMPM that connect classroom learning and nursing experiences would be effective for improving the competency of nurse managers. Therefore, the effectiveness of such a programme should be assessed using nurse managers as the participants.

Given this background, the present study aimed to develop a learning programme for nurse managers that would allow them to connect learning with their own experiences and to clarify whether such a programme would improve competency in nursing management.

METHODS

Programme development

The components of the learning programme developed in the present study were as follows: (1) reflection papers for the participants to revisit all of the material and write a paper that linked whatever seemed most relevant to themselves and their job after completing each subject (six times in total), (2) one‐on‐one feedback from the researcher (lead author) by e‐mail each time the participants made an entry in their reflective papers and (3) reflective group sessions among the researcher and nurse managers for 1 h each time in the middle of and at the end of the programme (two times in total). After completing the programme, each nurse manager was paid 5000 JPY by the lead author for their participation.

The second‐level programme was carried out through prefecture A and included the following lecture subjects: ‘health care system’, ‘organisational management’, ‘human resource management’, ‘resource management’, ‘quality management’ and ‘integrated practical training’. The 3‐month programme included a total of 180 h of instruction. The same second‐level programme was conducted in 2019 and 2020. Lectures were given for each subject by lecturers other than the researcher (lead author).

Design and study protocol

The present quasi‐experimental study used a convenience sample and a non‐random group assignment pretest–posttest design. The intervention group participated in a learning programme to connect learning from the second‐level programme with their own experiences, whereas the comparison group participated in the second‐level programme only. Pretest and posttest surveys were carried out before the start and after the completion of the second‐level programme (see Figure 1).

FIGURE 1

Design of the study for the effects of the learning programme on nurse managers to connect learning from the second‐level programme with their own experiences

Outcome measures

To measure the perceived job competencies linked to the performance and staff retention of first‐line nurse managers working in a hospital setting, the Japanese First‐Line Nurse Managers Competence Inventory (JNMCI), the original and Japanese versions of which were developed by DeOnna (2006) and Sakamoto et al. (2016), respectively, was used. The JNMCI consists of the following nine subscales: (1) ‘promote staff retention’, (2) ‘facilitate staff development’, (3) ‘perform supervisor responsibilities’, (4) ‘develop a nursing practice environment’, (5) ‘support training for staff’, (6) ‘develop the self’, (7) ‘conduct daily unit operations’, (8) ‘ensure quality care’ and (9) ‘manage fiscal planning’. The JNMCI scale is composed of 40 items that are rated on a 4‐point Likert scale ranging from 1 (never) to 4 (all the time). Higher JNMCI scores indicate better nurse management competency. The reliability and validity of the JNMCI have been confirmed (Sakamoto et al., 2016). Cronbach's alpha of the JNMCI is .94.

Participants and setting

The inclusion criteria for the present study were as follows: (1) a nurse manager and (2) a participant in a second‐level programme for certified nurse administrators. The study was conducted at a nursing association in prefecture A in the Kyusyu region of Japan.

Procedures

The participants were recruited using a document containing information about the study, including notice of a payment of 5000 JPY for each participating nurse manager, and a request for participation to all nurse managers who were participating in a second‐level programme for certified nurse administrators, through the prefectural nursing association in 2019 and 2020. We explained the study purpose and ensured confidentiality, anonymity, and the safety of personal data to all participants both verbally and in writing. Written consent was obtained from all nurse managers who agreed to participate in the study. All nurse managers were also informed of their right to withdraw from the study at any time without penalty and were given a withdrawal form that they also had the option to send by mail if necessary.

We gathered data for the pretest before the start of the second‐level programme in a room at the nursing association in prefecture A. We set up reflective group sessions 2 months after the completion of the second‐level programme in a room at the nursing association and gathered data for the posttest after the reflective group sessions in the same room.

The original parts of our programme were describing the reflection paper, getting feedback from the researcher and the reflective group sessions. Therefore, we conducted a fidelity evaluation on these parts. We distributed questionnaires to collect information for the fidelity evaluation at same time as the posttest.

The data collection period was from September 2019 to February 2020.

Ethical considerations

This study was approved by the ethics committee of our institution. In accordance with the Declaration of Helsinki, a written explanation of the study objectives, methods, protection of anonymity and voluntary nature of participation was given to all participants. We also explained that the collected data would only be used for the purposes of this study.

Statistical analysis

SPSS version 26.0 (SPSS, Tokyo, Japan) was used for the data analyses, with the level of significance set at 5%. Unpaired t tests and the χ 2 test were used to compare the participants' basic characteristics. We confirmed that the JNMCI scores were normally distributed and used paired t tests to compare the differences in JNMCI scores before and after the programme. To confirm the effectiveness of the programme, we analysed the differences between the intervention and control groups using unpaired t tests.

RESULTS

Recruitment and baseline comparison between the two groups

The flow of the participants through the study is shown in Figure 2. The study participants were 14 and 15 nurse managers from the intervention and comparison groups who participated in the second‐level programmes in 2019 and 2020, respectively. From among these nurse managers, 13 (92.9%) from the intervention group and 15 (100%) from the comparison group completed the study. No significant differences in the participants' characteristics were found between the intervention and control groups. However, significant differences were found in pretest scores (P < .05) (see Figure 2 and Table 1).

FIGURE 2

Flowchart of the study

TABLE 1

Comparison between the two groups (n = 28)

Demographic variables	Intervention group (n = 13)		Comparison group (n = 15)		t	df	P
	M	SD	M	SD
Age (years)	45.50	4.99	49.10	4.72	−1.96	26	.061
Years of experience (as a nurse manager)	4.15	2.70	4.93	4.17	−0.58	26	.569
Attribute	N	%	N	%	Total	χ 2	P
Sex
Female	12.00	92.3	14.00	93.30	26.00	.01	.72
Male	1.00	7.7	1.00	6.70	2.00
Scales and subscales	M	SD	M	SD	t	df	P
Baseline
JNMCI	3.18	0.53	3.66	0.49	−2.49	26	.020*
Promote staff retention	3.56	0.46	3.63	0.63	−0.34	26	.735
Facilitate staff development	3.00	0.88	3.30	0.66	−1.03	26	.313
Perform supervisor responsibilities	3.83	0.60	4.12	0.66	−1.21	26	.238
Develop the nursing practice environment	3.00	0.91	3.56	0.50	−2.06	26	.049*
Support education for staff	3.80	0.59	3.84	0.85	−0.17	26	.863
Develop self	2.18	0.85	2.44	0.71	−0.90	26	.374
Conduct daily unit preparations	3.28	0.57	3.67	0.46	−1.99	26	.058
Ensure quality care	3.03	0.87	3.29	0.81	−0.83	26	.415
Manage fiscal planning	1.92	0.99	2.04	0.98	−0.33	26	.748
Posttest
JNMCI	3.63	0.27	3.69	0.48	−0.39	26	.700
Promote staff retention	3.71	0.25	3.83	0.52	−0.77	26	.448
Facilitate staff development	3.71	0.56	3.67	0.69	0.19	26	.853
Perform supervisor responsibilities	4.06	0.25	4.21	0.57	−0.93	26	.359
Develop the nursing practice environment	3.55	0.52	3.71	0.46	−0.82	26	.418
Support education for staff	3.82	0.55	4.04	0.65	−0.97	26	.341
Develop self	2.87	0.73	3.02	0.74	−0.54	26	.594
Conduct daily unit preparations	3.71	0.53	4.00	0.53	−1.46	26	.156
Ensure quality care	3.56	0.61	3.69	0.76	−0.48	26	.638
Manage fiscal planning	2.56	0.80	2.31	1.11	0.68	26	.502
Difference
JNMCI	0.45	0.38	0.03	0.39	2.89	26	.008*
Promote staff retention	0.22	0.43	0.20	0.36	0.10	26	.919
Facilitate staff development	0.71	0.75	0.37	0.52	1.44	26	.163
Perform supervisor responsibilities	0.23	0.60	0.10	0.59	0.58	26	.566
Develop the nursing practice environment	0.55	0.78	0.15	0.65	1.51	26	.142
Support education for staff	0.26	0.71	0.20	0.71	−0.65	26	.524
Develop self	0.69	0.69	0.58	1.10	0.32	26	.749
Conduct daily unit preparations	0.43	0.48	0.33	0.40	0.59	26	.560
Ensure quality care	0.36	1.26	0.40	0.78	−0.11	26	.913
Manage fiscal planning	0.64	0.90	0.27	0.88	1.11	26	.276

Abbreviation: JNMCI, Japanese First‐Line Nurse Managers Competence Inventory.

P < .05.

Characteristics of the nurse managers

The characteristics of the nurse managers who participated in the study are shown in Table 1. The mean age ± standard deviation (SD) of the nurse managers in the intervention and control groups was 45.5 ± 5.0 and 49.1 ± 4.7 years, respectively, and one nurse manager was male in each year. The mean length of experience ± SD as a nurse manager in the intervention and control groups was 4.2 ± 2.7 and 4.9 ± 4.2 years, respectively.

Number of reflection paper entries

The total number of reflection paper entries made by the 13 nurse managers in the intervention group over the course of the programme was 61.

Feedback from the researcher

The researcher read the reflection papers written by the nurse manager and provided written feedback for each entry. After receiving the feedback from the researcher, the nurse managers revised their reflection papers to clarify what they had learned from the programme and what seemed relevant to their job. The researcher then checked the revisions and responses.

In the reflective group sessions, the researcher asked nurse managers about (1) which lectures left a lasting impression and (2) if they could connect learning in that lecture with their own experiences. The nurse managers discussed these topics freely during the reflective group sessions.

Pretest and posttest comparison

The results of a comparison of JNMCI scores between the intervention and comparison groups are shown in Table 1. The mean ± SD pretest JNMCI scores were significantly higher in the comparison than in the intervention group. The mean ± SD pretest score for the ‘develop a nursing practice environment’ subscale of the JNMCI was significantly higher in the comparison than in the intervention group.

Significant increases were seen in the mean ± SD JNMCI scores in the intervention group after compared with before the programme (3.63 ± 0.27 vs. 3.18 ± 0.53, respectively, P < .01). Mean ± SD JNMCI scores also increased in the comparison group after compared with before participating in the programme, but these changes were not significant (3.69 ± 0.48 vs. 3.66 ± 0.49, respectively, P = .764). A significant difference in JNMCI scores was observed between the intervention and comparison groups (0.45 ± 0.38 vs. 0.03 ± 0.39, respectively, P < .01). However, no significant difference in the subscale scores of the JNMCI was found between the intervention and comparison groups (Table 1 and Figure 3).

FIGURE 3

Effect of the learning programme on average JNMCI scores (n = 28). *P < .01. JNMCI, Japanese First‐Line Nurse Managers Competence Inventory

Programme evaluation

A fidelity evaluation was conducted to assess the participants' satisfaction with the learning programme and whether they had connected learning from the programme with their own experiences. The participants evaluated the programme by completing a four‐item questionnaire with a 5‐point scale for each item, with five points representing a perfect score. The evaluation contents were as follows: ‘usefulness of describing the reflection paper’, ‘usefulness of getting feedback from the researcher’, ‘usefulness of the reflective group sessions’ and ‘satisfaction with the programme’. The highest mean score was for ‘usefulness of getting feedback from the researcher’ (4.4 points), followed by ‘usefulness of the reflective group sessions’ (4.2 points), ‘satisfaction with the programme’ (4.0 points) and ‘usefulness of describing the reflection paper’ (3.9 points).

DISCUSSION

In the present quasi‐experimental study, data were collected from two groups at different time points. As the homogeneity of attributions affected the internal validity of this programme, it was important to examine the homogeneity of attributions between the two groups. No significant differences were found in the participants' characteristics. However, the mean ± SD pretest JNMCI scores were significantly higher in the comparison than in the intervention group, thereby indicating significant differences in competency between the two groups before participating in the programme.

In this study, the mean ± SD pretest score for the ‘develop a nursing practice environment’ subscale of the JNMCI was significantly higher in the comparison than in the intervention group. The nurse managers in the comparison group participated in the study in 2020, and we recognize that they may have struggled to develop the nursing practice environment during the COVID‐19 pandemic. Therefore, the score for ‘develop a nursing practice environment’ in the 2020 comparison group was significantly higher compared with that of both the comparison and intervention groups in 2019.

Effectiveness of the programme

A comparison of JNMCI scores indicated significant improvement on the posttest in the intervention compared with the comparison group. Regarding the evaluation of the programme, the participants appreciated its usefulness in connecting learning with their own experiences. The effects of the IMPM developed by Mintzberg (2004) were as follows: (1) sharing materials, (2) applying methods, (3) changing behaviours and (4) provoking new frames of perceptions. The programme thus appeared to help nurse managers share materials and apply the methods that they had learned through the programme to improve their competency. Therefore, we believe that the components of the programme are effective for promoting a transfer of learning to the workplace among nurse managers.

A previous study reported significant relationships between experiential learning and nursing management competency among nurse managers who participated in an experiential learning‐based programme (Kuraoka, 2019). In addition, significant relationships were observed between ‘reflective observation’, which is one factor of the experiential learning inventory on the job, and ‘leadership’, which is one factor of nursing management competency (Kuraoka, 2019). Our programme and that reported by Kuraoka (2019) used reflection as the method of delivery, and each study indicated comparable results, which suggests that reflection is important to improve the competency of nurse managers.

The present programme involved reflection papers, corresponding feedback from the researcher and reflective group sessions. The results of the fidelity evaluation indicated that getting feedback from the researcher was the most useful for the nurse managers, followed by the reflective group sessions and the descriptions of the reflection papers. A previous study reported that mentoring and coaching were important in nurse manager development programmes (Flatekval & Corbo, 2019; Manning et al., 2015). In an Australian programme, a mentoring and coaching model was used to guide the coaching of prospective nurse managers (Manning et al., 2015). As a result, although mentorship was not the only component of that programme, significant improvements in managerial skills and the confidence to undertake a nurse manager role were seen in the participants who had received mentoring. Another 3‐month pilot study aimed at developing the competencies of eight nurse managers by conducting coaching during lunch sessions showed positive results (Flatekval & Corbo, 2019). Feedback from the researcher in the present study corresponds to mentoring or coaching. Furthermore, our programme and others (Flatekval & Corbo, 2019; Manning et al., 2015) that included feedback, mentorship or coaching for didactic learning were shown to be effective for improving the competency of nurse managers. We therefore believe that additional support for mentorship and coaching involving feedback would be even more effective.

In the present programme, the researcher provided feedback, but no organisational support was provided. We consider that it is important for nurse managers to get support from researchers when participating in a second‐level programme, which could help them consider the relationship between the learning contents and their experiences in their workplace. On the other hand, nurse managers need organisational support, for example, from the director or vice‐director of nursing, to transfer learning to their workplace after participating in a second‐level programme. In a previous literature review on the common components of nurse manager development programmes, Ullrich et al. (2021) indicated that organisational support is needed by leaders to backfill positions so that participants can complete programmes and take roles to consolidate learning and experiences. In the future, it will be necessary to design nurse manager development programmes that involve organisational support to promote the transfer of learning from second‐level programmes to the workplace.

Limitations and future challenges

This study had some limitations. First, this was only a second‐level programme conducted through a prefectural nursing association, so the generalizability of the results is limited and potential biases should be considered. This study also used a non‐equivalent control group design instead of a randomized controlled trial, and the two groups were not homogenous; therefore, the internal validity in regard to the intervention effect was weaker. The validity of this programme needs to be confirmed in a randomized controlled trial. Second, the sample size was small; therefore, no significant differences in the mean JNMCI subscale scores were observed, as each JNMCI subscale only has 3 to 10 items. In the future, it will be necessary to increase the sample size and examine the effects of the programme on the JNMCI subscales. Third, the present study focused on JNMCI scores among nurse managers immediately after participating in the programme. To examine the effects of this programme on nursing management practice in the workplace, JNMCI scores should be evaluated over the long term. In addition, it will be necessary to clarify the practices of nurse managers who participate in this programme using a qualitative study and examine changes before and after participation.

CONCLUSION

The present learning programme for nurse managers was found to improve competence. These findings suggest that to improve nursing management competency, future nurse manager development programmes should include reflection papers, feedback and reflective group sessions. A randomized controlled trial is also needed to confirm the validity of this programme.

IMPLICATIONS FOR NURSING MANAGEMENT

It seems that nurse manager development programmes are inclined to provide only didactic learning from the perspective of efficiency. However, it is difficult for nurse managers to transfer learning from formal training programmes to their workplace with only didactic learning programmes.

In this study, we developed a learning programme for nurse managers to allow them to connect learning from the programme with their own experiences and thereby improve nursing management competency. The results suggested that nurse manager development programmes should include reflection papers and feedback, as well as reflective group sessions, to improve competency among nurse managers. Therefore, nurse manager development programmes should allow nurse managers to transfer learning from formal training programmes to their workplace. It is important for learning programmes for nurse managers to integrate interactions with the instructor and other members of the programme into the programme for a period of time and aim to transfer learning from formal training to their role in the workplace.

Furthermore, in the present programme, the researcher provided feedback, but no organisational support was provided. In the future, it will be necessary to design nurse manager development programmes that involve organisational support to further promote the transfer of learning from second‐level programmes to the workplace.

CONFLICT OF INTEREST

None declared.

ETHICAL APPROVAL

This study was conducted after obtaining approval from the ethics committee for Epidemiological Studies at Japanese Red Cross Kyusyu International College of Nursing, Fukuoka, Japan (approval 18‐011).