A Study Regarding Nursing Leadership.

PURPOSE: The research included the analysis and processing of questionnaires applied in county hospitals in Craiova. The purpose of this article is to highlight the qualities, skills and competencies of a leader, necessary in the development of leadership and professional development skills. MATERIAL AND
METHOD: We performed a descriptive and cross-sectional study involving 166 medical staff from hospitals in Craiova. Between January 2020 and January 2021, we used a questionnaire as an investigative tool containing 26 questions on complex leadership issues. The results were stored in Microsoft Excel files (Microsoft Corp., Redmond, WA, USA) and were statistically analyzed using the Microsoft Excel XLST AT (Addinsoft) software suite. SARL, Paris,). Secondary data processing: calculation of fundamental statistical parameters, mean and standard deviation of their ratio, coefficient of variation, graphical representation and calculation of regression coefficients was performed with Excel, Pivot Tables using controls, Functions, Statistics, Diagram and Data Analysis module. In conclusion, a better organization of the management of the hospital units is required, taking into account the leadership in nursing.

Introduction

In the current epidemiological context, healthcare leaders in hospital health systems are responding to complex and diverse challenges.

They need to adopt, adapt and develop new leadership skills to meet current and future challenges [1,2,3].

Health services must meet the needs of data security-in order of priority-patient, staff and the environment.

These services provided by health facilities must be practiced inside the limits of their competencies and resources [4].

The concept of leadership must consider ensuring non-discriminatory patient access to health services according to their needs, within the competence of the health unit [5,6,7].

A responsable and truly involved leader in the institution in which he operates, has the ability to develop a strong organizational culture, with its own strategies and policies, to which all employees adhere, in order to improve its performance [8,9].

The concept of leadership has as core value the healthcare leadership and patient bedside leadership, involving the creation of a common mission, overcoming political, organizational barriers, inspiring and motivating all team members [10].

What best defines medical leadership?

A choice, a vocation, or a calling?

Regardless of the answer, patient care remains the basic foundation of nursing practice that can transform the choice of nursing into a successful higher career [11,12].

At the same time, we can add that leadership is a complex phenomenon that affects almost all organizational, social and personal processes [13].

In this new era, nursing leadership requires skills that involve reshaping the future of the nursing profession, as well as the role of nurses in caring for patients, families, and promoting healthy communities [14].

The scientific "theories" of nursing have shaped nursing, giving it disciplinary status, thus providing distinct notions that can be labeled as guidelines for research, practice, education, and leadership [15,16].

Competitive leadership is a complex and valued component of health education, with a major impact on the provision of high standards of education, research and clinical practice [17,18].

In order to meet healthcare in the 21st century, competent leaders will be increasingly important in all medical professions, including pharmacy and dentistry [19].

In this context, a new type of leader is being modeled, one that ensures the balance between autonomy and responsibility, which involves teamwork in order to improve the quality of services provided to patients [20].

Material and Methods

The group of subjects included in the descriptive and cross-sectional study was represented by 166 medical staff from the hospital units in Craiova.

The study period was January 2020-January 2021, the study being conducted through voluntary participation.

For the study, a questionnaire was used as an investigation tool, which is an extremely useful investigation in management actions aimed at describing the behavior, knowing the reasons for the actions, finding out the opinions and preferences of the group included in the study.

The questionnaire contains 26 direct, indirect, factual, opinion, knowledge and control questions (questions about gender, age, past, marital status, education, professional qualification, professional experience, skills of a leader) (Figure 1).

Figure 1

The level of education of the studied group

Our research included in a first stage the analysis and processing of some questionnaires answered by the nurses from the County Emergency Hospital Craiova and the “Filantropia” Municipal Clinical Hospital from Craiova.

The questionnaires were disseminated in accordance with the rules of the General Data Protection Regulation and the study protocol was developed in accordance with the ethical guidelines of the Helsinki Declaration and was approved by the Ethics Committee of the University of Medicine and Pharmacy of Craiova-no 168/03.10.2021.

The questionnaire used was completed in county hospital units, with over 500 employees.

The information obtained was stored in Microsoft Excel files (Microsoft Corp., Redmond, WA, USA) and was statistically analyzed to investigate which relationship best or worst describes a leader, using the Microsoft Excel XLST AT software suite. (Addinsoft). SARL, Paris, France).

Secondary data processing-calculation of fundamental statistical parameters, mean and standard deviation of their ratio, coefficient of variation, graphical representation and calculation of regression coefficients was performed with Excel, Pivot Tables using controls, Functions, Statistics, Diagram and Data Analysis module.

Results

The basic characteristics of the investigated group are detailed in Table 1. Most of the nurses who participated in the study (96.36%) were employed as primary care nurses, 61.82% of them with higher education.

Table 1

Initial characteristics of the studied group

Sex	M	56	33.94%
	F	109	66.06%
Age	<25 years	3	1.82%
	25-35 years	21	12.73%
	36-45 years	51	30.91%
	46-60 years	90	54.55%
Area of residence	a. urban environment	108	65.45%
	b. rural environment	57	34.55%
Total number of employees	d. over 500 employees	165	100.00%
Position within the company	b. senior nurse	159	96.36%
	c. head nurse	6	3.64%

From the total of 166 people included in our study group, 3 had specialized high school studies (sanitary high school), 42 had post-secondary studies, 102 had higher education and 18 had postgraduate or master's studies (Figure 1).

The age distribution of the group according to seniority in work is detailed in Figure 2.

Figure 2

Distribution by age according to seniority in work

Overall, 67% of the questionnaires were completed by women with an average age between 46 and 60 years, and with a current seniority in the workplace, between 16-25 years-49%.

We also investigated the percentage of current leaders and we wanted to know how many of the 166 investigated were considered future leaders.

76% of them were not leaders at the time of the study and only 14.29% considered a future leadership role (Figure 3 and Figure 4).

Figure 3

Present status of leadership

Figure 4

Position on future leadership

At present, from the analysis of the data processing provided, we found that the subjects do not consider that they have a current leadership position, although 75% of them trust themselves, 50% of them trust the employees, and also trust in the solid professional knowledge they have.

In order to define the notion of leadership and the necessary qualities of a leader in a medical unit, it was proposed to evaluate on a scale from 1 to 5 the qualities that the subjects consider to have.

The interviewees consider in a very high proportion of 75.9%, self-confidence to be extremely important.

The next parameter analyzed was trust in the collaborators and the vast majority appreciated that this trait must be fulfilled in the highest degree by the one who holds the leader position.

Strong professional knowledge is also required in the highest degree representing 77.78%.

Regarding the open and permanent communication with those around them, with the work team in particular, it was also evaluated as an absolutely necessary quality in proportion of 75.93%.

Last but not least, one's own vision is also evaluated at a high degree of 59%.

The interviewees consider to a large extent that a leader must have a sense of humor, this being a very important quality in relaxing the atmosphere at work.

74% of respondents believe that a leader must take responsibility for the decisions made (Table 2).

Table 2

Leadership traits according to study participants

Open, permanent communication with those around you	2	1.85%
	3	3.70%
	4	18.52%
	5	75.93%
Own vision	3	16.67%
	4	24.07%
	5	59.26%
Humor	1	3.70%
	2	1.85%
	3	14.81%
	4	38.89%
	5	40.74%
Assuming the decisions taken	3	11.11%
	4	14.81%
	5	74.07%

Following the evaluation of the questionnaires, we investigated the ability of the subjects to recognize the qualities necessary for the leadership position, so we noticed that most of those involved rated with maximum marks confidence in: self (Q16.1), solid professional knowledge (Q16.3), communication open with those around you (Q16.4), the ability to inspire people around you (Q16.7), supporting employees in carrying out tasks (Q16.10), making quick decisions (Q16.11), the desire to contribute to professional growth of employees (Q16.22) and ability to avoid conflicts (Q16.23).

The results of the study are detailed in Figure 5.

Figure 5

Necessary qualities for a position in leadership

Surprisingly we found that a fairly large share considered important: self-vision (Q16.5), humor (Q16.6), authority (Q16.8), courage (Q16.9), independence (Q16.16), strong ambition (Q16.17), informal communication with everyone around (Q16.18) and only the focus of clear objectives (Q16.21).

Regarding the promotion of a leader and his characteristics, a percentage of 82.27% considered that the leader can achieve success only together with those who support him, and the promotion must start from within the organization with a percentage of 76.36%.

Also, 80% of the interviewees consider that the leaders are people with special characteristics, while only 61.82% consider that in order to be a leader, you have to be born with the necessary qualities, and 16.36% totally disagree with this statement (Figure 6).

Figure 6

Leader qualities that those interviewed strongley agree with

The investigated statements are detailed in Table 3.

Table 3

The investigated statements

No	Statements	Evaluation
		1	2	3	4	5
1	Leaders are people with special characteristics
2	In order to be a leader, you have to be born with the necessary qualities
3	The leader can only succeed with those who support him
4	Leaders need to be promoted from within the organization
5	In this organization, leaders are managers
6	Leaders do not need special training to succeed

The following question regarding organization and organizational culture, being a comprehensive column produced various results as follows: 87.27% of respondents stated that maintaining work harmony within the organization is extremely important in establishing its performance (Q21.7), that it is important for employees to be constantly consulted before the leader makes a decision that majorly affects them (80%), many-81.82% consider it particularly important to communicate informally (Q21.17), and over 70% consider that the activity in the organization means first of all the team activity (Q21.21), a good leader is the one who takes care of his people, regardless of their results (Q21.26) and that it is necessary for the leaders to work together with collaborators to build lasting relationships (Q21.36).

On the other hand, a significant percentage of 21.82% stated that the Romanian health system offers more threats than opportunities for development, and 20% believe that the Romanian health system does not allow the development of realistic organizational strategies and policies.

We also noticed that over 25% said that changes only happen when the situation in the organization deteriorates, that leaders usually postpone final decisions, and that leaders avoid getting involved in big issues and wait for time to resolve them, while only 58.18% believe that leaders tactfully resolve organizational conflicts.

The complete results are described in Table 4.

Table 4

Organization and organizational culture questionnaire results

Statement	Agreement	Disagreement
The staff of the organization is of the opinion that within it the situation will evolve positively in the future	43.64%	25.45%
Maintaining work harmony within the organization is extremely important in determining its performance	87.27%	1.82%
Leaders are interested in both the results obtained by employees and their private problems	52.73%	25.45%
It is important that employees are constantly consulted before the leader makes a decision that is of major concern to them.	80.00%	0.00%
There are big differences in reward in the organization, based on the evaluation of individual performance.	40.00%	12.73%
An important feature of the organization is transparency	58.18%	29.09%
Informal communication is especially important for the running of the organization	81.82%	1.82%
The human resource in the organization is seen as its most important asset	69.09%	14.55%
Organizational activity means first and foremost teamwork	78.18%	3.64%
The working atmosphere is pleasant and it motivates people	61.82%	14.55%
Leaders are interested in developing the potential of employees	49.09%	20.00%
A good leader is one who cares for his people, no matter what their outcome	72.73%	7.27%
Leaders constantly challenge us to come up with new solutions to achieve our goals	69.09%	9.09%
In the organization, leaders anticipate change and take the necessary steps to improve performance	65.45%	16.36%
Leaders take risks in implementing change	43.64%	14.55%
Leaders tactfully resolve organizational conflicts	58.18%	12.73%
Leaders work with employees to build lasting relationships	78.18%	5.45%

In the medical units from which the respondents came, we asked them to compare the characteristics of those they consider leaders compared to other assistants and we found that 98.18% consider professional knowledge as indispensable for the role of leader compared to 89% for the role of executor.

The detailed results of the study are described in Figure 7.

Figure 7

Required qualities of leaders and executors

Asked about the qualities that their assistant leaders should have, they answered that self confidence, strong professional knowledge and open communication were the most highly sought after qualities.

The results are detailed in to Figure 8.

Figure 8

Attributes wanted from a leader

More than half of the subjects rated the ability to make changes to the highest degree as necessary.

Discussions

The constant stimulation to make changes and in general the motivation of the work team is appreciated to the greatest extent.

Independence is not necessarily required, as evidenced by the answers of those questioned, ambition, informal communication with everyone around, the ability to learn in any situation, the ability to create a pleasant work environment, are important qualities that must be holds a leader they believe they have in various proportions.

Clearly, some nurses are active in leadership.

The nurses interviewed had early family and life experiences, as well as self-reflected learning that was important for their subsequent involvement, so this led them to engage in leadership positions in different ways.

Understanding in public schools of social values such as ability to avoid conflicts, supporting colleagues in carrying out tasks or equal opportunities for all was very important, and they were subsequently emphasized in nursing schools as a core value in nursing [22].

Another factor that contributed to their involvement was the concern for patient care.

Moreover, the nurses interviewed, as well as those in the study by Gebbie et al., 2000 [23], identified their nursing education and subsequent nursing work as essential for the acquisition of the necessary knowledge and skills.

Another important aspect is that the nurses interviewed do not see in a large percentage, a leading position in the near or distant future.

In this regard, it is important to emphasize that employees consider this position a difficult but also a political one.

This point is critical because the study by Gebbie et al. [23] also found that no nurse had planned a career in politics, and their political involvement was a gradual evolution influenced by their personal and professional life experiences.

Given that nurses are health care experts with a special commitment to patients, more nurses should expand their expertise in leadership.

This activity would shape them in a positive way professionally and would benefit the general public.

A leader is obliged to offer, by all means, and to create together with the team, a pleasant working environment, the parameter with which everyone agrees.

It must focus on absolute clear objectives, have a desire to increase the professional training of employees and, as described in the literature, conflict avoidance must be largely fulfilled.

Sometimes conflicts must be resolved, confronted and eventually led to progress.

One aspect that is considered very important in the development of leadership skills is courage and 57,41% say that it is largely necessary.

Regarding the support of employees in carrying out tasks, we must emphasize that, to a large extent, the interviewees, 72%, said that it is absolutely necessary to have support in carrying out tasks as well as quick decision-making.

The interviewees considered the decision-making to be useful in their ability to make changes, being in conclusion an essential quality of a leader, supporting the definition and data in the literature [21].

Regarding the motivation and motivation of the team, all the subjects agree that this is a very important parameter in the development of the team, subsequently and the constant stimulation of the collaborators.

Conclusions

Most of the assistants who participated in the study had a higher education but do not consider that they have a current leadership position despite their self-confidence and solid professional knowledge.

The study group considers open and permanent communication with others and the work team to be absolutely necessary.

The majority of health professionals also considered that a leader should take the decisions he or she makes and maintain a relaxed atmosphere in the workplace.

Other qualities of the leader considered significant by the studied group were represented in order of: teamwork, speed of decision-making in critical situations without creating conflicts, desire to contribute to the professional growth of the employee by allowing him to-explain his/her own vision regarding certain situations and considers it to be significant in certain circumstances.

Regarding the promotion of a leader, the majority of the group considered that success is achieved only with those who support it, and the promotion must start from within the organization.

Decision-making is useful in the ability to make changes, being an essential quality of a leader.

In conclusion, a better organization of the management of the hospital units is required, taking into account the leadership in nursing.

Conflict of interests

None to declare.