Nursing Managers’ Coronary Care Unit Management Experience

Abstract

Background:

The Coronary Care Unit (CCU) requires effective managers to consider- the patient’s acute condition. Studies have indicated that nursing managers of such units face many challenges. The purpose of the study is to explain nursing managers’ CCU management experience.

Materials and Methods:

The current study has been conducted with a qualitative approach from November 2017 to February 2020 in the CCU of Al Zahra Heart Hospital in Shiraz, Iran. The participants consisted of 18 individuals out of nursing managers and Coronary Care Unit Nurses in Charge selected as purposeful. The data has been collected using unstructured interviews, focus groups, and field notes. The researchers used content analysis proposed by Graneheim and Lundman for interpreting the content of textual data using regular classification.

Results:

Data analysis led to the emergence of 3 themes and 8 subcategories. The theme of Inadequate Interaction by the Nursing Managers has been derived from the conceptualization of three subcategories “Senior Managers Insufficiently Supporting the Nursing Manager”, “Nonempathetic Communication by Nursing Manager” and “Nursing Manager, not Providing Ground for Motivating and Promoting Staff”. The main theme “Impaired Control and Supervision” includes two subcategories “Lack of Sufficient Supervision on Nursing Care Performance”, “Lack of Suitable Instrument to Monitor Unit’s Equipment and Nursing Staff’s Performance”, and the main theme, “ Incapability to Organize Performance”, is made up of three Subcategories “Nursing Managers Being Incapable to Manage Time”, “Inappropriately Organizing Activities”, and “Nursing Managers’ Limited Power in Planning Managerial Activities.”

Conclusions:

The current study-derived findings present a realistic image of nursing managers participating in CCU management, so the resulting themes indicate nursing managers’ perception of CCU management as ineffective. Thus, it is imperative to focus on promoting CCU nursing managers’ managerial performance.

Introduction

In the Coronary Care Unit (CCU), patients with acute conditions are hospitalized. Thus, they need active managers so that in such units, effective and safe management is required, and the CCU head nurse, as the leading and operational manager, is in charge of the managerial activities to achieve the goals, performs these activities as integrated and faces many challenges in this respect.[1] The head nurses not only need to perform clinical skills, but they also have to carry out the managerial duties assigned to them as part of the management task.[2] At the same time, carrying out care and management duties brings about some challenges for the head nurses so recognizing their experiences in CCUs can pave the ground for better and more accurate care and management service providers for nursing managers and other nurses. On the one hand, effective CCU management by nursing managers leads to promoting the quality of nursing care,[3] patient safety,[4] patient satisfaction,[5] a healthy work environment[6] and reducing job burnout.[5] Also, lack of effective management in CCUs stimulates the nurses to leave service provision,[7] job burnout,[8] nurse dissatisfaction,[8] ineffective interaction,[9] and reduced quality of nursing care.[10]

Jäppinen study (2022) reported that the nursing managers had a moderate to high level of stress due to their workload, so they had a strong desire to leave the organization. They had less job satisfaction and did not have a good understanding of their work environment. Also, results showed nurse managers need sufficient resources, a clear division of work, and more capable structures to carry out their activities effectively.[11] The role of head nurse is seen as one of the most difficult roles of managers in healthcare organizations[12] A study showed that nursing managers experienced a lack of sufficient authority and structural deficiencies, and managers felt that they could not do anything without authority.[13]

There are various studies about the managerial performance of head nurses, most of which are quantitative studies and have been conducted in general wards and have exclusively examined the various managerial aspects of head nurses.[14,15,16,17] There is no research on the managerial performance of CCU head nurses, therefore, considering that in the CCU department, patients with critical conditions of heart disease are admitted, head nurses play an important role as frontline managers of treatment, and they face many challenges in the field of ward management. Since the concepts of convenience cannot be measured and explained using quantitative tools, so qualitative research aims to discover the understanding of people’s inner world, which helps to identify the phenomenon more deeply by explaining the experiences that have informed people.[18]

Therefore, the researcher conducted a study to explain nursing managers’ perception of CCU management with a qualitative approach, which provides useful information to policymakers and senior managers of the health system to make efforts to enhance such managers’ management as much as possible.

Materials and Methods

In the current research, a content qualitative study of the conventional type has been applied to find out nursing managers’ experiences with CCU management.

This study is part of a doctoral dissertation that was conducted from November 2017 to February 2020 in the coronary care units (CCUs) of Al Zahra Heart Hospital in Shiraz, Iran. The head nurses and supervisors with experience working in CCUs were invited to participate in this study. The sampling was done purposefully among the nursing managers. The criterion to select the participants was having CCU management experience and being interested in expressing their experiences in such a way that they could present a reliable image of the phenomenon under study. Overall, 18 participants who were asked for informed consent and to whom the goal of the study and the data collection approach -was described took part in the study. Unstructured interviews, focus groups and field notes were applied to collect the data. The interviews started with open-ended questions on CCU management-related experience statements: “What is your experience of managing the head nurse of the CCU?” And with exploratory and follow-up questions, such as “Could you explain more? “ What do you mean? “Why was it asked?” They were required to delve deeper into the issues and problems related to how to manage CCU. The place and time of the interview were arranged in line with the participants’ requests and the nursing manager’s office for an average of 47 minutes. Overall, 14 cases of interviews and one focus group discussion were performed with 4 supervisors, and the researchers also took notes on 5 different situations by being present in the research environment. The researcher used the audio recording program installed on the mobile phone to record the interview, which was then transcribed.

In the data analysis, the conventional content analysis was employed. According to Vaismoradi, considering the stages proposed by Graneheim and Lundman, content analysis is well suited for analyzing the multipurpose, important, and sensitive phenomena of nursing.[19] It is through qualitative content analysis for interpreting the content of textual data using regular classification that the overt and covert themes in the text are identified. Based on this method, the stages taken are like this: after each interview, the interview tape was transcribed and typed word by word; the whole text was read several times to come up with a general perception of its context; the semantic units were extracted and encoded; and then the similar codes were integrated. Following this stage, the initial identification codes were put into more comprehensive categories, and the main themes of the categories were determined at the abstraction level. This way, efforts have been made so that the intracategories have the maximum homogeneity and the intercategories have the maximum heterogeneity. The data resulting from each interview was a guide for the next one, and in this manner, sampling lasted until data saturation, so that from the 12^th interview onward, no new code or data was yielded. To be further assured, two more interviews were conducted, and no new data was discovered.

To be assured of the qualitative data’s accuracy and reliability, Lincoln and Guba evaluation criteria were used.[20] The credibility method includes the researcher being involved in the research subject in the long term and the participants getting to control and review the data. After encoding each interview, the researcher returned to the participant to get assurance of the codes’ accuracy and interpretations, and to modify the codes that did not reflect the participant’s perspective. On the one hand, for integration, several data collection methods, such as interviews, focus groups, and field notes were conducted with the highest diversity from the head nurses, supervisors, and nurses with different working experiences at different sessions. Also, the finding’s conformability or auditability was verified and analyzed by being controlled by two experts familiar with a qualitative study to ensure the categories’ consistency. To ensure the dependency of the interview, the researcher rechecked all data by an external nurse manager reviewer. In the current study, considering transferability, the researcher made efforts to pave the ground for the possibility of pursuing the direction of the research for others by vividly, accurately, and purposefully describing the study process and the tasks taken so that they could decide about employing its results.

Ethical considerations

Firstly, the necessary measures were taken to get the permit from the Ethics Committee of Modares University (IR.TMU.REC.1396.596 date 2017.07.16) to enter the clinical domain. On the one hand, ethical etiquette in research, like informed consent, anonymity, confidentiality, and the right of the participants to quit the study when they desire, was observed. Ahead of the interview, the goal behind the study and the data confidentiality were explained to the participants.

Results

Eighteen participants took part in this research, which consisted of 6 supervisors, 9 head nurses, and 3 nurses in charge in the age range 28–51 years. And with a work record of 5 to 23 years.

Out of the data analysis, 250 initial codes were extracted based on the similarities and differences; the reduction was done in four stages, and ultimately, three main themes, “Inadequate Interaction by the Nursing Manager,” “Impaired Control and Supervision,” and “Incapability to Organize Managerial Performance, “were codified, and 8 subcategories were formed in line with the three main themes [Table 1].

Table 1.

Formation of the main theme from themes

Theme	Subcategories	Categories
Inadequate interaction by the nursing managers	Nursing managers not being sufficiently supported by the senior managers	The lack of attention of superior managers to the nursing manager
		Perceived and unreceived head nurse support from the nursing manager
	Nursing manager not providing the ground for motivating and promoting the staff	The lack of attention of the nursing manager to the ability of nurses
		Not having the necessary facilities to encourage staff
	Nonempathetic communication by the nursing manager	Inappropriate communication between the head nurse and the nurses
		Nursing manager’s hammering behavior with nurses
Impaired control and supervision	Lack of sufficient supervision on nursing care performance	Lack of supervision of the nursing director on nursing care
		Lack of monitoring of nursing records and patient education
	Lack of suitable instruments to monitor the unit equipment and nursing personnel’s performance	Not having an objective standard to monitor the department’s equipment
		Lack of objective criteria for evaluating nursing personnel
Incapability to organize managerial performance	Nursing manager being incapable to manage time	Inattention of the nursing manager to time management in carrying out activities
		Lack of organization of the time of changing shift
	Inappropriately organizing activities	Improper division of labor among nursing staff
		Inadequate organization of activities
	Nursing managers’ limited power in planning managerial activities	Unnecessary interference of the supervisor in the personnel shift schedule arranged by the head nurse
		Not having the authority of the nursing manager to plan the activities of the department

Theme1: Inadequate Interaction by Nursing Managers: The main theme, namely, “Inadequate Interaction by Nursing Managers” encompasses three subcategories “Senior Managers Insufficiently Supporting the Nursing Manager”,” Nonempathetic Communication by Nursing Manager” and “Nursing Manager not Providing Ground for Motivating and Promoting Staff “, which are illustrated in the following separation.

Nursing Managers not Being Sufficiently Supported by Senior Managers: The concepts resulting from the data indicate nonprofessional interaction between the senior managers and the nursing manager, the matron ignoring the nursing manager’s notice about human workforce supply problems, and the nursing manager not receiving the due support and not being perceived by the matron, the issues mentioned by the participants in the following:

One of the head nurses stated the following concerning the managers’ non-professional interaction: “The nursing managers just pay attention to their supervisors and accept whatever report they present without checking; they admonish us and do not give us the chance for explanation. In the sessions, they suppress us regularly and give us negative feedback. This way, our motivation will diminish.”

Another head nurse points out the lack of support on the matron’s side: “One day I objected to a nursing shift change; the nurse usually referred to the nursing manager for help with her/his problem, and the manager ordered me to resign to the shift schedule change without asking for my input.”

Theme2: Nonempathetic Communication by Nursing Manager: CCU supervisors were dissatisfied with the lack of intimacy in the unit and viewed it due to the aggressive behavior of the head nurse, the imposed psychological pressure dominating the unit, and the head nurse being too tough so that participant No. 11 expressed so: “The staff in this unit are somehow afraid of something and do not feel well. The head nurse here yells and rebukes the nurses (Supervisor: 41-year-old, female, work experience: 17 years).

Also, one of the nurses in charge stated: “The head nurse does not treat them as friends and comes up with adverse reactions quickly when irritated.” (Nurse: 35-year-old, female, work experience: 8 years).

Theme3: Nursing Manager not Providing Ground for Motivating and Promoting Staff: Moreover, the nursing managers expressed the following matter about not providing the ground for motivating and promoting the staff: “We have to provide the ground for motivating the nurses and weigh up their potentials, but at the moment, a suppressing trend is prevalent, and the statistics of writing the staff’s error forms are high, but the incentive statistics for us aren’t that high.” (Supervisor: 43-year-old, female, work experience: 18 years).

The main theme “Impaired Control and Supervision” includes two subcategories “ Lack of Sufficient Supervision on Nursing Care Performance” and “Lack of Suitable Instrument to Monitor Unit’s Equipment and Nursing Staff’s Performance”, which will be illustrated by separation in the following.

Nursing Manager not Supervising Nursing Care: The participants weren’t absolutely satisfied with the care provided and pointed out cases such as not providing training to the patient, not implementing the correct procedure of drug administration to the patient, and the nurses’ faulty reporting, and mentioned that such cases result from not effectively monitoring the nurses’ performance and not checking the equipment and the stuff to get assured of their safety. Besides, the head nurses’ companies lack suitable instruments for supervising the nurses’ performance. So that’s one of the head nurses said, “I do not have a checklist at hand, but I check whatever is required for the unit in my mind.” “The head nurses perform poorly in terms of supervision and do not monitor care constantly.” (Supervisor: 38-year-old, female, work experience: 12 years).

Also, one of the supervisors talked about the care provided: “When once visiting the unit, I inquired into the training received; the patients lacked any sort of information about it, and the nurses did not follow the right way of administering the drug (Supervisor: 40 year old, female, work experience: 15 years).

The main theme, “Incapability to Organize Performance”, is made up of 3 subcategories “Nursing Managers Being Incapable of Manage Time”, “Inappropriately Organizing Activities”, and “Nursing Managers’ Limited Power in Planning Managerial Activities”.

• One of the supervisors stated the following about the nursing manager being incapable of managing time: “Some units have the head nurses with highly stressful personalities who constantly exert stress on the staff; for example, they want to do everything at that time when it’s the time for nurse change of shift report and follow up on the patients’ affairs between such cases that lead to prolonged nurse change of shift report and the staff’s dissatisfaction (Supervisor: 38 year old, female, work experience: 12 years).

Concerning the task division by the head nurses, the nurses expressed that: “Our head nurse’s problem is not paying so much attention to patients’ division; one nurse takes care of 4 patients requiring high care levels and 3 other nurses care for 3 patients with a lower level of care, so if the patients get divided in the right manner, the tasks will be performed better and there will be fewer errors.” (Nurses: 36-year-old, female, work experience: 8 years).

• “Another problem in our unit is a group of individuals always being in charge and another group constantly working in the unit”(Nurses: 31 year old, female, work experience: 5 years).

The head nurses complain about not having the power to change or add the senior managers’ intended goals, so one of the head nurses said: “As a head nurse, I lack any sort of power to do anything, and I am only the performer of the unit quality improvement goals.”

Discussion

The present study examined the nursing managers’ experiences with CCU management and revealed that CCU management is encountering several challenges in managerial performance, particularly in communication, monitoring, and organization. These study-derived findings encompass the main themes such as “Inadequate Interaction by Nursing Managers”, “Impaired Control and Supervision”, and “Incapability to Organize Managerial Performance”.

Considering the acute condition of CCUs, the nursing managers’ role is highly significant; the organizations often select CCUs nursing managers out of the clinic nurses, who are not prepared –to take up the new role. The studies emphasized the importance of focusing on the nurse managerial competency and the requirements for their performance evaluation. Inefficiently selecting a nursing manager exerts negative impacts on the work environment, job satisfaction, managerial effectiveness, staff participation, and patient outcomes.[21,22]

One of the management skills is to create effective communication with the covered staff, so the studies reported that the head nurses do not create adequate professional communication, and a lack of such skills can have negative effects on the nurses and their team performance.[21] Adams (2019), in their review of nursing managers’ role in supporting CCU nurses, investigated i19 studies, and through their data analysis, 3 themes resulted, including Establishing Professional Relations, Leading the Way,” and Meeting CCU Nurses’ Requirements. The study findings indicate that nursing manager behaviors exert a positive effect on CCU nurses’ well-being and CCU nurses are inclined to have nursing managers who are highly skilled in leadership and capable and consider nursing managers’ supportive roles as important, complicated, and challenging.[23]

In the current study, about the concept known as nonempathetic communication with the nursing manager, the participants set forth an example of non-professional behaviors conducted by the units’ nursing managers, and the hammer behaviors of nursing managers with the nurses formed an unpleasant working and physiological atmosphere in the unit. Jankelova’s study (2019) results indicated that job satisfaction among nurses is significantly influenced by the communication skills of their head nurses. However, the current level was also evaluated with the lowest score.[24]

The above study results aren’t consistent with those of this research, since the head nurses didn’t manage to have a befitting interaction with the staff, the issue that brought about the staff’s dissatisfaction.

On the other hand, the results of the qualitative study by Ika et al.[25] showed that head nurses play an effective role in preventing interdisciplinary conflicts so the resulting themes that include integrated-effective communication is a type of interdisciplinary conflict prevention, a head nurse should have broad insight and a flexible personality to avoid conflicts with doctors. The head nurse is responsible for coordinating and negotiating to prevent interdisciplinary conflicts, and a supervisor creates a favorable work environment to prevent interdisciplinary conflicts.

Not proving ground for motivating and promoting the nursing staff is one of the concepts of the study, so the participants mentioned the most important motivational barriers, such as the head nurse not paying attention to the nurses’ work records, the nursing staff’s capability and growth, and not preparing the motivating ground for the staff. Considering that health organizations encourage canters to have positive management practices to promote motivation and high-quality care,[26] it’s required for the CCU nursing managers to employ the necessary facilities and conditions for encouraging and motivating the nurses for their optimization and empowerment.

The research done by Gunawan (2019) also pointed out that nursing managers need to pay attention to increasing the motivation of nurses to improve interpersonal relationships and their career plans, and in this way, they make nurses improve their performance by improving their qualifications.[27] On the one hand, the study done by Ankomah (2016) reported that among the motivating factors, career advancement is the factor inducing motivation among nurses.[25] The results of this study are consistent with those of the present study.

Moreover, in our study, “Impaired Control and Supervision” is another resulting concept. Regarding this, the studies revealed that nursing managers have to be equipped with the required skills and the potential for systematically providing efficient supervision.[10,11,14,15,28] Their research-drawn results suggested that CCU nursing managers do not monitor nurses’ care performance. Also, the participants noted that the nurses overlook some of the care affairs of the patients, and perhaps one of the reasons behind this is the lack of CCU nursing managers supervising the nursing care and documentation. On the one hand, CCU nursing managers pointed out the lack of an objective instrument for evaluating the nurses’ performance and unit supervision equipment as a factor in not properly supervising the unit. On the one hand, CCU nursing managers considered the reason behind ineffective supervision to be a heavy workload and a wide scope of supervision. In this respect, the research done by Cupit (2019) also reported nursing managers’ scope of supervision: almost 56% of nursing managers had an acceptable scope of supervision, while 44% of them had an excessive scope of supervision.[29]

Another main concept in the current study is the inability to organize managerial performance. The study’s derived results showed that the inability to organize managerial performance disturbs CCU management by inappropriately managing time, dividing the activities, and nursing managers’ limited power was pointed out.

The studies proposed several cases as factors influencing time management, so analyzing time management by the managers, Sinanovic (2018) reported that 95% of time management was related to the activities that should have been assigned to the staff, but the managers did them. Besides, the study showed that most cases resulted in time management disorders, a shortage of staff (95.5%), and disturbing and insignificant contacts (90%).[30] The study done by Setoodegan (2019) revealed that managers have to concentrate on time management since managing time can have a positive effect on organizational skills and raise productivity.[31]

One of the concepts resulting from the data analysis is “Inappropriately Dividing Activities”, thus indicating that the care models are highly significant in setting up a nursing work environment. The managers then have to manage the allocated resources and make sure of the most suitable model for supporting the nurses to be able to divide tasks and present effective clinical outcomes.[29] The nursing work environment is complicated, so prioritizing tasks is a must and requires redefining the daily nursing workload. Concerning this matter, delegating effective authority to the managers leads to increased productivity. In this regard, Al Otaibi (2022) suggested that nursing managers should provide nurses with legitimate power and high ethical standards to increase their work commitment and enthusiasm. Leaders who are willing to share their passion, knowledge, and skills with nurses create a harmonious relationship and increase their satisfaction.[6] Delegating power to the managers raises job satisfaction, motivation, and personal growth and makes the individual feel appreciated, and they will appreciate others in return. Collaboration increases, and teamwork is stimulated and promoted.

Therefore, given the study’s extracted results, it seems that CCU nursing managers do not manage effectively, and managing the nurse’s and the patients’ nursing care affairs is accompanied by some nuisances. Thus, regarding the acute CCU conditions and the nurses encountering hard work and CCUs induced stresses, it’s imperative to pay special attention to the nursing managers’ performance and competency and pave the ground for their managerial performance promotion by focusing on competently selecting CCU nursing managers and executing managerial skills’ development programs. Zendrato (2019) reported that the creation of an effective nursing manager didn’t happen overnight; rather, it depends on ongoing processes and the learning infrastructures for the nursing managers. Nursing managers play a critical role in shaping the work culture and building the patients’ quality of care, which includes knowledge development plans, skills, and other interpersonal potentials. For nursing management success, the managers must have expert skills and competencies to create a culture of leadership work, lower burnout, and raise the quality of service provision to the patients.[32]

This study was limited to a group of nursing managers and nurses in a specific location and could not be generalized to other groups and locations. More studies seem necessary to explain the managerial experiences of nursing managers in coronary care units in different geographical locations.[6]

Conclusion

The results of the current study drawn results in present a clear-cut picture of the participating nurses’ real perceptions and experiences of CCU management, so the main themes proposed in the research are Inadequate Interaction by Nursing Managers, Impaired Control and Supervision, and Incapability to Organize Managerial Performance. Recognizing and describing the nurses’ perception of CCU management can bring about valuable data in various dimensions to be able to decrease and resolve the existing problems so that ineffective CCU management-induced outcomes affect the patients, nurses, and nursing managers from various aspects and lead to reduced quality of care, the patient’s safety disturbance, the nurse and the patient getting dissatisfied, job burnout, leaving a nursing career, reduced work motivation, and a lack of job security. Consequently, it’s required to emphasize and support CCU management promotion more than before.

Conflicts of interest

Nothing to declare.

Funding Statement

Research Administration of the Faculty of Medicine of Tarbiate Modarres University