The Lived Experiences of Becoming First-line Nurse Managers: A Phenomenological Study

Abstract

Background:

Designated roles of first-line nurse managers (FLNMs) are very complex, this study aimed to develop a deeper understanding of their meaningful lived experiences.

Materials and Methods:

This study employed a phenomenological study using semi-structured interviews with FLNMs (n = 7) at the General Hospital of Belitung, Indonesia. The data analysis was thematic.

Results:

Four major themes were identified from the analysis of textual data: Feeling extraordinary, the inability to do, desire to leave the unit, and influenced by work motivation. The findings of this study revealed the positive and negative experiences of becoming FLNMs. The positive experiences were related to the feeling challenged and extraordinary to deal with many roles in management and leadership. The negative experiences included personal conflict related to the desire to leave the unit, and feeling unable to manage. However, the works of FLNMs were influenced by internal and external motivation.

Conclusions:

This study better informs nurse executives to develop competence and performance of FLNMs, and keep their motivation by revising performance appraisal system.

Introduction

First-line nurse manager (FLNM) role is seen as the hardest role in healthcare.[1] FLNMs play a critical management role because they can influence the success of healthcare organizations, especially at the unit level. Their role is pivotal in the development and retention of the staffs, and in the responsibility to assure the mission of the facility translated into everyday practice.[2]

FLNM is defined as a registered nurse having 24 h accountability for the management of a unit(s) or area (s) within a healthcare institution. The term FLNM has been used interchangeably in the literature with the terms head nurse, ward manager, nursing unit manager, and ward leader.[1]

In Indonesia, the role and competency of FLNMs are explained in the job description based on the standard of the Department of Health of Indonesia, which is divided to be management of operation (managerial focus), and management of nursing care (clinical focus).[3] At this point, the managerial competence of FLNM in operational management determines the implementation of nursing care process. The roles and competences are expected to bring better nursing care and nursing outcomes. However, literature reported that finding competent FLNMs is one of the greatest challenges facing healthcare today.[4] Therefore, knowing the lived experiences of becoming FLNMs is the first step in rectifying any disparities among them.[5]

Although, FLNM is a key person in creating, maintaining a healthy work setting, and achieving optimal work satisfaction of staffs, he or she must be able to work in a relatively stress-free environment and good working condition before managing the staffs. In Indonesia, little is known about the lived experiences of FLNMs in Indonesian context. Thus, this study aimed to explore the lived experience of becoming FLNMs. The findings of this study would therefore be useful to develop the competence of FLNMs and enhance efficiency and effectiveness in nursing care delivery and management proficiency as part of a management development process.[5]

Materials and Methods

This was a phenomenological study conducted in 2015 to reveal the nature of the lived experiences of becoming a FLNM in the General Hospital of Belitung Indonesia.

Interpretive phenomenology, as outlined by Van Manen,[6] employs both interpretive and descriptive elements in order to gain deeper understanding of the nature of the essence of everyday lived experiences. The reflections on the essential themes that describe and explain the phenomenon through the art of writing balance the research context by viewing each piece as a whole.[6]

Respondents were recruited using a purposive sampling method that generated 12 contacted FLNMs. The participants were contacted through email, short message service (SMS), and phone call to inform them about the purpose of the study. The inclusion criteria were the respondents who had at least 2 years of managerial experience, and had to be willing to participate and talk about their lived experiences of becoming FLNMs. There was no age and gender restriction of becoming FLNMs in this study. From the original 12, only seven FLNMs were eligible and had been willing to join this study. Five FLNMs were excluded because they had no time to participate and did not respond to further communication. However, based on Creswell,[7] the sufficient sample size for phenomenological study are five to twenty five participants.

Upon accepting the invitation, potential respondents were given oral and written information about the research, and after they signed a consent document, an appointment was scheduled for an interview. Interviews were conducted in Bahasa Indonesia or Belitung language. Three researchers conducted semi-structured interviews, namely, J.G., A.S, and N. The interview ranged between 60 min and 120 min. Each interview and transcript was individually analyzed and then reviewed and discussed collaboratively by the researchers. The interview was taken place in the meeting room in each ward of FLNM to avoid the noise and the other disturbances during interview. The interviews were audio-recorded, transcribed verbatim, and validated by re-listening to the recording by researchers.

The interviews were performed from July 2015 to August 2015. The informants in this study were initially asked with an open-ended question, “How do you feel to be a FLNM? and what are the opportunities and challenges they have?” and continued until the data reached saturation.

Data were analyzed using thematic approach suggested by van Manen, a detailed or line-by-line approach, the highlighting approach, and the holistic approach. First, interview transcripts were read carefully and repeatedly for emerging themes: Detailed reading of sentences, then using highlighting or selective approach, and finally reading holistically. In the holistic approach, the researcher views the text as a whole and attempts to understand the overall meaning. The researcher then highlights or selects phrases and statements that seem essential to the study.

Second, developed the key words and concepts dialogue with the texts. Finally, themes were interpreted from components of experience to the whole experience and back again. Researchers worked to gain and understanding and engagement with the text related to phenomenon under inquiry. Finally, every sentence is analyzed, and through this process essential themes are discovered. These themes are then reconstructed into a description of the lived experience of the participants.[8] All of the themes are then translated into English. J.G provided the first translation, which was then agreed by other researchers.

Issues of trustworthinesswere addressed through internal member checking during the interview by the principle investigator and through the verification of participants by face-to-face and online discussion. Peer-review was done by an independent person or an experienced researcher to compare and contrast on the data quality and interpretations, and noted that documented all methodological issues and decisions. Bracketing was ensured although the interviewer or principle investigators were mostly Indonesian nurses by discussing among researchers about personal biases, and experiences with the research topic. In addition, the researchers kept audit trails and notes concerning interpretive/thematic decisions.

Ethical considerations

Ethical approval for this study was obtained from Kesatuan Bangsa Perlindungan Masyarakat or Government Institution of Society Protection in Belitung with Number: 070/219.a/BKBPPB/2015. The formal consent was also obtained from the Director of General hospital of Belitung. All participants in this study were recruited and informed about the aim of the study. They were assured that participation in this study was voluntary. Moreover, they were able to voluntarily withdraw from the study. The researchers guaranteed the confidentiality of their data and also ensured them that their information would be published anonymously. In the end, the researchers asked the informants to read and sign the written informed consent form. It was certified that all participants have obtained all appropriate consent form.

Results

Seven FLNMs were identified using purposive sampling to ensure that relevant data were collected. Participants' ages ranged between 35 years and 47 years. There were three male head nurses in the inpatient wards holding bachelor degree, one female head nurse in the intensive care unit (ICU) holding bachelor degree, and three female head nurses in inpatient wards holding diploma degree. The demographic variation came from the minimum and maximum ages of being government employee (18–60 years old).[9] At the time of the study, all of participants had managerial experience of becoming FLNMs at least 2 years.

Findings emerged from the data using van Manen's thematic approach. Four themes included feeling extraordinary, the inability to do, desire to leave the unit, influenced by work motivation.

Those themes are illustrated below with exemplars from the informants' stories using pseudonyms for the informants.

Theme 1: Feeling extraordinary

Majority of informants agreed that they feel extraordinary becoming FLNMs. It was indicated that they accepted the leading position with complex roles. Informants expressed this in the following statement:

“…It's more than expectation, I feel like different person with so many roles in my hand…” (A5). Another participant mentioned:

“…It's very challenging, we have to know about quality, patient safety, finance, clinic, human resource management, and anything…”(A3)

“…I feel like I am running a small business and try to make it work. I feel good with that…”(A2).

Theme 2: The inability to do

Some of participants expressed that they were stuck and unable to do so many roles, like informants said:

“…Being a head nurse is so hard, I need to learn management and clinic together. I feel I have inability to do, but I need to learn more…”(A4)

“…I need to do this, I need to do that, take care of everything, sometimes I am not able to do that, I need a help…” (A3).

Theme 3: Desire to leave the unit

The third theme was desire to leave the unit. This desire indicated that informants might not be able to deal with the complex roles to be a FLNM and then had an intention to leave the job. This theme was closely related to the theme “the inability to do” like one participant said that she wanted to resign because there was a conflict role and too many jobs to get accomplished.

Theme 4: Influenced by work motivation

Majority of informants agreed that their works were influenced by internal and external motivation. The internal motivation included job itself and advancement, while external motivational factors were relationship with staff, supervision, working condition, and salary. The informants expressed this in the following statement:

“…Sure, my work performance is influenced by internal and external motivation. For internal motivation, I need to have a chance to develop my self to be a good manager, and for external motivation I need more salary because the job to be head nurse is hard…” (A1)

“…For me, supervision from the boss is one of factors to influence my work. If they watch my work, I feel motivated. Otherwise, if there is no supervision at all, I just relax and enjoy…” (A6)

“…As long as I have a good relationship with my staff, especially from senior staff, everything will be oky. Because sometimes the senior staff are quite difficult to manage…”(A2)

“…Although it's too much consuming my energy, if the work condition is better, and there are good facility, and clean environment. I feel oky with that…” (A7).

Discussion

This phenomenological study was conducted to explore the lived experiences of becoming FLNMs. There were four themes emerged, namely feeling extraordinary, the inabilities to do, desire to leave the unit, and influenced by work motivation.

The theme “feeling extraordinary” indicated that FLNMs were satisfied with their roles and felt special to be a nurse manager. This feeling indicates a good character of nurse managers to accept their roles, which are very challenging and rewarding, as literature stated that in difficult time, in rapidly changing times, in hard times, the character of the leader is more important than in other times.[10]

This feeling usually occurs to those who have years of experience and knowledge, who know what work and why, and they consider that being a nurse manager is to lead the team rather than be led by another manager. Thus, this can be tremendously refreshing.

The feeling extraordinary in regard to relationship with the staffs was also described in the result of this study, which is similar to the previous study mentioned that if you ask most nurse leaders what is the most satisfying aspect of their roles, they will very likely tell you that it is the connectedness that they feel with their staff.[11] In addition, being a FLNM is likely running a business and trying to make it work. Many nurse leaders reported that they really do enjoy the challenges of solving complex problems and described themselves as business owners.[11]

On the other hand, the feeling extraordinary might be related to the personality of nurse managers. Personality means the set of emotional qualities and ways of behaving that makes a person different from other people, or the quality or state being a person.[12] Personality traits are dimensions of individual differences in tendencies to show consistent patterns of thoughts, feelings, and actions.[13] In this regard, transformational leaders tend to display a high level of confidence and self-esteem as well as feeling extraordinary as found in this study, which may inspire their subordinates to share a common vision and convince them of the possibility of reaching a goal that is higher than they expect.[14] It is impossible for neurotic leaders who lack confidence and are unsure of the future, to exert idealized influence on their subordinates.[14]

The theme “The inability to do” indicated that not all FLNMs could deal with the complex roles of nurse manager, which is related to both management (mobilizing people and resources) and leadership (influence and vision). FLNMs also need to be available 24-h a day, 7 days a week without break to deal with complex issues.[15] These tiring works could greatly make them stressful and fatigue and ineffectively carry out their expected missions without requisite tools, resources and structures to support their high demand work. Thus, it is the responsibility of top nurse managers and those who employ them to understand the intricacies of this crucial position such that they can together optimize role efficiency and effectiveness.[16]

In response to the inability of nurse managers, government of Indonesia collaboration with all public hospitals have been providing the trainings of management of nursing care and services, and training for nursing care delivery ad [Professional Nursing Practice Model (PNPM)], or called as Model Praktik Keperawatan Profesional (MPKP) and Sistem Pengembangan Praktik Keperawatan Profesional (SP2KP) in Indonesian terms since 2005. The content of ward management training includes the management of nursing practice model, strategy for activity based planning, internal audit, communication, coordination and information system of ward, primary care nursing, and management of nurse staffing. While for PNPM/MPKP includes professional value, management approach, nursing care delivery, professional relationship, compensation, and reward.[17]

Unfortunately, similar with the findings of this study, although the trainings had been provided, there had been an outcry of poor competency among FLNMs identified in the previous studies, for instance, the study conducted by Almidawati revealed that head nurses had low competence (56.6%) based on planning, organizing, directing, and evaluating.[18] It is similar with the study conducted by Yatimin who analyzed the managerial competence of ward head nurses with the results showed that the competence of head nurses in operational management and management of nursing care was low and not based on standard.[19] These; however, will impact to the nursing and patient outcomes.

The theme “Desire to leave the unit” indicated that retaining nurse managers is needed. In this study, nurse managers reported that they were stressful and overwhelmed with roles and responsibilities, and they had limited support to deal with the demands for their services. Literature revealed that intention to leave for nurse manager is affected by workplace stress,[20] and induced by role overload, role ambiguity, fiscal responsibilities, inadequate human resources, and intrapersonal distress.[20,21] The other factors also include burnout, career change, retirement, and promotion. Majority of nursing managers plan to leave their position in the next 5 years.[22] In response to that, minimizing nurse manager stress, enhancing nurse manager coping behaviors, and facilitating desirable nurse manager decision making are all strategies consistent with engaging and retaining both nurses managers and staff nurses in the profession.[16] Additionally, nurse managers need supportive structures and resources that give them flexibility and control assistant with their significant responsibilities.[23]

Besides, this finding is also closely related to the process of the recruitment of FLNM. In this hospital, the criteria to select FLNMs are only based on the length of working experiences, not based on their competencies. There is no yet competency examination and evaluation of nurses in this hospital, which is considered as a main cause of the inability of FLNMs and the intention to leave the unit.

The theme “Influenced by work motivation” indicated that the performance and behavior of FLNMs in this study are influenced by internal and external motivational factors. The internal motivation emerged from the data included job itself and advancement, while the external motivation included relationship with staff, supervision, working condition, and salary. Literature said that when FLNMs are motivated and subsequently satisfied with their jobs, it will lead to good competence that can positively affect patient satisfaction and organizational effectiveness. Motivation leads to preferences in job behaviors, and such preferences may lead to the manifestation of a number of roles and competencies that influence the agendas in which managers want to participate. However, these findings were in line with Herzberg motivational theory that consists of internal and external factors.[24] Herzberg's two-factor theory, also called motivation-hygiene theory believes that an individual's relation to work is basic and that one's attitude towards work can very well determine success or failure. Hygiene factors (external) include salary, working condition and fringe benefits; and motivator factors (internal) such as recognition, responsibility, achievement, and opportunity for progression. Herzberg found that a combination of these factors increased motivation and improved individual performance.[24]

Limitations of this study were the small sample size that cannot be generalized to all FLNMs who work in government hospitals in Indonesia, which the lived experiences of becoming FLNMs are different from the other settings. However, findings of this study contributed further to knowledge in this area. In future investigations, it might be possible to recruit more participants from various settings, and it is suggested for further studies to identify the influencing factors of nurse managers' performance and provide the intervention to develop FLNM's competence and performance.

Conclusion

This study investigated the lived experiences of becoming FLNMs. The results showed positive and negative experience. The theme “Feeling extraordinary” was considered to be a positive experience to accept complex roles when becoming nurse managers, and it is necessary to keep encouraging them to feel the same way and be confidence with their jobs. The negative experiences were also perceived by FLNMs under the theme “The inability to do and desire to leave the unit,” which indicated that the wide range of role-related responsibilities of nurse manager could not be managed, as far as we know that to be a great nurse manager takes a high level of leadership and managerial skills. On the other hand, FLNMs' job and performance were greatly affected by work-related motivation. Thus, from these findings, there were some recommendations for FLNMs and hospital managers in this study, namely to re-analyze the process of recruitment and selection of FLNM, which is based on their competency along with working experience; evaluate the competence and performance of FLNMs frequently, and provide better performance appraisal system for work motivation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.