Investigation of the Control Process in Nursing Care Management: A Qualitative Study

Abstract

Aim

This study aimed to determine how nurse managers managed nursing care control processes at hospitals.

Method

This study was conducted using a qualitative method in a phenomenological research design. The study sample consisted of nurse managers and nurses from a research and application hospital at a state university, a state hospital, and a private hospital affiliated with the Ministry of Health. The maximum variation sampling method was used because it provided the maximum potential of reflecting the diversity of the participants that formed the groups. A total of 60 nurses, including 10 executives and 10 clinical nurses from each institution, were interviewed. The data were obtained using semi structured in-depth interview questions and analyzed using a thematic analysis method.

Results

Each hospital’s nursing care controlling system was hierarchically structured. However, the control process, assessment criteria, and management culture differed among the hospitals. The top and midlevel executives’ control methods were similar. They conducted control using data flow such as patient information and indicators. However, junior executives conducted observation-based control. In addition, nursing care executives did the planning in consideration of the subordinates’ lack of experience, presence of a problematic worker, and process development studies in the determination of control intervals.

Conclusion

There were differences in the operation of the control processes based on the organizational structure of the hospitals. The controlling systems at the university hospital and state hospital studied were not effectively planned, but they maintained ordinary control.

INTRODUCTION

The concept of management has been used since the first time managers and managees emerged, and it has developed along with the pace of development and changes of human history. Evidently, the definitions of management concepts are given under the effect of historical, geographical, and cultural contexts. When people talk about management, it is sometimes evaluated as a process, while it is sometimes considered as bodies, people, groups, or group of information (Lamond, 2005; Mahajan, 2009). Another way of looking at management is to approach it as a process with management functions. According to this approach, management can be defined as the process of integrating sources with planning, organizing, directing, and controlling activities and coordinating them (Çolakoğlu, 2012).

Each manager from every level has the responsibility of supervision. Organizations consist of hierarchical levels, and every level is supervised by the upper one. Since it can be problematic if senior managers supervise all the staff, the manager at each level should define the limits of their management domain. Managers should have clear management areas in their organizations, and employees should also be informed about them. A manager can directly perform their supervisory roles, while they can also assign it to their trustworthy junior administrative officers by delegating powers. At this point, it is important to authorize this delegated person and train them for this role (Cambalikova & Misun, 2017; Whitebead, Weiss, Tappen, 2010).

Nursing service management provides the nursing resources function in a coordinated and integrated way by applying a management process to develop the purposes of nursing care and nursing services (Huber, 2014). In the control process, in the last stage of the management process, decisions are taken by providing data again for the planning stage as a result of observations and evaluations and the process starts all over again (Koçel, 2013). The control process is a function of evaluating whether the instructions given or principles determined are in line with the plans or not (Çolakoğlu, 2012). The control process is structured with the stages subsequent to each one. These stages define the control standards aimed at the targets and purposes at the planning stage, qualitatively and quantitatively measuring the activities, comparing the measured results with standards, and executing decision-making to decide whether there will be a change or not (Can, Azizoğlu & Aydın, 2011, Robbins & Coulter, 2013). Nursing service managers use the help of control outcomes for several managerial activities, e.g., improve the quality of nursing services, monitor the compliance with defined care standards, observe care-related quality indicators, contribute toward the personal and professional development of employees, and find solutions to determined problems (Say, 2013; Sullivan & Phillip, 2013). Nursing service managers need to monitor patient care and analyze the differences between what is planned and what is applied, as well as make changes when necessary; further, the control processes should be continuous.

When the literature was examined, few studies related to the control of management processes involving nursing services were found. Therefore, this study was conducted to determine how the control of nursing services in hospitals can be performed by managers.

Research Questions

1. How the control process is carried out in nursing services?

2. In the control process, what is the role of nurse managers at all the managerial stages?

3. What is the content of the control process?

METHOD

Study Design

Since the control process in nursing services for managers and employees has not been sufficiently examined before, this research was made in a phenomenological pattern that facilitated the collection of multidimensional qualitative data.

Sample

The universe of the research consists of nurse managers and clinic nurses in a research and application hospital working under a public university, a public hospital under the Ministry of Health, and an accredited private hospital. Maximum diversity sampling from purposive sampling was chosen in order to obtain the maximum reflection of the individuals’ diversity that can be a party to this study. For this reason, three different institutions were sampled, namely, nurse managers working in different managerial positions (as hospital head nurse/nursing services manager/nursing services deputy manager, supervisor nurse, and head of service); having different experience and training; and nurses with different descriptive characteristics, such as education level, unit they worked in, and professional experience.

In the qualitative research, achieving data fullness is stated as the basic criterion in sampling selection (Kuş, 2009). In this study, interviews were planned with 20 nurses, 10 managers, and 10 clinical nurses from each institution, and the study was concluded after a total of 60 interviews.

Data Collection

Preparation

In order to obtain the research data, the literature was reviewed and semistructured interview questions were formulated. Before starting the interviews with the participants, the questions were tested by conducting an interview process with a participant to improve the interviewing skills of the researcher.

A candidate pool was created from three different institutions, namely, nurse managers working in different managerial positions (as hospital head nurse/nursing services manager/nursing services deputy manager, supervisor nurse, head of service); having different experience and training; and nurses with different descriptive characteristics, such as education level, unit they work, and professional experience. Thereafter, with the help of volunteers from these groups, in-depth interviews were conducted.

In-Depth Interview Process

Interviews were conducted in the managers’ rooms, meeting rooms, or nurse’s rooms according to the preferences of the participants. After meeting with the participants in the environment prepared for the interview, the purpose of the interview was initially explained. Information about the duration of the interview, reason for the sound recording, and confidentiality of all the data obtained from the interview were orally given to the participant and in written form through the volunteer participant information form. During the interviews with the voice recorder, participants were reminded that they could switch off the device at any time. During all the interviews, attention was paid to the participants’ reactions and behaviors, breaks given in the interview, and notes about the environment to be recorded in the interview guide. Interview times ranged from 30 to 60 min.

Statistical Analysis

The data were evaluated with the thematic analysis method. Every interview was recorded with a voice recorder, and the interviewers transcribed them on a computer. In the first stage, the following were conducted:

• Participants’ written version of expressions were read,

• It was tried to define the meaning of these expressions,

• The significant expressions were defined with names,

• Similar codes in different sections were brought together,

• Similarities and differences between the codes were evaluated and themes emerged.

The institutions, management positions, and ages of the participants were written at the end of the statements.

• A research and application hospital affiliated to the state university (UH), a public hospital affiliated to the Ministry of Health (PH), and an accredited private hospital (Pri.H).

• Head nurse/nursing services manager: senior level manager (SLM); head nurse/nursing service deputy manager and observer nurse: medium level manager (MLM); and service responsible nurse: junior manager (JM).

• Service nurse (SN).

Ethical Considerations

The research data were collected after the approval of the ethics committee of the Human Research Ethics Committee of Abant İzzet Baysal University Social Sciences (approval date: January 29, 2015; protocol no.: 2015/02) and permissions from the three institutions where the research was conducted. In addition, a voluntary participant information form was read to all the participants who accepted to participate in the study and their written consents were obtained.

RESULTS

When the results of the in-depth individual interviews of managers and nurses regarding the functioning of the control process of nursing services in hospitals were thematically evaluated, it was evident that they were gathered under six subthemes (Figure 1).

Figure 1.

Subthemes of the functioning of the control process of nursing services in hospitals

• Subtheme: Control process culture.

• Subtheme: Hierarchal structure.

• Subtheme: Control time planning.

• Subtheme: Control time intervals.

• Subtheme: Control criteria.

• Subtheme: Control process nurse manager methods.

In the control process culture subtheme

“I was appointed to have more control; we control nurses and we control the cleaning staff and even data staff…” “I am confused about whom to control; I keep controlling on and on…” (MLM, UH).

“In our organization, the control process is very complicated; everyone seems to see themselves having control over the nursing services; this can be the supervisor, hospital director, head manager, or hospital head physician.” (SN, UH).

“Nursing services work together with quality, and vice versa; nursing services are evaluated with these self-assessments.” (SN, PH).

“Control is actually not judging but supportive, e.g., saying things like thank you, it seems you did hard work, or asking if you need anything.” (JM, Pri.H).

In the hierarchal structure subtheme

“Our director does not come here and make patient visits; this is not the method. He/she comes periodically, asks if we are doing okay, asks if we have any complaints, and if there is anything that he/she can do; it is more like a social visit. Generally, patient visits are conducted by the responsible nurses with staff. Vice directors get information about the patients.” (JM, Pri.H).

“Me and my colleagues follow the areas in which the nurses work daily, such as the doctors do visits, we control them, we have daily visits. We have friends here working as supervisor nurses and they take supervisory nurse shifts until midnight in all the areas where nursing services are provided, and we have observer nurses working after the daily shifts and at weekends, making follow-ups and controls on our behalf.” (SLM, PH).

Control time planning subtheme

“...I cannot say there is periodic patient control.” (SLM, UH).

“Me and my colleagues follow the areas in which the nurses work daily, such as the doctors do visits, we control them, we have daily visits.” (SLM, PH).

“Today, we checked the files; tomorrow, I will check the patient IDs, definitive wristbands are on their wrists or not; I randomly enter patient rooms and check if they are clean.” (MLM, PH).

“Nursing care service managers come daily and visit everyone.” (SN, Pri.H).

Control time intervals subtheme

“Some nurses in charge are not sufficiently experienced yet; unfortunately, we had to make some of them responsible because of which their inexperience is reflected in clinic and they need continuous control.” (MLM, UH).

“To be honest, particularly when we detect problematic staff and if we see them while they are doing something wrong or if we are aware of something like that, we observe them while being careful not to offend them. Sometimes, I control new staff more often.” (MLM, PH).

“It depends on the problem or the process you want to improve. However, we visit everywhere equally with routine controls or we control. Controls may change depending on the authority of that department’s responsible person. Some people in charge are new and inexperienced; they only learn stuff when we spend more time there, while we do the opposite if there are people with a lot experience; we say ‘Ayse, or Fatma, or who is in charge, know how to handle that place’ and we do not recheck the same issue repeatedly in that case.” (MLM, Pri.H).

In the subtheme of control criteria

“We don’t have any written one, but we know it as the daily routine. All of us know what we need to do; it’s the same standard.” (JM, Pri.H).

“In any way, there can be a verbal warning before or warning that ‘I will control you on that particular issue’…” (SN, UH).

“Not written, but there are certain rules. Each patient has to get body care, linens must be changed, or mouth care is provided, but these things are not written. Our nurse in charge checks if they are done and controls our papers.” (SN, PH).

The subtheme of the nurse managers’ methods during the control process was analyzed based on the manager levels (Table 1)

Table 1.

Methods used by nurse managers during the control process

	Senior managers	Medium level managers	Junior managers
Monitoring administrative / hierarchical report flow	V	V
Monitoring patient and employee outcomes	V	V
Examination of patient registration system	V	V	V
Monitoring of Employees / Subordinates	V	V	V
Physical structure of clinics and supervision of support services	V	V	V
Bedside visits		V	V
Interview with patients		V	V
Monitoring of patient deliveries			V
Examination of maintenance plans			V
Observing patient care			V
Material and inventory management			V

When the methods used by the nurse managers in the control process were examined, it was determined that the senior and midlevel managers used similar methods (Table 1).

“My control method is more one-on-one; for example, I do not take a file and go to control the junior staff, but I ask for the reports from them. Each department has their report for each shift and they send the situation of the patients in their sections in each shift via e-mails, e.g., their diets, their day of hospitalization, addiction, or their doctor…I do not visit all the patients in the morning or all the floors, but I assess the reports. If I see any conflict, I get the report of the supervisor. But I do my control online, most of the times. I read reports…our nurse for the patient care development and training reports to me once a week. We also have monthly reports and three-month reports from our nurses in charge.” (SLM, Pri.H).

“We observe many indicators from the departments…I see indicator results as a big finding for us…indicators can tell everything; we do not need to go and look at the patient if good care is provided to him/her or not.” (SLM, Pri.H).

“I take the file before I enter a patient’s room and I check everything, such as entrance form, informed consent form, signature of the nurse giving information, if the patient has come with wheelchair or walking or elevator, or anything that is not checked in the file.” (SLM, PH).

“The first thing I check, honestly, is the cleaning; when you enter, you must feel the floor to be comfortable and even before anyone says anything, it must speak for itself. This is why I first check cleanliness and order, if people coming and going look shining to you; it means that the service is going well.” (MLM, PH).

“I pay visits to the floors more like a social visit, to the patients or to our colleagues there, to see what they are doing. I ask as to who has the most responsibility to introduce their patients, and they do it; at that time, I also know about the nurse regarding their command on their job and what we do. I learn and see these from the nurses.” (SLM, Pri.H).

“Generally, we go to the patient’s room with their nurse; sometimes, if the responsible person is available, he/she joins, too. This is not the standard. In our file controls, the person in charge, the nurse, and I are together. We look at the diagnosis and check if necessary care was given according to the diagnosis. I particularly check that.” (MLM, Pri.H).

When the methods used by junior managers in the control process are evaluated, it can be said that since they share first-degree responsibility of patient care control, they adopted a close-observation-based control approach.

“As our daily routine, in our morning visits, we check the files first different than that on the other floors…when we see the patient and ask if they need anything, I also check their intravenous fluid, etc., and I state that if there is anything lacking.” (JM, Pri.H).

“I check if our backside notes are in an order or not or if he/she checks on their own initiative when necessary.” (JM, UH).

“I check the files, I code my name if I control the files so that the manager sees that I checked it and then I deliver the file with self-confidence.” (JM, PH).

“Apart from that, I visit the service every morning and check the cleaning and ask certain questions regarding the patients because it is important to have satisfied patients in terms of cleaning. We have some problems with the meals given to patients; therefore, we ask such questions whether the meal was warm, good, and are they happy or not.” (JM, PH).

“We have competence tests every year; for example, we have to start now and evaluate people’s competence in a given period of time.” (JM, Pri.H).

“I do my controls daily: I start with takeover, and I check if there is anything missing or faulty or any problems with the patients like lack of certain medicines. Then, we start with the delivery of the patient to the person in charge.” (JM, PH).

DISCUSSION

Control process culture subtheme consists of the evaluation of nursing services control process of three hospitals via participant expressions

When the findings were examined, it was determined that there was an unregulated control process in the university hospital and the nursing service managers supervised different service groups (such as cleaning personnel and secretary) and considered control as an obligation. In addition, the nurses stated that they were uncomfortable with the control exercised by different occupational groups such as hospital director and chief physician and controls that are not related to patient care by nursing service managers; they defined such control as “complicated.” This problem can be attributed to the understanding inadequacy of professional management in the university hospital. In their study, Can and İbicioğlu (2008) stated that they evaluated university hospitals in Turkey in terms of management; they found that the most important problem in these hospitals was the “management problem,” that is, the lack of a professional management approach.

It was determined that in a public hospital, the perception of quality controls of the managers and nurses was based on the fact that the control process was built on quality processes. This control structure can be considered as a process in which the quality-weighted control contents also direct the mid- and junior level managers by the senior management because the quality scoring process of the hospital is used to evaluate the performance of the senior management. In the private hospital, the managers stated that the control process was transparent; it had become a part of the working life and was adopted as a whole by their organization. Similarly, nurses generally perceived the control process as positive. The reason behind their positive approach can be that the managers and employees stated similar and common purposes for the control processes, and the results were shared with the employees; these results were used for service development, and the adopted control process was somewhat institutional and had a transparent structure. In addition, the fact that the private hospital was an accredited hospital and that different quality processes were carried out in the institution can be interpreted as being effective in handling the administrative processes more professionally. In their study, Yalçın and Baykal (2012) stated that the quality of work in accredited hospitals as well as the organizational culture for bringing participants and suggestions were dominant.

In the hierarchal structure subtheme

From the statements of the participants in all the institutions where the research was conducted, it was evident that the hierarchical order is used in exercising managerial control, such that each senior controls their juniors in the management field and each level manager plays different roles in these controls. In the literature, it has been stated that the control process is a senior management activity and the managers have controlling roles in different ways (Koçel, 2013; Huber, 2014). In particular, depending on the fact that public hospitals adopt the bureaucratic management approach in the classical management theory, it can be considered that it is expected to have a function in accordance with the hierarchical structure.

Control time planning subtheme

Evidently, private and public hospitals carry out the control more regularly, but the university hospital performs control with very long intervals and irregular inspections. Henry Fayol, who put forward the management process approach, stated that controls can only be effective if they are done within a reasonable time (Çolakoğlu, 2012). In particular, the insufficiency of control periods in university hospitals can be attributed to the absence of a structured control process and the shifting in management activities by senior and midlevel managers out of nursing services.

Control time intervals subtheme

It was reported that the frequency of controls by nursing service managers increased with the inexperience of subordinates, presence of problematic employees, and process development studies. The reason for this increase is that managers think that inexperience, particularly in subordinates, may increase errors and conflicts with problematic personnel, and such problems are likely to occur in the change processes. With this increase, it can be thought that managers create risk management. In the thesis study by Çiftçibaşı (2011), it was stated that nurse managers increased their control over their problematic employees.

In the subtheme of control criteria

There were no control criteria in all the three hospitals. Although it was stated that the protocols and standards were used as the basis for control in the private hospital, it did not have a written inspection form or document. The lack of specific control criteria in the control process can be attributed to the lack of clarification of this process.

In the subtheme of the nurse managers’ methods during the control process

When the methods used by the nurse managers in the control process were examined, it was determined that the senior and midlevel managers used similar methods. Rather than observing the units and patients, the senior managers observed the hierarchical report flow online. Some of these reports were supervisory nurse reports, shift reports, quarterly or annual reports, and event notification reports. In particular, the reporting process at the private hospital varied as much as possible and the content of the report highly reflected patient care, while the other two hospital patient care reports are less expressed by senior managers.

Senior managers in the private hospital stated that they particularly observed patient and employee outcomes (indicator). In this hospital, a midlevel manager was appointed for monitoring patient outcomes and formulating standards. In the public hospital, certain outcomes were mentioned, but at the university hospital, this was not mentioned for the control process. In the literature, it has been mentioned that scientific management understanding is based on qualitative and quantitative data and these data are important to be used at every stage of the management process for the managers’ decision-making roles (Say, 2013). Twigg, Pugh, Gelder and Myers (2016) stated that the follow-up of patient outcomes forms the guiding data for managers in monitoring patient safety. It can be thought that the monitoring of patient and employee outcomes in the control process is related to the accreditation of a private hospital and the professional approach of the management in monitoring the inputs and outputs.

A senior manager at the public hospital stated that he/she evaluated the patient registry process and controlled patient files and nurse interventions for his/her control process. On the other hand, the private hospital manager stated that he/she did the file check when he/she started working, but stopped doing that after getting reactions from the nurses. Midlevel managers at the public hospital and university hospital stated that they observed the patient registry process and talked about the results with the employees. Evidently, the senior managers’ and midlevel managers’ examinations of the patient registry process result from their close-up control approach toward the process.

The control of the physical structure and support services of the clinics were specified by the top managers of the public and university hospitals. In particular, a very large frame was drawn by the state hospital administrator ranging from toilet paper to a broken door handle. Midlevel managers also mentioned the same supervisory role in these two hospitals. The control role of nurse service managers at the public hospital may be because of senior managers’ working under healthcare services directorate and the manager’s job definition covers services out of nursing services, such as cleaning to food services. In the university hospital, although it is not a part of their job descriptions in this context, it is seen that senior and midlevel managers perform these roles. This can be attributed to the expectations of the senior management of the hospital and that the senior management of nursing services are not aware of their own job descriptions. In addition, the shifts of duties of the senior management of nursing services in setting up administrative processes in two public hospitals can be related to their activities related to the chief physician in the organization chart, while nursing services in the private hospital are at the same level as the medical services.

The senior managers of private and public hospitals stated that they infrequently monitor the employees in clinics. On the other hand, private hospital managers define these clinical visits as social visits. Observation of their subordinates by senior managers is difficult, but when they closely observe them as well as their rendered services, the senior managers understand their subordinates better and the employees can further know their senior managers.

Evidently, the midlevel managers of the three institutions comprehensively monitor the employees in the control processes and evaluate the operations and practices performed. While more strategic tasks are expected from senior managers, midlevel managers are expected to ensure smoother operations and that the processes continue without interruption (Koçel, 2013). Therefore, this managerial group can be interpreted as observing the employees in greater detail.

Bedside visits are a type of control preferred by midlevel managers. It has been stated that during this type of control, clinical nurses primarily provide information about the care of patients and accompany the nurses in charge during the visit. In other controls, the managers indirectly observe the employees, while in this control method, the manager and nurse directly interface with each other. The data that the manager obtains from here is unfiltered direct data and allows reading between the lines (Robbins & Coulter, 2013). Further, it should be considered that managers prefer this method to directly evaluate patient care. It should also be noted that the continuation of direct confrontation between the manager and employee during the control may lead to conflicts.

No senior managers mentioned that they met with the patients during the control process, while only one of the midlevel managers stated that they did this. In studies conducted on this subject, it was observed that senior managers generally evaluated the generic patient profile by conducting patient satisfaction studies (Özer & Çakıl, 2007; Yoder-Wise, 2014). The manager’s interview with the patients during the control process can be interpreted as their wish to directly obtain information. In the literature, a direct interview is one of the methods used by the managers to obtain information during the control. A direct interview is considered to be important for obtaining direct and sincere information (Robbins & Coulter, 2013). The private hospital manager stated that he had formed a team to receive patient opinions and evaluated these reports.

When the methods used by junior managers in the control process are evaluated, it can be said that since they share first-degree responsibility of patient care control, they adopted a close-observation-based control approach.

When the control methods were examined, the junior managers of the three hospitals said that they checked the patient records; the private hospital manager stated that he/she makes it a point to follow patient care; the university hospital managers said that they do it to monitor the nurses; and the one(s) in the public hospital said that they do it to give certain explanations to their upper managers. This difference can be explained with the difference in the top management’s approach. Moreover, the control role of the patient care during primary care belongs to junior nurse managers. The reports indicating every detail about what is done during patient care involve the patient files and care plans; moreover, these files are also legally important. Junior managers are thought to give importance to file controls for this particular reason. The important detail here is that the things on the file should be done and the ones done should be written.

The majority of junior managers emphasized that they controlled the physical structure of the clinics and the functions of the supportive services. In their study on the business analysis with nurse managers’ observation, Harmancı et al. (2011) stated that when nurse managers spent time on functions, they mainly spent time on supportive services as the third one on the list. The reason for this may be the expectations of senior managers and the interruptions of junior managers to the entire operation of the service as the people responsible for the units.

The junior managers of each institution stated that they control the employees by monitoring their own managers. However, private hospital managers regularly monitor their employees once a year in the form of competency monitoring. It can be said that this type of control is applied to monitor patient care practices and intervention by the administrator, if necessary. In the literature, the importance of good technical skills of the junior managers and the necessity of directing the employees in this regard are emphasized (Huber, 2014; Koçel, 2013).

The junior managers from the public and university hospitals emphasized that their daily controls start with patient takeover. In the private hospital, on the other hand, the working hours of the nurses started even before the managers; therefore, the managers could not participate in the takeover and delivery times. One of the easiest ways for the junior managers to assess the continuing of service is patient takeover times. Some junior managers of the private and public hospitals stated that they had interviews with the patients as a part of their controlling roles. They expressed that they indirectly evaluated the employees in this way. Although there was no direct study in the literature about this, it was important that junior managers, who play an important role in the control of patient care, evaluated the opinions of the patient groups receiving services.

Study Limitations

• - The qualitative data obtained reflect the participants’ perspectives. Therefore, it is not possible to make a generalization.

• - In national and international literature, there are a small number of publications covering the control processes of nursing services. Therefore, the study could be discussed with a limited portion of the literature.

CONCLUSION AND RECOMMENDATIONS

In this study, it was observed that there were functional differences between institutions in terms of control process operations; further, in university and public hospitals, the control processes are not sufficiently planned and they work with the classical control approach. In control process planning, it has been determined that there is hierarchal planning. Moreover, the control time intervals are defined according to the experience of the people responsible for the service, number of problematic staff, and processes. Evidently, the control methods of the senior management and midlevel managers are similar: they conduct controls with data flow (e.g., patient file information and indicators), while the junior level managers performed controls using observational methods. Nursing service managers stated that they had to spend time on other support services (such as cleaning) during the control processes.

While every stage of the management process is important for nursing service managers, proper planning and maintenance of the control process should be a priority for formulating an effective management approach. In future studies, it will be useful to examine the control processes of nurse managers in larger sample groups.