Improving Nurse Managers’ Competencies: A Systematic Review

Priscylia Maria Sandehang

and Muthmainnah

Fakultas Ilmu Keperawatan, Universitas Pelita Harapan, Karawaci, Tangerang, Indonesia

Universitas Andalas, Kampus Limau Manis, Padang, Sumatera Barat, Indonesia

Keywords: Competence, Healthcare Service, Nursing Care, Nurse Manager, Nurses’ Role, Review Literature.

Abstract: Nurse managers’ competencies greatly influence the quality of services and nursing care. Consequently, the

aim of this study is to identify and to define the competencies of nurses working in management roles in the

healthcare system so they can undertake their roles effectively. This research used a systematic literature

review design and analysed 40 articles. Twenty-five studies were from Europe and 15 from outside Europe.

The literature was limited to articles published in English between November 2003 and 2018 that were

searched using these keywords: nurse manager, competence, nurses, career plan, improving, assessment

tools, clinical competence, professional competence. In this study, six dimensions of nursing managers’

competencies emerged: sociodemographics, technical, networking, administrative, staff development, and

legal and ethical. This literature review provided scientific evidence for decision makers to consider the

implementation of a nurse manager competency system, including leadership development, the redesigning

of managers’ role, building networks, clinical skills and climbing the career ladder. Future studies are

suggested to investigate the usefulness of the competency model for assessing nursing managers’ readiness

to between job applicants, implement continuing education programmes for nurse managers, and develop

and plan their careers.

1 INTRODUCTION

Competence is a critical attribute for safe, ethical,

high-quality care (Kendall, Gallagher & Blegen,

2009). It is essential to one’s contribution in

ensuring healthcare delivery (Flinkman & Salanterä

2015). Competence development has been described

as a process that occurs over time (Benner, 2001;

Keane, Lincoln, & Smith, 2012). Hence, the process

of forming competence, especially for nurses, is not

done briefly. There is a sustainable process through

education, clinical experience and self-capacity

building to reach comprehensive competence.

Nowadays, globalisation and science-tech

developments are causing huge changes in the

world. Nursing services is an integrative part which

is not separate from these changing needs. Thus, this

field must undergo improvement and innovation so

it does not get left behind. Based on that perspective,

nursing organisations must change and review their

management models to improve the quality of their

service.

The nurse manager has played an important role

in health services, especially in the hospital sphere,

since this professional is responsible for managing

nursing services and for taking measures that include

administration, the delivery of care and teaching–

research. The work requirements of nurse managers

include nursing management, knowledge and

interaction with the entire organisational

environment to contribute to an institution’s success

(Furukawa & Cunha 2011).

Generally, the ability of leaders in health services

consists of communication, creating a vision,

managing, managing strategies and motivating

others, engaging in openness and being

approachable, making decisions and becoming role

models, knowing their roles, becoming experts and

solving problems. However, the definition of

competencies has become complex, and there is no

consensus among scholars on nurse manager

competencies (Kantanen, Kaunonen, Helminen, &

Suominen, 2015; Pihlainen, 2016). Moreover, there

are various models of nurse manager competency –

and in several countries, the nurse manager is not

even legally recognised.

Thus, it has become a challenge for nurses and

academicians working in nursing to think seriously

Sandehang, P. and Muthmainnah, .

Improving Nurse Managers’ Competencies: A Systematic Review.

DOI: 10.5220/0008201300570066

In Proceedings of the 1st International Conference of Indonesian National Nurses Association (ICINNA 2018), pages 57-66

ISBN: 978-989-758-406-0

about and formulate the vital aspects of nurse

managers’ competency. Chase (1994, 2010)

developed a Nurse Manager Competencies Model

that classifies nurse manager competencies into five

main categories: human resource skills, technical

skills, leadership skills, financial management

conceptual skills. The key competencies synthesised

by Pihlainen, Kivinen and Lammintakanen (2015)

from Chase (2010) found the highest self-reported

nurse manager competency ratings included human

resource management and leadership. The lowest

self-reported nurse manager competencies involved

conceptual skills and knowledge. Perhaps critical

thinking and problem analysis are not yet entrenched

in the nursing profession.

Although there were various literature about

nursing competencies, but there were still lack of

finding about main dimension of nurse manager in

all healtcare setting. This, coupled with a lack of

motivation to learn and understand caring concepts,

are essential issues for the identity of the nurse

manager competencies Furthermore, the existing

studies of nurse manager competencies have

analysed only the proficiency level in competencies

of nurse managers working in hospitals and

neglected the question of why nurse managers differ

from each other regarding their management

capacity. So this study aims to close this research

gap by syntesized the main competencies of nurse

manager.

2 METHOD

A systematic literature review was conducted for

five months. The researchers used the systematic

review for identifying studies to describe diverse

types of nurse manager competencies in a clinical

setting during a certain time period. This paper

focuses on a competence-based approach for leaders

and managers, instead of merely the profession-

centred view of point, even though the profession-

centred approach dominates previous studies.

Searches have probed systematic reviews

published in the journal. A review of literature

published over the past 15 years uses databases:

PubMed, CINAHL, PsycINFO, Scopus, Proquest

and EBSCO. The search period spanned 2003 and

2018 because there are dramatically increasing of

the amount of the literature regarding the

competence-based approach to management and

leadership during this period.

The literature was searched using these

keywords: nurse manager, competence, nurses,

career plan, improving, assessment tools, clinical

competence, professional competence. These words

were searched for in combination and individually.

The inclusion criteria for the articles were as

follows: (1) full paper was publication in English;

(2) focus on a nurse manager; (3) focus on a

competence and its predictors or determinants, both

in all research methods of literature reviews; and (4)

a full-text paper. The criteria for excluding articles

were as follows: (1) the study was not published as a

full paper, (2) lack of reliable or valid testing and (3)

publication more than 15 years according the

COSMIN checklist (see figure 1). After evaluating

studies with relevant titles and abstracts, the

researchers identified 40 relevant articles targeting

competence and nurse managers. The metodological

quality of each study were review. Both of authors

(PMS, M) directly filters the titles, abstracts and

complete and relevant articles. Then, the researchers

independently review each 20 articles and consensus

was reached through discussion.

3 RESULT

3.1 Study Characteristics

The systematic review involved 40 studies, which

were mainly quantitative and conducted in

municipal care, hospitals and all healthcare settings.

All level of competence were analysed in all studies.

Figure 1 explains the steps according to which

databases were searched.

Figure 1: Diagram of database search.

ICINNA 2018 - The 1st International Conference of Indonesian National Nurses Association

3.2 Study Findings

The findings of this study are summarised in Table 1

in the Table 1 appendix that was extracted from 40

publication printed from 2003 from 2018. In this

study, six dimensions of nursing manager

competencies emerged: sociodemographics,

technical, networking, administrative, developing

staff and legal ethics. Each dimension consisted of a

nursing manager’s explanation of a role concerning

related sections.

Sociodemographics. The aspect of

sociodemographics aligned with nurse manager

competence consists of several aspect such as: age,

higher education, the duration of one’s work

experience, employment status and participation in

educational programmes.

Technical. The dimension concerning technical skill

includes the planning and delivery of care,

therapeutic intervention, ensuring the quality of

nursing care, modifying care plans according to

individual needs, integration of nursing sciences, IT

development and current nursing or healthcare

research, and developing effective communication.

Networking. Nurse managers must have networking

skills, such as building and managing relationships,

interprofessional collaboration, involving

stakeholders and community.

Administrative. The next most important

competence of nursing managers is administrative

skill, which includes the ability to manage financial

aspects of the job, allocating and using resources

effectively, ensuring cost-effective services and

controlling documentation.

Developing staff. The nurse manager must support

and develop the nursing staff, providing supervision

and coaching for staff, inspiring and motivating,

team building and teamwork, knowing employees’

needs, empowering staff, managing conflict,

providing fair rewards and punishments for staff and

arranging the Contionuing Professional

Development (CPD) for nursing staff.

Legal and ethical. The nurse manager must display

competence with laws and ethics to protect nursing

services and nursing staff and to safely serve

patients. The ability to display legal and ethical

competence, such as in decision making, is guided

by ethical values, ensuring patient and staff rights,

understanding the legal aspect of nursing services,

maintaining a nursing code of ethics and staying

current with nursing and healthcare policies.

4 DISCUSSION

Competence is determined by one’s qualifications,

education, skilfulness and experience. In addition, it

is judged by a group of people, including colleagues

who are specialists or competent in certain practices

(Jennings, Mutsch & Schleman 2009). This process

includes the determination of clinical competence,

whereby nurses are considered competent (Petri &

Govern, 2013). Competence is the ability to work

properly, so that it is known as the main component

of professional standards. Competence is considered

the biggest contributor to differentiating managerial

effectiveness as seen from expertise, habits and

attitudes (McCarthy & Fitzpatrick 2009).

In addition, the competency of nurse managers

must be assessed continuously to ensure safe within

the scope of the competent delivery of nursing care.

Robust and reliable assessment methods are

important for assessment to be more objective.

Assessment tools represent a particular

conceptualisation of competence, both in the nature

and range of competences presented and the

language used for assessment (Watson et al. 2002).

Competency-based career mapping supports health

workers’ collaborations that can increase patients’

safety, ease access and coordinate effective health

services, optimise the health of health service

providers, share knowledge and skills, as well as

escalate roles and communications (Burton 2015).

Three central ideas demonstrate the reasons for

differences among nurse managers according to

nurse manager competencies: job security, degree of

autonomy and executive power in different

healthcare organisations (Erjavec & Starc 2017).

Competencies are interconnected with education and

formal and informal training. Nurses’ competencies

merit a clear understanding based on the stages.

Additionally, higher education is conducted to

improve the profession and ensure quality nursing

cares.

Human Resources management executes

recruitment and maintains the retention of skilful

employees so hospitals can provide quality services

(Porkodi & Haque 2012). Organisations can reach

competitive superiority through their talented, skilful

and experienced staff. One way to ensure nurses are

working at their maximum performance in working

is through the career stages (Shammot 2014).

The sociodemographic dimension, which

consists of variables such as older age, higher

education and permanent employment were

associated with higher competence for a nurse

manager (Flinkman et al. 2016; Wangensteen et al.

Improving Nurse Managers’ Competencies: A Systematic Review

2015; Numminen et al. 2017). It is conceivable that

a nurse manager who adapts maturely in various

situations can think critically, a skill inculcated by

education level, and is aware of the need to keep

improving their ability and be loyal to the

organisation. In addition, there is a correlation

between higher self-assessed competence and the

length of work experience (Numminen et al. 2017;

Flinkman et al. 2016). Nurse managers play vital

roles in an organisation. They must ensure nursing

delivery and care are implemented according the

rules. They must also possess a science-based

education and a minimum competency certificate

that will guarantee the community of their

proficiency (Kerfoot, 2012). Nurse managers require

additional competencies because of the uniqueness

of the healthcare environment and conceptual

philosophy, since nurses have a social responsibility

for the health of individuals, families and

communities.

Technical skills are the most important for a

manager to possess, especially for the first-line

manager. First-line managers (FLMs) must have a

comprehensive understanding of a change’s

implementation so they can facilitate it in their areas

of responsibility (Kumah et al. 2016). Even in the

research conducted by Kumah et al. (2016), as a

group, nurse managers from specific healthcare

organisations felt most competent in terms of

technical healthcare skills.

The dimensions of technical skill include the

planning and delivery of care, therapeutic

intervention, ensuring the quality of nursing care,

modifying a care plan according to individual needs,

integration between nursing science, IT development

and current nursing or healthcare research, and

developing effective communication. Rapid

innovations in science and technology can lead to

increased levels of concern in nurses about security

and safety of patient and nurse, as well as nurse

competency (Karami et al. 2017). Therefore, nurse

managers must be responsible for ensuring the

quality of nursing delivery care and services. In

addition, nurse managers at all levels are asked to

integrate concepts regarding current science and

technology developments into nursing practice.

Nurse manager roles requiring healthcare,

context-related competencies comprise social,

organisational, business and financial dimensions.

Within the operational category of competencies,

they identified technic, process, clinical and

development competencies to be a vocal point for

their managerial role. Communication skills were

described with diverse attributes such as: dialogue,

networking, giving a clear information, clarity of

written and oral fluency, facilitating discussion and

active listening (Furukawa & Cunha, 2011).

Additionally, communication skills work in

conjunction with the healthcare strategy, vision and

mission.

A study in the UK about the development of

nurse network managers found they support each

other, provide an environment that helps develop

ideas and solutions, communicate between members

with communication tools and face to face, and vote

to influence government policies and strategies

(Chapman, 2012). Research in Indonesia found data

that internal factors, namely, knowledge, skills,

values and external factors (organisational culture)

affect the leadership competencies of the head nurse

in a hospital. Cultural background in an organization

also depends on the nature and the culture of the size

and type of organization, the number of employees

and senior manager roles. Organizational culture

impacts on the effectiveness of nursing care

delivery. Culture is a set of shared mental

assumptions that guide the way we think, act, and

behave in the workplace. Those who do things in the

“proper” way will lead to the success of

competencies. Those who chose not to do things in

the proper way do not last long with an organization.

However, the organizational culture is closely

associated with senior managers. Every top manager

has different expressions and understandings in

influencing the culture of the organization.

Leadership competencies influence the motivation

and performance of nurses.

Healthcare institutions have two customers, that

is the internal customer and external customer.

Consequently, a healthcare institution must maintain

and develop its staff. The implication is that nurse

managers have the responsibility to build an

effective team, nurse, coach staff through changes,

problem solve and provide a reward system for

nurses. Nowadays, healthcare is facing the problem

in which nurses, especially newly graduated nurses,

feel fatigue, insecure and uncomfortable regarding

their daily routine as a nurse. Accordingly, the rate

of nurse turnover has increased, leading to negative

conditions for health organisations and eventually

harming nursing delivery care.

Nurse managers must also deal with

administration, such as finance and budgeting,

allocating and using resources effectively, ensuring

cost-effective services and controlling

documentation. They often learn experientially to

reach a blend of clinical and business management

capabilities, often with little to no training and many

ICINNA 2018 - The 1st International Conference of Indonesian National Nurses Association

other challenges encountered while on the job.

Having a clear understanding of the need to develop

these skills is critical when selecting managers.

However, it is more important when a nurse decide

to prepare themselves to be a nurse manager (Chase,

2010).

The important competence that nurse managers

must gain is managing ethical and legal issues. The

combination of the needs of patients, colleagues and

managers may lead to moral stress for nurse

managers. Reinforcing the skills of nurses,

especially their ethical competency, could be a

solution to reduce moral stress, as Kälvemark-

Sporrong et al. declared. In instances where unit

managers supported best practices, nurses also

experienced them as ethical practices. Above all, this

is important since nurses are more likely to leave

jobs because of moral stress, combined with lack of

managerial support when acting ethically.

5 CONCLUSIONS

A large collection of literature on the competence of

nurse managers was found in this search. The author

summarised the literature search that made a sincere

contribution to the improvement of nurse manager

competencies. In this study, six dimensions of

nursing manager competencies emerged:

sociodemographic, technical, networking,

administrative, staff development and legal-ethical.

The results highlighted that nurse manager have

to be more committed and more competent to their

organisations. However, it is necessary to conduct

more comprehensive studies for exploring the gaps

in the human resource management of healthcare in

different contexts and cultures, especially between

Western country (such as Europe and United State)

and Eastern country, such as Asia. It is been

important thing as cultural background determines

the competencies of nurse manager and profile of

the organization.

Also, future studies are suggested to investigate

the usefulness of the competency model for

assessing nursing managers’ readiness to between

job applicants, implement continuing education

programmes for nurse managers, and develop and

plan their careers.

ACKNOWLEDGEMENTS

Acknowledgement and high appreciation to the

editor and anonymous reviewers for their

constructive comments and recommendation.

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APPENDIX

Figure 1: Diagram of database search.

Author, year

Research

design

Competency define

(Flinkman et al.

2016)

Systematic

review

Ther are positive

correlation between:

age, higher

education, duration

of work experience,

employment status,

and participation in

educational

programmes with

competence.

(Yeon et al. 2017) Quantitative

The clinical

competence

dimensions were:

Scientific, technical,

ethical, aesthetic and

existential.

(Numminen et al.

2017)

Mixed Method

The 73‐item scale

consists of seven

categories, with

responses on a

visual analogy scale

format.

(Wong et al.

2013)

Qualitative

The major aspects

that inﬂuencing

nurses’ decisions to

pursue management

roles are:

‐ personal

demographic (age,

education, clinical

experience and

life

circumstances),

‐ personal

disposition

(intrinsic rewards,

professional

commitment and

leadership skills)

and

‐ situation

(opportunities of

leadership

development,

perception of

manager role

perceptions and

the presence of

mentors).

(Efendi et al.

2018)

Qualitative

Nurses have to

emphasize nursing

as a thinking

profession and

highlight clinical

knowledge and

Author, year

Research

design

Competency define

competence. Nurses

need to affirm their

professional identify

that can be

demonstrated in a

number of ways.

Nursing has to be

view their work as a

career and have to

be proud to attach

the tiltle “nurse” to

their last name.

(Kumah et al.

2016)

Cross sectional

survey

Five important

competencies were

considered by the

first line managers

were effective

communication,

technical

competencies,

ability to organise

staff through

change, skill of

conflict

management,

problem solving

skills, effective team

building and

leadership skill.

(Jacob et al. 2008) Quantitative

Six aspects for

effective workplace

that were: job

autonomy, learning

opportunities,

supervisor support,

coworker team

support,

involvement in

decision making,

and flexibility of

workplace.

(Erjavec & Starc

2017)

An online

survey and in-

depth

interviews

The competencies of

nurse manager are:

technical, human

resources,

conceptual,

leadership and

financial.

(Karami et al.

2017)

Descriptive

analytic study

The competency of

nurses in various

clinical positions

leadership (9 items),

were clinical care

(10 items),

interpersonal

relationships (8

items), professional

development (6

items), legal-ethical

practice (8 items),

teaching-coaching

(6 items) and

research aptitude-

critical thinking (8

items).

Improving Nurse Managers’ Competencies: A Systematic Review

Author, year

Research

design

Competency define

(Gunawan et al.

2018)

literature review

Antecedents to

CBHRM in nursing

include

organizational

factors (such as:

organizational size,

culture, the nature of

human resource

(HR) department,

type of organization,

and the number of

employee),

individual factors (

such as

competencies of

human resource

manager, role of top

managers, intention,

and characteristics),

and human

resources policy.

(Gunawan &

Aungsuroch 2017)

Literature

review

The attributes of

managerial

competence include

developing self,

management

function (POSAC),

leading, managing

legal and ethical

issues, and

delivering health

care. Antecedents to

managerial

competence are

internal and external

factors.

(Kvas et al. 2013) Quantitative

The norms for the

competency profiles

for three leadership

levels in nursing

were flexibility at

work, creativity,

leadership,

organizational

climate,

networking&influen

cing, realization

skills, ethics,

interprofessional

relationship, positive

attitude towards

knowledge and

education

(Wangensteen et

al. 2015)

A cross-

sectional design

Competence

categories: Planning

and delivery of care,

Teaching functions,

Professional

leadership, Research

utilization and

nursing values and

Professional

awareness.

(Silva et al. 2018)

Integrative

review of

articles

The ability of

communication in

the leadership and

Author, year

Research

design

Competency define

supervision

relationship, conflict

resolution regarding

teamwork, planning

in organizations of

services, technical

competence in

professionals’

qualification, and

prevision and

provision of material

resources.

(Donaher et al.

2007)

An integrative

review

Developing self (16

items), recruiting

(11 items),

developing others

(15 items), utilizing

(8 items), retaining

(8 items), and

managing human

capital (58 items)

(Pihlainen et al.

2016)

systematic

literature review

The characteristics

of management and

leadership

competence were

categorized into the

following groups:

health-care-context-

related, operational

and general.

(McCarthy &

Fitzpatrick 2009)

A cross-

sectional

descriptive

design

Behavioral

indicators are

currently being used

to assess

management skills,

design and

implement

continuing

education programs

for nurse managers,

and provide advice

about career

development and

planning for nurse

managers.

(Bjork et al. 2007)

Cross sectional

survey design

Managers in

cooperation with

unit personel should

become aware of

and develop system

to support learning

and use of

competence.

(Numminen et al.

2017)

Quantitative

Empowerment

increased minimally,

whereas perceptions

of practice

environment, ethical

climate, and

occupational

commitment

decreased.

Empowerment,

satisfaction with

current job and

ICINNA 2018 - The 1st International Conference of Indonesian National Nurses Association

Author, year

Research

design

Competency define

quality of care, time

from graduation &

work experience

explained 25.6% of

the change in

competence.

(Wilkinson 2013)

Systematic

literature

A unique set of

dimensions of

continuing

competency are

clinical care,

leadership,

interpersonal

relationships).

(Wong et al.

2013)

Qualitative

(focus group

methodology)

Staff nurses identify

aspect of

management role:

the need for

graduate education,

development of

budget and human

resource

competencies, heavy

workload, large span

of control, job

insecurity, potential

work life imbalance

and reduce patient

contac

(Titzer & Shirey

2013)

Analysis

method

Talent management

as a human

resources recruiting

and retaining

strategy whereas

succession planning

was the

responsibility of

current leaders

(Onishi et al.

2008)

Qualitative

It is important to

focus more attention

on qualitative aspect

of nurses’

professional

experience in

service education

(Supamanee et al.

2011)

Qualitative

Nurses’ clinical

leadership

competencies

emerged,

comprising hidden

characteristics

(motive, attitude and

values) and surface

characteristic

(specific knowledge,

management &

nursing informatics)

(Pillay 2009) Quantitative

Management

competency

variables were

delivery of health

care, planning,

organizing, leading,

control, legal and

ethical issues, and

Author, year

Research

design

Competency define

self management.

(Furukawa &

Cunha 2011)

Quantitative

The nurse managers’

most frequent

competencies

according to their

superiors were:

leadership, focus on

patient and

teamwork

(Johan Tri Agus

Yuswanto 2013)

Qualitative and

quantitative

research

Expected leader

attitude on

developed model

based on statistical

counting and also

functioned as

competency are

mentioned below:

good coach for staff,

inspirational

motivation, team

building and team

work, institutional

structured, knowing

staffs’ need

(Kerfoot 2012)

Literature

review

The ability to use

evidence based

management and

leadership processes

is variable based on

the rigor of the

person’s

understanding of

evidence and

research based

clinical processes

and outcomes

(Kantanen et al.

2017)

Quantitative

Head nurses and

directors of nursing

evaluated

themselves to be

most competent in

areas of general

competence and less

competent in the

areas of special

competence.

(Deyo et al. 2016)

Literature

review

It is important to

understand the

competencies and

education required

to support nurse

manager role

(McCarthy &

Fitzpatrick 2009)

Quantitative

and qualitative

General

competencies for

nurse managers:

communication and

influencing skills,

building and

managing

relationships,

integrity, personal

commitment,

resilience and

compsure, service

irritation and

Improving Nurse Managers’ Competencies: A Systematic Review

Author, year

Research

design

Competency define

innovation,

promoting evidence

based decision

making, practitioner

competence and

professional

credibility

Machell., et al.

(2009)

Literature

review

Competence gives

you the potential

credibility that you

need with colleagues

if they are accept

your leadership

(Chapman 2012)

Literature

review

Top nurse manager

who work in

positions of

influence with

board-level

authority

(Widhi Sudariani

et al. 2016)

Quantitative

and qualitative

Development of

leadership

competency model

can increase the

motivation and

performance nurse

Mildon, B (2014).

Literature

review

Competencies refer

to specific

knowledge, skills,

and personal

attributes required

clinical nurse

specialist practice

safely and ethically

in a designated role

and setting

(Erjavec & Starc

2017)

Qualitative and

quantitative

Reasons for nurse

managers’

differences in

proficiency levels

are the level of job

security, autonomy,

and support of the

healthcare team.

(Doran et al.

2015)

Quantitative

Leaders need pay to

attention to how late

career nurses are

selected and

matched to

organisational

projects

(Palmer 2014)

Qualitative and

quantitative

Increasing nursing

pay is one strategic

to consider in

decreasing turnover

and increasing

satisfaction

(Likupe 2015) Qualitative

Managers need to be

aware that good

policies can be

misinterpreted and

disadvantage

minorities and

should therefore

take steps to

promote good

Author, year

Research

design

Competency define

practice

(Duffield et al.

2014)

Qualitative

Methods of job

enrichment need to

be considered as

part of career

development policy

ICINNA 2018 - The 1st International Conference of Indonesian National Nurses Association