SCHOOL OF NURSING AND MIDWIFERY COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA, LEGON STRATEGIC MANAGEMENT PRACTICES OF NURSE MANAGERS AT THE GREATER ACCRA REGIONAL HOSPITAL. BY AYISHETU NDEOGO (10876887) THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF A MASTER OF PHILOSOPHY DEGREE IN NURSING DECEMBER, 2022 University of Ghana http://ugspace.ug.edu.gh i DECLARATION This is to certify that, this thesis is the result of a research undertaken towards the award of a Master of Philosophy Degree in Nursing at the school of Nursing and Midwifery, University of Ghana, Legon. All references have been dully acknowledged. This thesis has not been submitted either in whole or part to any institution for any degree. University of Ghana http://ugspace.ug.edu.gh ii DEDICATION I dedicate this work to my family and friends, for the great support throughout the entire period of this project. University of Ghana http://ugspace.ug.edu.gh iii ACKNOWLEDGMENT I express my profound gratitude to God for giving me good health, strength and the ability to complete this programme successfully. My sincere appreciation goes to my supervisors Prof. Adelaide M. Ansah-Ofei and Dr. Atswei Adzo Kwashie for the guidance, constructive suggestions and encouragement. I am most grateful. I am most grateful to every member of the Department of Research, Education and Administration of the School of Nursing and Midwifery for the amazing support given to me. Thank you. Very special gratitude goes to my family for their enormous support and encouragement throughout the programme. My heartfelt appreciation to all the participants who voluntarily decided to share their experiences to enrich this research. To my friends, Mariam Adam Al-Hassan, Magdalene Boamah, and Yennuten Paarima, thank you and God richly bless you for your encouragement. University of Ghana http://ugspace.ug.edu.gh iv TABLE OF CONTENTS DECLARATION ................................................................................................................... i DEDICATION ...................................................................................................................... ii ACKNOWLEDGMENT .....................................................................................................iii TABLE OF CONTENTS .................................................................................................... iv LIST OF TABLES ............................................................................................................... ix LIST OF FIGURES .............................................................................................................. x LIST OF ABBREVIATIONS ............................................................................................. xi ABSTRACT ........................................................................................................................ xii CHAPTER ONE ................................................................................................................... 1 INTRODUCTION ................................................................................................................ 1 1.1 Background ................................................................................................................... 1 1.2 Problem Statement ........................................................................................................ 4 1.3 The Purpose of the Study .............................................................................................. 6 1.3.1 Objectives of the study ............................................................................................... 6 1.4 Research questions ........................................................................................................ 7 1.5 Significance of the study ............................................................................................... 7 1.6 Operational definition of terms ..................................................................................... 8 CHAPTER TWO .................................................................................................................. 9 LITERATURE REVIEW .................................................................................................... 9 2.1 Introduction ................................................................................................................... 9 2.2 Conceptual Framework for the Study ........................................................................... 9 2.2.1Application of Wheelen and Hunger‟s model of Strategic Management .............. 13 2.3 Review of Related Literature ...................................................................................... 13 2.3.1 Environmental Scanning ....................................................................................... 14 2.3.2 Strategy Formulation Practices ............................................................................. 21 2.3.3 Implementation of Strategy................................................................................... 25 2.3.4 Strategy Evaluation and Control Practices ........................................................... 31 2.3.5 Challenges Encountered by Nurse Managers in the Practice of Strategic Management .......................................................................................................... 33 2.3.6 Summary of the Literature .................................................................................... 36 University of Ghana http://ugspace.ug.edu.gh vi CHAPTER THREE ............................................................................................................ 38 RESEARCH METHODOLOGY ...................................................................................... 38 3.1 Introduction ................................................................................................................. 38 3.2 Research design ........................................................................................................... 38 3.3 Research Setting .......................................................................................................... 39 3.4 Target population ........................................................................................................ 40 3.4.1 Inclusion criteria ................................................................................................... 40 3.4.2 Exclusion criteria .................................................................................................. 40 3.5 Sampling Technique .................................................................................................... 41 3.6 Sample size .................................................................................................................. 41 3.7 Data collection tool ..................................................................................................... 41 3.8 Data collection procedure ............................................................................................ 42 3.9 Data Management ....................................................................................................... 43 3.10 Data Analysis ............................................................................................................ 44 3.11 Methodological Rigour (Trustworthiness) ................................................................ 44 3.12 Ethical Consideration ................................................................................................ 46 3.13 Summary ................................................................................................................... 46 CHAPTER FOUR .............................................................................................................. 48 FINDINGS OF THE STUDY ............................................................................................ 48 4.1 Introduction ................................................................................................................. 48 4.2 Socio-Demographic Characteristics of Participants .................................................... 48 4.3 Organisation of Themes and Sub-themes .................................................................... 49 4.4 Environmental Scanning Practices .............................................................................. 51 4.4.1 Methods used for Environmental Scanning Practices Observation ...................... 51 Round checks .................................................................................................................... 52 Supervision ........................................................................................................................ 52 4.4.2 Tools Used for Environmental Scanning .............................................................. 52 4.5 Strategy Formulation Practices ................................................................................... 53 4.5.1 Meetings ................................................................................................................ 54 4.5.2 Discussing and deliberating on problems as a group ............................................ 54 4.5.3 Setting Targets ...................................................................................................... 55 4.6 Strategy Implementation Practices .............................................................................. 55 4.6.1 Staff Involvement .................................................................................................. 56 University of Ghana http://ugspace.ug.edu.gh vii 4.6.2 Assignment of Responsibilities............................................................................. 56 4.6.3 Motivation ............................................................................................................. 56 4.6.4 Regular Training ................................................................................................... 57 4.6.5 Supervision ........................................................................................................... 57 4.6.6 Interdepartmental Collaboration ........................................................................... 58 4.6.7 Feedback ............................................................................................................... 58 4.6.8 Use of Different Leadership Styles ....................................................................... 59 4.6.9 Management of Organisational Culture ................................................................ 59 4.6.10 Use Protocols and Standards ............................................................................... 60 4.6.11 Use of attendance book ....................................................................................... 60 4.7 Strategy Evaluation and Control Practices .................................................................. 61 4.7.1 Comparison of Targets .......................................................................................... 61 4.7.2 Use of Appraisal forms ......................................................................................... 61 4.7.3 Management of Logistics ...................................................................................... 62 4.7.4 Use of Time-in and Time-out Books .................................................................... 63 4.7.5 Use of Position Power ........................................................................................... 63 4.7.6 Use of Leave and Duty Rosters ............................................................................ 63 4.7.7 Setting of Guidelines............................................................................................. 64 4.7.8 Conflict Resolution ............................................................................................... 64 4.8 Challenges encountered in Practicing Strategic Management .................................... 64 4.8.1 Limited Number of Staff ....................................................................................... 64 4.8.2 Staff Burnout ......................................................................................................... 65 4.8.3 Change Resistance ................................................................................................ 65 4.8.4 Lack of Adequate Logistics .................................................................................. 66 4.9 Summary of Findings .................................................................................................. 66 CHAPTER FIVE ................................................................................................................ 69 DISCUSSION OF FINDINGS ........................................................................................... 69 5.1 Introduction ................................................................................................................. 69 5.2 Demographic characteristics of Participants ............................................................... 69 5.3 Environmental Scanning Practices .............................................................................. 70 5.4 Strategy Formulation Practices.................................................................................... 74 5.5 Strategy Implementation Practices .............................................................................. 76 5.6 Strategy Evaluation and Control Practices .................................................................. 78 University of Ghana http://ugspace.ug.edu.gh viii 5.7 Challenges encountered in Practicing Strategic Management .................................... 80 5.8 Summary of Discussion .............................................................................................. 82 CHAPTER SIX ................................................................................................................... 84 SUMMARY, IMPLICATION, LIMITATIONS, CONCLUSION AND RECOMMENDATIONS ................................................................................................... 84 6.1 Introduction ................................................................................................................. 84 6.2 Summary of the Study ................................................................................................. 84 6.3 Implication of the Study .............................................................................................. 87 6.3.1 Implication for Nursing Practice ........................................................................... 87 6.3.2 Implication for Nursing Research ......................................................................... 88 6.3.3 Implication for Nursing Education ....................................................................... 88 6.4 Insights Gained from the Study ................................................................................... 88 6.5 Limitation of the Study ............................................................................................... 89 6.6 Conclusion ................................................................................................................... 89 6.7 Recommendations ....................................................................................................... 90 6.7.1Recommendation for Ghana Health Service.......................................................... 90 6.7.2 Recommendation for Regional Health Directorate .................................................. 91 6.7.3 Recommendations for Greater Accra Regional Hospital (GARH)....................... 91 6.7.4 Recommendations for Nursing Administration .................................................... 91 6.7.5 Recommendation for Future Research .................................................................. 91 REFERENCES ................................................................................................................... 92 APPENDIX........................................................................................................................ 103 Appendix A: Research Instrument .................................................................................. 103 Appendix B: Ghana Health Service Ethics Committee .................................................. 105 Appendix C: Consent Form ............................................................................................. 106 Appendix D: Ethical Clearance ....................................................................................... 107 Appendix E: Letter of Support ........................................................................................ 108 University of Ghana http://ugspace.ug.edu.gh ix LIST OF TABLES Table 4.1: Demographic information of study participants ..................................................... 49 Table 4.2: Identified themes and subthemes ............................................................................ 50 University of Ghana http://ugspace.ug.edu.gh x LIST OF FIGURES Figure 2.1: Wheelen and Hunger‟s Model of Strategic Management (2011) .......................... 12 University of Ghana http://ugspace.ug.edu.gh xi LIST OF ABBREVIATIONS SM = Strategic Management NM = Nurse Manager GARH = Greater Accra Regional Hospital HONM = Head of Nursing and Midwifery DDNS = Deputy Director of Nursing Services PNO = Principal Nursing Officer SNO = Senior Nursing Officer University of Ghana http://ugspace.ug.edu.gh xii ABSTRACT Strategic management practice is essential in the health care system especially, among nurse managers, since nurses are front liners in health care delivery. The study sought to explore the strategic management practices of nurse managers. A conceptual framework of the strategic management process was used to guide the study. A qualitative exploratory, descriptive design was utilized. Twelve (12) participants were purposively sampled from the Greater Accra Regional Hospital (GARH). A semi-structured interview guide was used to collect data from the participants, and thematic analysis was used to analyse data. Five themes were identified from the data: environmental scanning practices, strategy formulation practices, strategy implementation practices, strategy evaluation and control practices, and challenges encountered in Strategic Management. The study's results showed that nurse managers scanned their internal environment using methods like observation, round checks, and supervision, as well as SWOT analysis as the tool, but the external environment received little attention, so opportunities were not maximized and threats were not reduced. The study recommends that nurse managers should give as much attention to external environmental scanning as the internal environment for efficient and effective strategy formulation and implementation practices. Furthermore, the management of the Greater Accra regional hospital, should give nurse managers support as well as training on strategic management to better equip their skills in contributing to the achievement of the hospital‟s objectives. Keywords: Strategic Management practices, Nurse Manager University of Ghana http://ugspace.ug.edu.gh 1 CHAPTER ONE INTRODUCTION 1.1 Background The contemporary healthcare industry is transitioning due to constantly changing disease patterns, budgetary cuts, the rising cost of healthcare, and inadequate staffing levels of critical staff (Odhiambo et al., 2021). The industry is increasingly becoming uncertain and unpredictable (Issack & Muathe, 2017). Given this, healthcare institutions are looking for strategies to enable them to remain competitive and relevant in business. Therefore, health care institutions have been encouraged to adopt strategic management to meet their clients' and policymakers‟ demands. Strategic management (SM) is a set of actions and decisions that lead to the formulation and implementation of plans designed to accomplish an organisation's goal (Maroa & Muturi, 2015). SM has become a subject of global interest and consists of environmental scanning, strategic formulation, implementation, and evaluations and control, which influence the organisation's competitive positioning, thus, determining its performance (Maroa & Hunger, 2015). It is from these four key elements SM is manifested. Strategic Management (SM) involves leaders responding to change, setting direction, and focusing on an organisation‟s mission and vision (Ginter et al., 2018). As a result, organisational leaders have adopted the art of strategic management to deal with both existing and unpredictable futuristic situations. Furthermore, SM practices permit leaders to maintain continuous improvement by assessing the organisational environment in which they operate, evaluating competitors, setting goals and strategies to overcome challenges, and then re-examining each strategy regularly to determine whether it fits or needs to be amended to meet the current state of affairs (Ginter & Duncan, 2018). Hence, University of Ghana http://ugspace.ug.edu.gh 2 all organisations should institute strategic management practices to ensure they fit within their competitive environment (Nkemchor & Ezeanolue, 2021). Proper SM practices offer a bridge between an organisation and its environment. It equips organisations to avoid a mismatch with their environment. Also, it must be consistent with its objectives, goals, values, internal and external environment, resources, organisational structures, and systems (Asongu & Odhiambo, 2021; Issack & Muathe, 2017). Using strategic management practices enable health facilities to outline their strategies, providing the essential purpose and direction to staff and customers (Issack & Muathe, 2017). Abraham and Leavy (2007) argued that the success of the concepts and tools in the practice of strategic management is demonstrated in scrutiny of the healthcare industry and competitive conditions, behaviour, and how managers handle the responsibility of formulating and implementing strategies as opposed to using high powered quantitative techniques. In advanced countries, the explicit adoption of strategic management systems and organizing frameworks has invariably instigated the linkage between internal hospital processes and resolving inconsistencies (Devitt et al., 2015). These may encourage behaviours that are consistent with the values identified with the organisation in their operating culture, the day -to -day activities, and structure for success. Furthermore, strategic management is an important and necessary tool to get a competitive advantage over competitors, improve performance, and ultimately, organisational development (Razali et al., 2016). In the Middle East, implementing SM practices increased hospital performance; however, fear of change led to hospital executives clinging to traditional methods of management by hospital executives (Alomran, 2019). However, SM is crucial in removing uncertainty and change resistance (Madzimure & Mashishi, 2021). University of Ghana http://ugspace.ug.edu.gh 3 In Africa, SM may enable hospitals to achieve their goals since it helps focus on their strategic advantages. Prentice et al. (2020) formed a framework that supports the creation of strategies for validating positive communication between strategic implementation through measurable strategic management practices in Africa. Although these do not significantly outline any conclusive impact of strategic management in Africa, it cannot be denied that adopting SM in healthcare organisations in Africa may positively impact change resistance and care delivery. Gachugu et al. (2019) proposed that strategic leadership and the external environment have a moderating effect on the relationship between strategies implemented and organisational performance. Hence, they recommended the adoption of strategic measures in most African organisations. Despite the difficulty in embracing change, it is imperative to implement strategies to achieve the health system's goals. The impact of strategic management has enormous positive effects. Hunger and Wheelen (1996) established that 89% of companies that practiced SM had a competitive edge over companies that did not. Furthermore, companies that do not use strategic management have less chance of survival (Capon, 1994). Carney (2009) acknowledges that the strategic action of managers may positively or negatively influence healthcare delivery, and these actions may be related to the relationship they developed, both externally and internally, with the organisation. The significance of these relationships and the strategic decisions of managers impact organisational performance through how they position the organisation in its specific sector (Hoskisson et al.1999). For instance, in the healthcare sector, if hospitals are perceived as facilities of excellence in a specific area, such as gynaecology or plastic surgery, strategic decisions made by the hospital executives will be forged toward maintaining the hospital's reputation in that field (Carney,2020). Again, Porter (2004) states that organisational performance is determined by the ability of the institute to find its unique position, and strategic management practice is the University of Ghana http://ugspace.ug.edu.gh 4 tool to enable the organisation to acquire that strategic position. Harrington and Ottenbacher (2011) explained that healthcare managers have restricted decision control regarding professional bureaucracies, unpredictability, and instability. This makes the healthcare industry a fascinating study platform for implementing strategic management practices. Carney (2009) however, explained that nurse managers tend to have little control over the strategic viewpoints that drive operational management in organisations, yet, as the largest group (nurses and midwives) within the health-care organisation, it is arguable that the success or failure of managerial approaches within the healthcare facility is largely dependent on them. Nurse Managers are, therefore, in a powerful position to ensure that the underpinning values, beliefs, and philosophies of managerial strategy are coherent with both the context and culture of nursing and the expected quality of care and patient outcome (Carney, 2020). Consequently, the need to utilise SM practices for their units. Nonetheless, strategic management practices are lacking, particularly in this study area. Hence, the need to carry out this study. This study, therefore, seeks to explore the strategic management practices of nurse managers at the Greater Accra Regional Hospital. To understand the strategic management practices of nurse managers, this study will be guided by the Wheelen and Hunger strategic mode 1.2 Problem Statement The competitive landscape of today‟s healthcare industry calls for the involvement of inspiring and engaging managers to meet the demands and expectations of policy makers and consumers (Fuertes et al., 2020). Nonetheless, achieving these expectations demand effective strategic management practices among healthcare managers. Though much has been written about the importance and benefit of strategic management practices for organisations especially, for the sustainability of healthcare organisations in the 21st century University of Ghana http://ugspace.ug.edu.gh 5 (Suriyankietkaew & Kungwanpongpun, 2021), the concepts, strategy and strategic management do not appear to have taken hold among nurse managers and the nursing profession in general (Crossan & Jasper, 2012). Indeed, the nurse manager‟s position is increasingly becoming visible within the healthcare institution as a vital link between the larger vision and the unit-based delivery of effective patient care and staff job satisfaction (Oroviogoicoechea, 1996). The role of nurse manager‟s role is complex, it involves two sets of values, that is, those values traditionally associated with nursing and values conventionally linked with management. These may cause tension and potential conflict, especially, if one is not adequately prepared for managerial positions (Jasper & Crossan, 2012). In healthcare systems such as in Ghana, the appointment of nurses into leadership and managerial positions is often based on clinical expertise and year of service entry with little and no consideration for leadership or managerial competence and performance (Ofei, 2015), thus, nurses are mostly not well equipped in management values to efficiently function in that position.. Consequently, it is worth noting that nurse managers are key stakeholders in healthcare because they control the largest human resource and translate organisational goals into action at the unit level (Ansah Ofei & Paarima, 2021). Nevertheless, nurse managers do not recognize their position as critical in achieving hospital goals. The nurse manager role and responsibilities, they fell short of examining their SM practices, which is critical to maintaining competitive advantage in the healthcare industry. For instance, previous studies have reported on nurse managers' governance practice financial management skills (Paarima et al., 2021), coordination practices (Ofei & Paarima, 2021); leadership competencies (Ofei & Paarima, 2022; Paarima et al., 2022) and planning practices (Ofei et al., 2021). Contemporary research on strategic management in this part of Ghanaian-origin University of Ghana http://ugspace.ug.edu.gh 6 focuses more on the perspective of managing HIV /AIDS and Malaria (Afi et al., 2018.; Ofei, 2007). Therefore, it is important to examine the SM practice of nurse managers given their pivotal role in Ghana‟s healthcare system. At the Greater Accra Regional Hospital, where this study was conducted, SM is often seen as a core management activity for the executive level managers (Medical director, Head of Nursing Services, Chief Accountant, Chief Administrator, Head of Pharmacy and Head of Records) despite its critical role at the departmental level. This may be the reason nurse managers are unable to function in their position, resulting in lack of direction, misuse or underutilisation of resources leading to inefficiencies and waste. Again, strategic management is a grey area and to initiate business orientation in the nursing management, this concept needs to be explored. In the recent performance review of the hospital, data depicted limited or no SM practices among nurse managers. Hence this study was carried out to explore the strategic management practices of nurse managers in the hospital. 1.3 The Purpose of the Study The study aimed to explore the strategic management practices of nurse managers at the Greater Accra Regional Hospital. 1.3.1 Objectives of the study The specific objectives are to; 1. Describe nurse managers' environmental scanning practices at GARH 2. Describe nurse managers‟ strategy formulation practices at GARH 3. Describe nurse managers' strategy implementation practices at GARH 4. Describe strategy evaluation and control practices of nurse managers in GARH 5. Describe challenges encountered by nurse managers in the practice of Strategic Management at GARH University of Ghana http://ugspace.ug.edu.gh 7 1.4 Research questions The research questions for the study were: 1. How do nurse managers conduct environmental scanning? 2. How do nurse managers formulate strategies? 3. How do nurse managers implement strategies? 4. What strategy evaluation and control practices do nurse managers employ? 5. What challenges confront nurse managers in the practice of strategic management? 1.5 Significance of the study The practice of SM by nurse managers is vital in improving client satisfaction and achieving hospital goals. Studies have shown that organisations that practice SM have a greater chance of achieving their goals than those that do not. The knowledge generated will demonstrate the level of application of SM by nurse managers in the hospital. This will help to bridge any gap between theory and practice in nursing leadership. All stakeholders in training nurses and nurse managers will also be better informed about the need to train nurses on strategic management and the effective strategies needed to improve the nurse managers‟ role in strategic management to achieve institutional goals. The study's outcome will help understand the challenges nurse managers experience in applying this concept to achieving organisational goals. University of Ghana http://ugspace.ug.edu.gh 8 1.6 Operational definition of terms Variable Conceptual Definition Operational Definition Strategic Management Practices A set of managerial decisions and actions that determines the long- run performance of an organisation (Wheelen & Hunger, 2012) A set of managerial decisions and actions that determine the long-run performance of an organisation Nurse Manager A registered nurse in leadership role responsible for managing nursing department and having direct supervision of staff nurses in a healthcare organisation (Penconek et al., 2021) A registered nurse who has been officially appointed to lead and manage a nursing unit in the hospital. University of Ghana http://ugspace.ug.edu.gh 9 CHAPTER TWO LITERATURE REVIEW 2.1 Introduction This chapter reviews literature on strategic management practices of nurse managers at the department level. It also provides a conceptual understanding of the strategic management practices in relation to their day-to-day activities, management of organisational culture, management of strategy, and challenges experienced or perceived to be experienced in practicing strategic management. The literature review highlights current research on the subject and identifies gaps in the literature. A thorough search of peer-reviewed research articles was conducted from various databases, including Google scholar, PubMed, Science direct, journal of nursing administration (JONA), journal of clinical nursing, CINAHL and SAGE. The keywords used in the search of literature included strategic management practices, nurse manager, and organisational culture. Apart from a few milestone studies and theoretical literature, the articles reviewed were from 2010 to date. 2.2 Conceptual Framework for the Study Three different theoretical frameworks were considered appropriate for the conceptual framework of the study. Namely, Fred David‟s Strategic Model (2007), Wheelen‟s and Hunger‟s Model of Strategic Management (2011), and Robbin‟s and Cutler‟s Model (2017). David (2007) defines strategic management as the "art and science of formulating, implementing, and evaluating cross-functional decisions that enable an organisation to achieve its objectives." The three stages of the strategic management process, according to University of Ghana http://ugspace.ug.edu.gh 10 David (2007), are strategy formulation, strategy implementation, and strategy evaluation. Developing a vision, mission statement, evaluating the internal and external environment, and long-term objectives are all considered components of strategy formulation. Strategy implementation, the second stage, entails establishing annual goals, creating policies for each business function, and allocating resources for organisational goals. According to David (2007), strategy evaluation is the last phase. This stage aims to correct strategy- related actions while measuring and assessing performance (Shujhat et al. 2016). Though this model is relevant to the study objective, it was however not adopted because it tends to favour quantitative approach in examining correlations among variables. With this current study‟s purpose of exploring the strategic management practices of nurse managers using the qualitative approach, David‟s strategic model becomes inappropriate. According to Robbin and Coulter (2017), strategic management is a set of managerial decisions and actions that determine an organisation's long-term performance. Strategic management, according to the authors, is crucial because it enables managers and organisations to respond quickly to environmental changes, perform better, and coordinate varied organisational units to concentrate on a single set of objectives. The components of Robin and Coulter's model include determining organisational goals, performing analysis, formulating strategies, implementing strategies, and evaluating the outcomes. The Robbins and Coutler model begin by generating missions and resources, followed by analysis. According to Robbin and Coutler, organisations should first identify their mission and goals while taking into account both internal and external customers as well as the market, and then move on to analysis, formulation, implementation, and evaluation of outcomes. This model was considered unsuitable as it did not start with environmental scanning, which serves as a foundation for the other constructs to build on and is not in line with the study's objectives. University of Ghana http://ugspace.ug.edu.gh 11 The Wheelen and Hunger (2011) strategic management model depicts a systematic process of gathering data, planning, implementing, and evaluating results. It outlines four stages in the strategic management process: environmental scanning, strategy formulation, strategy implementation, and evaluation and control. This leads to a repetition of the whole process. These four steps make the model constructs and have served as a successful guide for managers carrying out strategic management studies. The Wheelen and Hunger (2011) model of strategic management was chosen as the most appropriate model amongst the reviewed three models for the study because its construct fits into the study's objectives. In this regard, the Wheelen and Hunger (2011) strategic management model has been considered the most appropriate conceptual framework for this study. Wheelen and Hunger (2011) explained environmental scanning as the monitoring, evaluating, and dissemination of information from the external and internal environments to key players within the organisation. The easiest way to carry out environmental scanning is through strengths, weaknesses, opportunities, and threats (SWOT) that strategically affect the organisation. Once these variables are identified, managers can determine the organisation‟s mission, fitting itself properly into the environment (Wheelen and Hunger. 2011). How environmental scanning is performed, and the data gathered forms an important feature of SM. The development of long-term strategies for the successful management of environmental opportunities and threats in light of an organisation's strengths and limitations is referred to as strategy formulation (Joeliaty et al., 2020; Wheelen & Hunger, 2012). It includes defining the business mission, defining feasible goals, devising strategies, and establishing policy standards. This stage is more beneficial when a good environmental scan has been carried out. Strategy formulation helps managers conceive a good mission, which University of Ghana http://ugspace.ug.edu.gh 12 sets the organisation apart from similar ones. With a well-conceived mission, specific objectives, strategies, and policies are formulated (Wheelen & Hunger, 2011). According to Wheelen and Hunger (2012), strategy implementation is the process of putting defined plans and policies into action via establishing programs, budgets, and processes. This process includes modifications to the organisation's culture, structure, and management system. Middle and lower-level managers under the direction of upper management often implement these techniques. Day-to-day resource allocation choices are frequently involved in strategy execution. The evaluation and control phase of SM is described as the process of monitoring organisational activities and performance results so that actual and intended performance may be compared. The information gathered by managers at all levels is used to take corrective action and fix problems. Although evaluation and control are the final significant component of strategic management, they may also identify flaws in previously executed strategic plans, prompting the process to restart. Figure 2.1: Wheelen and Hunger’s Model of Strategic Management (2011) University of Ghana http://ugspace.ug.edu.gh 13 2.2.1Application of Wheelen and Hunger’s model of Strategic Management This study explored the Strategic Management practices of nurse managers using the Wheelen and Hunger strategic management model (Wheelen & Hunger, 2011) as the conceptual framework. The first objective was how nurse managers scan their environment for information. This has become necessary because in exploring the SM practices of nurse managers, the processes used for environmental scanning by NMs is elicited to enable the researcher to build upon the concept's description. The second objective is to illuminate how strategies are formulated by nurse managers using the data gathered from environmental scanning. Under this objective, participants are asked to describe how they develop objectives to achieve organisational goals and communicate them to their units. The third objective of the study describes how strategies formulated are implemented to achieve goals. This objective aligns with the third construct of the study model. Under this construct, the participants are asked to explain how the strategies are implemented for achieving goals at GARH, their challenges, and coping mechanisms to ensure positive results. The fourth objective explores how nurse managers evaluate and control the strategies formulated and implemented. Under this construct, participants are asked to describe ways to ensure strategies are working or not, how feedback are given, and control mechanisms used for challenges faced during the process. 2.3 Review of Related Literature In this study, literature review was based on the constructs of the conceptual framework and objectives of the study. Also, the literature review centres on nurse managers' University of Ghana http://ugspace.ug.edu.gh 14 practices of strategic management and the challenges they encounter in practicing Strategic Management. 2.3.1 Environmental Scanning Globally, with the constant changes in the healthcare system, scanning the environment has become a vital tool organisation use to gain competitive advantage. An organisation can stay relevant by operating within the framework of forces that constitute its environment. Any organisation unaware of its surroundings is doomed to encounter difficulties brought on by the environment's rising complexity (Topalli, 2015). Environmental scanning as defined by Babatunde, and Adebisi (2012) is a process of gathering, analysing, and dispensing information for tactical purposes. Gathering data from the environment aids organisations in knowing the environment in which they operate and competitors so as to create a good fit and competitive advantage. In the view of Ginter, Duncan, and Swayne, (2018), environmental scanning is the ongoing tracking of trends and occurrences in an organisation's internal and external environment that bear on its current and future success. Environmental scanning is concerned with identifying emerging issues, situations, and pitfalls that may impact an organisation's future. The information gathered, including external events, trends, and relationships, is provided to key managers (in this case Nurse Managers) within the organisation and used to guide management in plans (Ginter, Duncan, & Swayne, 2018). It is also used to assess an organisation's strengths and weaknesses in the face of external threats and opportunities. Environmental scanning is a method of identifying, collecting, and translating information about external influences into useful plans and decisions (Helms & Nixon, 2010). As part of the environmental scanning process, the organisation collects and analyses information about its environment to forecast environmental changes' impact. This University of Ghana http://ugspace.ug.edu.gh 15 ultimately allows the management team to make more informed decisions (Schaltegger & Burritt, 2017). In their study, Demir and Ugurluoglu (2019) determined whether public and private hospital executives have knowledge of strategic management tools, what strategic management (SM) tools they use, to what extent they are satisfied with these tools and what tools they considered using in the future. The research data were collected via a survey. Results revealed that the hospital executives in the study did not have sufficient knowledge of the SM tools that constituted the basis of strategic management practices. It further indicated that private hospitals used many more strategic management tools than public hospitals. Strategic management tools mostly used by hospital executives, according to the research study, were total quality management, social media programs, strategic planning, and the mission and vision statements. The least used strategic management tool was business process reengineering. Also, most SM tools were used more by top executives who had received training in SM and those who perceived themselves to compete (Demir and Ugurluoglu, 2019). Aside SM being used extensively by top executives in the business field, little attention is placed on it when it comes to public health facilities (Mintzberg, 2017). Therefore, this study delves into strategic management in the health sector with a special focus on nurse managers. Akbarov, Hajiyeva and Akbarova (2021) reviewed different approaches to the strategic management of healthcare organisations in a paper titled strategic management for healthcare organisations in the Azerbaijan Republic. The review was conducted to meet persistent barriers in health care system as well as the applicability and feasibility of business analysis tools such as Strengths, Weaknesses, Opportunities, and Threats (SWOT) and Balanced Scorecard (BSC). Data were collected through patient satisfaction questionnaires University of Ghana http://ugspace.ug.edu.gh 16 filled by 218 people. Findings of the study revealed that, the combined SWOT-BSC methodology was powerful for creating a strategic map allowing healthcare organisations perform strategies more effectively in achieving goals. The SWOT-BSC methodology had the advantage of being flexible to market changes and ensuring adaptability of healthcare organisations. Also, the findings of Akbarov, Hajiyeva and Akbarova (2021) affirm Wheelen and Hunger, (2011) framework of which SWOT analysis is embedded in environmental scanning and strategy formulation. Iranian Public Hospitals were the subject of a research by Pourmohammadi et al., (2020) using a comprehensive environmental scanning methodology. To keep up with the constantly changing environment, the researchers updated their dynamic method of environmental scanning every three to four years. The macro and micro surroundings of the hospitals were the focus of the environmental scan. Based on the PESTLE (political, economic, social, technical, legal, and environmental) and Douglas West framework, an in- depth interview and survey were utilized as part of mixed-method research to identify important environmental elements. The researchers were able to discover the major problems affecting hospitals at the macro and micro levels by using environmental scanning to discover changes in illness patterns, bed allocation management, improper hospital budgeting, and economic punishments. The findings highlight the relevance of strategic management adoption in a health organisation. In a study conducted by Graham, Evitts, and Thomas-Maclean (2008) in Canada to examine the use of environmental scanning for primary care research, it emerged that the passive and active approaches were the modes of environmental scanning employed by health organisations. The passive approach involves “casual and opportunistic” data collection from already established external contacts or more focused data collection from University of Ghana http://ugspace.ug.edu.gh 17 well-respected existing sources, such as industry databases or published documents (Choo, 2001). Active approach on the other hand involves an organisation taking action, analysing reactions, and creating data-collection tools to obtain “rigorous and objective” data. In both cases, the active approach is accompanied by a willingness to “revise or update existing knowledge.” According to McCallin and Franklin, (2010) as cited in Ofei (2015), nurse managers are expected to identify challenges, design and implement innovations to help their unit achieve patient outcome targets while reducing costs to increase efficiency. This, therefore, suggests that the ideal environmental scanning approach for nurse managers is the active approach. However, implementing environment scanning by nurse managers has become an issue of great concern because of the paucity of scholarly attention given to it and the rapidly changing terrain and emergence of public health issues. Furthermore, the relative complexity of the environment, the perceived availability of information, and the organisation's willingness to "intrude" on the environment to gather data all played a role in selecting either an active or passive approach. There are instances where both approaches are adopted (Heavey, Mowday, Kelly & Roche, 2009). A classic example is Rowel et al. (2005), whose study revealed the use of both active and passive approaches by the management of some selected health facilities in addressing the rise in cancer in African Americans. Additionally, COVID-19 and its effects on nursing and regulation were examined by the National Council of State Boards of Nursing (NCSBN) in 2021. The study employed the passive approach by relying on workforce databases at the state and federal levels to help send nurses to emergencies. The passive approach was adopted due to the perceived availability of information and the high risk of COVID spread if an active strategy had been University of Ghana http://ugspace.ug.edu.gh 18 taken (NCSBN, 2021). Birinci and Eren (2013) conducted a study among universities and discovered that internal environmental analyses were given more importance whiles external environmental analyses were not conducted properly, hence, possible external opportunities and threats are not well known. These findings added that the Universities generally exhibited an inward- oriented concept of management, thus, unable to create a competitive environment within themselves and compete with other Universities globally. Lastly, Birinci and Eren (2013) concluded that, since strategic management processes were not discussed as a whole, institutional performance of universities in Turkey are not up to the mark and not positively affected. This implies that institutions will benefit massively if both internal and external environments are given equal attention; thus, complete strategic management processes positively affect institutions. The study used the survey method with a questionnaire for data collection. Furthermore, Babatunde, Adebola, and Adebisi (2012) looked at the connection between environmental scanning and organisational effectiveness. According to the report, organisations do environmental scanning in three different ways: ad-hoc, routine, and continuous. Ad-hoc scanning is a brief examination that occurs frequently and is typically started by a crisis. This is carried out to determine whether the issue is internal or external. The regular scanning mode employs a routine, program-like process (for instance twice a year). During environmental scanning, routine scanning uses primary data. Continuous scanning is the collection and processing of structured data on a variety of environmental parameters continuously. Businesses typically use the continuous scanning strategy with a central unit tasked with broad environmental scanning and qualitative and quantitative forecasting of specific variables. The results showed that strategic environmental scanning University of Ghana http://ugspace.ug.edu.gh 19 and organisational success are strongly correlated. The study's results further confirmed that firms that focus more on environmental scanning exhibit improved organisational performance. Additionally, the study's findings showed that organisations‟ profitability and market share could benefit from monitoring the surroundings for external environmental forces. The study concluded that continuous scanning or routine scanning is the best method for limiting the effects of environmental instability. Amuna, Al Shobaki, and Naser, (2017) conducted a study on strategic environmental scanning methodology for managing crises in the United Nations Relief Works Agency (UNRWA) Gaza Strip field in Palestine. The study utilized several descriptive-analytical methods with 235 UNRWA managers from a community population. The findings indicated that UNRWA‟s ad-hoc scanning mode was insufficient to manage the crisis. Thus, there was a weak relationship between environmental scanning and crisis management. Furthermore, the findings highlighted that scanning was only conducted during crisis which is not helpful; hence, a permanent schedule of environmental scanning for external and internal factors is essential for proper planning to deal with future potential crises (Amuna, Al Shobaki, & Naser, 2017). Additionally, research on environmental scanning and organisational future orientation was conducted by Rohrbeck and Bade (2012). The study analysed literature on four research areas: corporate or strategic planning, environmental scanning, futures research, and peripheral vision. Two hundred and fifty (250) publications from 1980 to 2011 were analysed to produce a robust integration and linking study on environmental scanning. According to the study findings, multiple papers have emphasized the correlation between an organisation's environmental scanning efforts and the amount of uncertainty felt by its top management. To react to external change, top management is seen to scan the surroundings. University of Ghana http://ugspace.ug.edu.gh 20 Furthermore, it was shown that all forms of businesses, big and small, may profit from environmental scanning. Through environmental scanning, large businesses can manage the increasing complexity of their internal and external environments. An investigation of environmental scanning practices was done by Mohd Said, Ishak and Siddiq (2018) in Malaysia. The study objective was to understand how this activity is conducted, the processes involved, who is responsible for conducting it, when it is conducted, why the processes are conducted, and what types of information were collected. The research utilized the qualitative approach using a semi-structured interview guide. The study identified that the most important environmental information for hotel organisations is task environment, such as information on competitors, consumers, and suppliers. This information is required for operational and tactical decisions made for daily hotel operations. Thus, the hotels had a slightly organized system to perform such activities regularly. The tools used for scanning the task environment were Online Travel Agent (OTA) reports, marketing research, published industry sources, Trends on the market, and personal networking. In summary, ample empirical studies have considered environmental scanning as the cornerstone for strategy formulation and implementation. Intrinsically, it involves gathering, analysing, and dispensing information for tactical purposes. However, the various approaches to environmental scanning vary among organisations. While some employ SWOT analysis as a tool in their environmental scanning practices, others segment the concept into two parts – active and passive approaches. In a quest to explore the strategic management practices of nurse managers at GARH, this study will describe the environmental scanning practices of nurse managers and other things pertaining to strategic management. University of Ghana http://ugspace.ug.edu.gh 21 2.3.2 Strategy Formulation Practices Strategy formulation is the process of establishing the organisation‟s mission and objectives, and choosing among alternative strategies (Suriyankietkaew & Kungwanpongpun, 2021). This process is essential to an organisation‟s success because it provides a framework for the actions that will lead to the anticipated result (Ofei, 2007). Furthermore, it forces an organisation to look at the changing environment carefully and be prepared for possible changes (Asamani et al., 2013). Formulation of a strategy also allows a company to assess its resources, allocate funds, and identify the best strategy for maximizing performance and increasing returns (Fuertes et al., 2020). The strategic formulation process entails identifying an organisation's mission, objectives, and goals, as well as choosing an effective approach. A strategic plan requires extensive research and decision-making (Ahmed, 2018). Developing strategies and choosing the appropriate alternative can be difficult (Abdel-Basset et al., 2019). Decision-making by nurse managers is a multifaceted, multi- responsibility position, which requires the execution of alternative decisions to address a variety of situations in the clinical area (Chisengantambu-Winters et al., 2020). These decisions can be simple or complex, frequently influencing patient care and how hospitals are managed (Nawaz, 2015). The vision, mission, policy standards, knowledge, skills, procedures, and healthcare environment are just a few of the important human and situational aspects that may have an impact on nurse managers' capacity to create effective strategies (Chisengantambu-Winters et al., 2020; Sarabi Asiabar et al., 2020; Nawaz, 2015). Formulating strategies is a major challenge within the health sector, especially by nurse managers (Carney, 2009), thus to ensure that hospitals meet their objectives, there is an increasing need for developing improved approaches to formulating strategies by nurse managers. University of Ghana http://ugspace.ug.edu.gh 22 Wang, Shi and Gan, 2018 conducted a study with the main aim of developing a model to serve as a planning tool suitable for decision-makers in healthcare. Using a multi- objective decision support approach developed the model BLMOPSO to help decision- makers formulate better strategy options to improve healthcare delivery. The study was carried out in China using developing cities. The findings revealed the model is suitable for healthcare decision-makers. Again, the study stressed that involving all staff in the healthcare facility in formulating strategies ensures efficiency and effectiveness. A qualitative study by Ofei et al. (2021) in the Greater Accra region that explored nurse managers planning practices using a sample of 15 nurse managers and 47 nurses from 19 primary, secondary hospital, and two specialty hospitals revealed that all units of the hospitals had satisfactory planning activities which were formal or informal, however, most of the plans were not implemented. Again, the study showed that the content of the plans was mainly about staff annual leave and not important topics such as training, staff supervision and logistics. It was reported further that, NM‟s hide away information and hardly involved colleagues in developing the unit vision. It was recommended that planning practices should be formal with full staff involvement to facilitate staff engagement. This implies that nurse managers require special practical training and supervision on developing and communicating achievable strategies. Again, in a quantitative study on the planning practices of nurse managers in Ghana, it was indicated that all NM‟s plan at the unit, with 59.8% of the NM‟s having quarterly plans (Ofei et al.2019). In this study, 522 nurses from 19 healthcare facilities were recruited. The data was collected and analysed using descriptive and multiple regression analysis. The study established that NMs spend 60-70% of their time planning at the unit. Also, 2.6% of NM‟s planning practices was linked to socio-demographic characteristics; nonetheless, University of Ghana http://ugspace.ug.edu.gh 23 experience of NM‟s contributed significantly to the regression model. This supports the claim that nurse managers with experience are key in formulating strategies to achieve goals. Moreover, Wei et al., (2019) in their study “Nurse leaders‟ strategies to foster nurse resilience, “aimed to identify how nurse leaders find ways to promote nurse resilience and reduce nurse burnout in the United States of America. The study employed a qualitative descriptive method using 20 nurse managers. According to the findings, nurse managers identified seven strategies to cultivate nurse resilience: facilitating social connections, promoting positivity, capitalizing on nurses' strengths, nurturing nurses' growth, encouraging nurses' self-care, fostering mindfulness practice, and conveying altruism. Fostering nurse resilience is an ongoing effort. Nurse managers play an important role in developing a resilient nursing workforce, which results in favourable organisational outcomes (Wei et al., 2019). The strategies outlined to promote nurse resilience will have an influence not only on the nursing staff but also on patient outcomes. The strategies given are simple and may be simply adopted in any context. Nurse managers are committed to demonstrating and facilitating evidence-based measures to improve nurses' resilience (Wei et al., 2019). Additionally, an investigation of the implementation of strategic management practices in Malaysian construction industry by Bakar et al. (2011), revealed that, most of the large construction companies claimed to have some form of written planning system that the managing director mostly formulates without the involvement of other employees. This study used a survey method for collecting data with responses from 78 large construction companies listed under G7 groups classified by Construction Industry Development Board (CIDB). Employees‟ involvement in formulating strategies promotes buy-in for effective implementation thus, it is essential to solicit employees' views and involve them in the process. University of Ghana http://ugspace.ug.edu.gh 24 Furthermore, in a related study by Ongoto and Murugi (2018) on strategic management practices and change implementation in selected public universities in Kenya, the study delved into how strategic management strategies and change were implemented in Kenya's public institutions. The Kurt Lewis hypothesis and the McKinsey 7S Model laid the study's foundation. The study used a descriptive research design to examine the issue. A total of 309 workers from five chosen institutions made up the target population, 174 of them were chosen using a random selection approach. The University of Embu, Karatina University, Machakos University, Chuka University, and Kirinyaga University were among the institutions. Structured questionnaires with open-ended and closed-ended questions were used to gather primary data. By analysing significant themes and drawing deductions based on the tenets of the theories used, qualitative data was studied using the content analysis approach. The statistical association between the study's variables was ascertained using the correlation and regression analysis methods. Because of the limited resources, evaluating the tactics that had been used was difficult. Some employees believed that certain goals couldn't be achieved because senior leadership didn't support them. According to the survey, few public colleges consult their staff before making important choices. Additionally, it was shown that leaders lacked the capacity to analyse developed strategies. As a result, the researchers advised universities to collaborate with consulting companies to develop, execute, and evaluate strategies. The study underpins the need to strategic management adoption in organisations. This has informed the researcher to investigate how strategic management at GARH understands prevailing strategies and how they can be improved to enhance healthcare delivery. University of Ghana http://ugspace.ug.edu.gh 25 2.3.3 Implementation of Strategy Strategy implementation is the process of putting plans and policies into practice by creating programs, budgets, and procedures. This process may entail modifications to the organisation's general culture, structure, and management system (Wheelen & Hunger, 2012). How to transform decisive plans into actionable drives is the epicentre of strategic implementation. Managers are essential in pushing toward the desired goals through benchmarked standards from which performance can be compared (Ofei et al., 2020). The process of putting a strategy into action is difficult and time-consuming. It is undeniably true that developing a sound action plan is far easier than making it happen. For a successful implementation process, managers and staff must be involved, and effective communication between all stakeholders (Ahmed, 2018). Successful implementation of effective strategies enhances the performance of organisations especially, in the nursing profession. According to Blahová and Knápková (2011), developing a strategy is perceived as simpler than effectively putting one into practice. Ahmadi et al. (2012) looked into why many firms fail and discovered that lack of strategy implementation, not formulation, is the primary cause of most failures. Regardless of the plan itself, according to Gecikova and Papcunova (2014), the organisation's ability to stand out depends on how well it is implemented. Varelas and Apostolopoulos (2020) explored the implementation of strategic management in the hospitality business in times of crisis in Greek. The study was performed on 131 tourism organisations. The study's findings revealed that the issues of implementation of strategic management in some hospitality businesses is the lack of concrete strategy for managing the business environment during economic crisis. Also, knowledge of implementing a strategy during an economic strategy was limited to big tourism businesses; University of Ghana http://ugspace.ug.edu.gh 26 small tourism businesses were completely unaware of strategic management approaches to use. This could be because of inadequate skilled personnel in implementing a strategy to manage the business environment. Additionally, small tourism businesses require orientation on implementing strategies to enhance performance. Again, Lawton & Parker, 1999, conducted a study in the United Kingdom titled Procedure and the Professional, the case of British NHS. The study revealed that the majority of nurses, doctors, midwives, and healthcare managers accepted the need for protocols to establish best practices and guide new staff. The study utilized the qualitative research approach using 24 focus groups. There was a general concern that flexibility in practice should be preserved. Alomran (2019) conducted a study on implementing strategic management practices in the Healthcare Sector in Saudi Arabia. The objectives were to investigate the level of adopting strategic management practices and explore the barriers to their implementation based on the opinion of the top management. The questionnaire was used to collect data from senior management of public and private healthcare facilities. The authors found that despite the need for strategic management practices in both public and private healthcare facilities, the main reasons why top management fail to implement formulated strategies, are the fear of change, insufficient capabilities of employees, and poor understanding of the strategic concept. Thus, the researchers recommended that while adopting strategic management, top management and members of staff ought to be trained continuously to ensure a successful strategy implementation. The option of training staff before, during and after the strategy implementation is in line with the study of Terzic- Supic et al. (2015). Terzic-Supic et al. (2015) conducted a quantitative study from 2006 to 2007 at the Centre School of Public Health and Management, Faculty of Medicine, University of University of Ghana http://ugspace.ug.edu.gh 27 Belgrade. It included 107 management members from 20 Serbian general hospitals. The prospective study was conducted to determine the learning outcomes after a specific training program for hospital management teams on strategic planning and management. The findings of the study provided evidence that training for strategic planning and management enhanced the strategic decision-making of hospital management teams. This indicates that better performance of an organisation depends on effective strategic planning since strategic decisions will improve organisational performance. There is, therefore, a need to incorporate effective strategic planning to improve organisational performance. Also, training staff on strategic management contributes greatly to good outcomes. Mwando and Muturi (2016) examined the role of strategic management practices in change implementation. The study concentrated on the influence of leadership styles, employee skills, and communication styles on change implementation in the government of Kenya Ministries. Data was collected from 95 respondents in 18 ministries. The study's results established that the ministries did not utilize strategic management practices to influence change implementation in their business. There was no allocation of resources to support the change process. The findings further described a lack of appropriate skills among workers as top management did not conduct employee training needs assessment before implementing the change. Thus, the researchers recommended that there is a need to introduce a strategic plan that will outline how change will be implemented gradually with minimal individual resistance. In a qualitative study, Rajala, Ruokonen and Ruismäki (2013) found that well- developed systems can help overcome the resistance of strategy implementation within an organisation. Top management is involved in resolving the conflict by mediating between groups, and they are also involved in promoting project acceptance by building cooperation University of Ghana http://ugspace.ug.edu.gh 28 between various stakeholders. The study concluded that even though organisational culture influences performance, there exists a difference between culture and change implementation. Naranjo-Gil and Hartmann (2006) researched how top management teams (TMTs) implement strategies through the use of management accounting systems (MAS). The study tested 884 top management team members and 218 general hospitals in Spain. The findings revealed that the implementation of strategy varied among firms based on the differences between professional and administrative TMTs in their use of management accounting systems. Thus, the level of professionalism in the TMT is related to the importance attached to the performance evaluation function of management accounting systems and the resources allocation function of MAS. The researchers further concluded that managerial background is an important, factor in strategy implementation. Thus, the background of TMT members should be considered during strategic implementation. Meyer, Pascucci, and Murphy (2012) studied the guide for implementing strategic management in complex organisational systems. The study was a qualitative case study conducted in two Brazilian hospitals: Hospital Universitário Cajuru (HUC) and Hospital Erasto Gaertne (HEG). The findings of the study established that the implementation of strategies in the hospitals concentrated on the practices and processes that are adopted and the strategists involved. The implementation of strategy in HEG hospital was viewed to be very successful compared to strategizing at HUC. The strategic implementation at HEG was performed by middle-level management with the support of employees at operational level. The system operated at the HEG hospital was decentralized, unlike that of HUC. At HUC, the findings indicated that only staff operating at top-level management were tasked to formulate a strategy. The scarcity of information available restricted the contributions of University of Ghana http://ugspace.ug.edu.gh 29 middle and lower-level management. The responsibility of middle and lower-level managers are to follow the general guidance from the top without room for interpretation or improvisation. The outcome of this centralized management is that those who decide what to do are not at all involved with implementing the strategies, and those in charge of implementing the strategies are unaware of the overarching goals and objectives of the hospital. The researchers further concluded that HUC‟s top administration ought to understand that one pitfall of the strategic management process squarely resides in the implementation stage, not in the formulation stage, of strategy making. El-Said and ElMakkawy (2017) evaluated the implementation of strategic management practices in Egypt. Based on a simple random sample technique, 48 five-star hotels in Egypt were surveyed. The study results indicated that most of the five-star hotels in Egypt apply the principles of strategic management in its different stages. The Pearson Correlation Coefficients was used in analysing the data collected. The findings proved that senior management support is the most important factor that affected the strategy implementation. This finding is in contrast to the findings of Meyer, Pascucci, and Murphy (2012), which placed more emphasis on the collaboration of middle and lower-level management in strategy implementation. The results also showed that external barriers have the greatest negative impact on the implementation process, in contrast to internal barriers with a limited impact. The results have proved that hotel chains are more in line with strategic management principles and more widely used for strategic management tools than independent hotels. Furthermore, hospitals are also key players in the service delivery, hence it is essential to understand how strategies are formulated and implemented, and also to evaluate the factors that impede the implementation of strategies. Similarly, Mopeni, Sobi and Modi (2014) established that strategy implementation in University of Ghana http://ugspace.ug.edu.gh 30 any organisation is determined by beliefs of workers. Employees should have a shared vision that fosters objectives addressing the critical actions needed for adopting strategies and reaching long-term goals. Lack of teamwork and communication between top-level managers and lower-level employees resulted in 71% failure of strategy implementation by state corporations. Top management plays a key role in building a supportive system that ensures strategy implementation. Furthermore, in a quantitative study conducted in the Malaysian construction industry by Bakar et al. (2011), it was established that large construction companies that implemented written planning systems gained higher performance compared to those who did not practice strategic management. The implementation of a strategic plan by these large companies was instigated by management skills, organisational structure, image and reputation, client relationships and firm‟s profit. It was also found that most of the large construction companies claimed to have some form of written planning system that the managing director mostly formulates without the involvement of other employees. The study's objective was to examine the implementation of strategic management practices in the Malaysian construction industry. This study used survey method for collecting data with responses from 78 large construction companies listed under G7 groups classified by Construction Industry Development Board (CIDB). Ongoto and Murugi (2018) conducted a study to look into how strategic management strategies and change were implemented in Kenya's public institutions. The Kurt Lewis hypothesis and the McKinsey 7S Model were the sturdy foundation. The study used a descriptive research design to examine the issue. Three hundred nine workers from 5 chosen institutions made up the target population, 174 of them were chosen using a random selection approach. The University of Embu, Karatina University, Machakos University, Chuka University of Ghana http://ugspace.ug.edu.gh 31 University, and Kirinyaga University were among the institutions. Structured questionnaires with open-ended and closed-ended questions were used to gather primary data. By analysing significant themes and drawing deductions based on the tenets of the theories used, qualitative data was studied using the content analysis approach. The statistical association between the study's variables was ascertained using the correlation and regression analysis methods. Because of the limited resources, evaluating the tactics that had been used was difficult. Some employees believed that certain goals couldn't be achieved because senior leadership didn't support them. According to the survey, few public colleges consult their staff before making important choices. Altogether, it has been shown that leaders lacked the capacity to analyse developed strategies. As a result, the researchers advised universities to collaborate with consulting companies to develop, execute, and evaluate strategies. Support from management helps avoid resistance and promotes implementation to achieve goals. 2.3.4 Strategy Evaluation and Control Practices According to Charumbira (2014), strategic evaluation and control is the process of monitoring planned strategic activities, comparing the outcomes to actual performance and projected performance, and using the knowledge obtained to make necessary corrections. Aspects of the environment of an organisation must be identified for monitoring, evaluating, and controlling to assess performance (Yambi, 2018). Results assessment is viewed as a key component of strategic evaluation and control in healthcare facilities in order to be aware of the organisation's desirability for quality of performance. According to Pourmohammadi et al. (2020), effective evaluation systems consist of four separate elements: comprehensiveness, comparability with goals, the capacity to compare assessed results, and measurability of strategic plans. This aspect of evaluation University of Ghana http://ugspace.ug.edu.gh 32 and monitoring is crucial in disseminating strategy by nurse managers. According to the study of Akinbowale, Lourens, and Jinabhai (2013), performance evaluation policies influence organisational strategy and human resource policies. Per the study findings, many organisational units struggle to persuade their staff to adopt the mind- set and practices intended to improve employee performance, which is why they constantly need to realign employee performance. For a business to successfully manage employee performance, training, and selection processes, its performance assessment policy must be effective. On a strategic level, personnel must constantly realign their performance with the changing aims and objectives of the business if quick and successful organisational changes are to be made in today's dynamic social, economic, and political environment. Additionally, Ahmad et al. (2019) researched on strategic management utilising a target population of 54 respondents. The researchers reported that a firm's usage of strategic controls affected how well a strategic management strategy works. Strategic management plays a significant role in the many levels of oversight and regulation of organisational results. To take corrective action for organisational growth once a plan has been adopted, businesses purposefully ask employees for feedback. This is critical because businesses must manage the factors that might influence a strategic strategy from the planning stage to implementation. Again, a qualitative study conducted in Uganda among 11 nurse managers with the objective of understanding the challenges experienced in healthcare revealed that ward managers make a timely work plan, like preparing duty rosters a week before the beginning of the following month in order to address any complaint from staff and to manage the staffing on the ward well (Kakyo & Xiao, 2019). The study concluded that it is important to prepare and improve the leadership, and management skills of nurse managers through University of Ghana http://ugspace.ug.edu.gh 33 education to have greater impact in the healthcare sector. Furthermore, a study conducted by Ofei et al (2021) on 522 nurses in 19 selected hospitals in Greater Accra revealed that nurse managers demonstrated moderate levels of governance practices by maintaining logbooks to check staff punctuality, effective appraisal, coaching, supervision, mentorship, and encouraging staff-directedness. Again, the study found that nurse managers using a little intimidation helped keep staff in check in order to achieve hospital goals. A quantitative cross-sectional design was used in the study. The study concluded that the position of nurse manager continues to evolve within the complex healthcare sector, necessitating the empowerment of nurse managers to effectively carry out this responsibility (Ofei et al. 2021). This implies that nurse managers should be assisted to gain experience in evaluation and control practices in order to ensure efficiency and quality unit and hospital outcomes. 2.3.5 Challenges Encountered by Nurse Managers in the Practice of Strategic Management Strategic management is key for business and organisational growth (Ndunge et al. 2019). However, each stage of strategic management (environmental scanning, strategy formulation, implementation, evaluation and control) presents its challenges, it renders strategic management ineffective and negatively impacted. When not managed, it renders strategic management ineffective and negatively impacts the expected outcomes of strategic management (Ndunge et al.2019). Given these, Ndunge et al. (2019) argued that many routine challenges affect the use and application of strategic management in an organisation. Hence, challenges in applying strategic management can be grouped under institutional and operational challenges. Ndunge et al. (2019) conducted a case study to determine the challenges that affect the strategic plan implementation at Kenya Medical Training College University of Ghana http://ugspace.ug.edu.gh 34 (KMTC). Ndunge used the census approach engaging all 28 KMTC campuses, which implemented strategic plans. The results showed that the main challenge experienced during the implementation of the plan is inadequate financing. Muthoka, M‟Mugambi, and Okeyo (2021) studied the role of strategic leadership style on compliance with public service ethics in Kenya. The sample of the study was 584 county employees. The findings indicated that strategic leadership was considered to be of moderate importance in the county of Kenya by employees across levels. The study also mentioned resistance to change, organisation structure and culture, reward mechanism, politics, and policy priorities for strategic leadership to service, as examples of challenges that impede strategy implementation when applying strategic management. Benevene and Cortini (2010) explored the human resource strategic management in Non-Profit organisations. The study adopted a multiple research approach. A semi- structured interview was administered to 122 senior managers of non-profit organisations. The study's findings indicated that the organisations did not consider training as a tool for strategic management of HR. Thus, the senior managers were trained on-the-job or self- taught rather than having a plan for training on strategic management. This created the challenge of having a proper strategy for HR management to plan, implement and evaluate strategies in the organisations. Through an organisational research perspective, Reay, Golden‐ Biddle, and Germann (2003), identified three major challenges for managers. These are, clarifying task reallocation, managing teamwork relationships, and constantly managing the evolving situation in teams. The authors suggested leadership strategies that managers may find useful in managing these challenges were encouraging team members to sort out „who does what‟, ensuring that task reallocation sustains job motivating properties, considering tasks allocation University of Ghana http://ugspace.ug.edu.gh 35 when issues of personal conflict are involved, paying attention to all aspects of team working relationships, facilitating encouraging relationships amongst staff members, lead from a „balcony‟ perspective, work as a team in developing goals, and regularly sharing with other managers experiences and lessons learnt. Concluding that three managerial challenges needed to be addressed for managers to be most effective. Also, managers can facilitate the introduction of a new role and improve sustainability in health organisations by employing precise leadership strategies (Reay et al., 2003). Thompson and Strickland (1993) identify that organisational resources required for achieving desired organisational outcomes can be grouped into physical, financial, human, and technological resources. These resources are vital to any organisation; hence, lack of effective resource allocation can affect the application of strategic management, especially when the resources are not abundant (Ndunge et al., 2019). From the viewpoint of David (2003), factors that can cause ineffective resource allocation to include vague strategy targets, lack of sufficient knowledge about tasks and priorities, organisational politics and overprotection of resources. Hajizadeh, Zamanzadeh, and Khodayari‐ Zarnaq (2021), explored the barriers and facilitators regarding nurse managers‟ involvement in the health decision-making process. The study adopted a qualitative descriptive approach and purposive sampling was conducted. Semi-structured one-to-one interviews were conducted with 16 respondents. Findings revealed three levels of barriers to the participation of nurse managers in health policymaking. Firstly, the individual level consisted of weaknesses in the characteristics of the nurse manager. The second, the organisational level, comprised of inefficient structure, and the third, the environment-related level, embodied external barriers to the organisation. Finally, three facilitators were found to improve nurse managers‟ participation in the University of Ghana http://ugspace.ug.edu.gh 36 decision-making process. These were improving collaboration and communication, governmental and non-governmental organisational activities, and reforming the health policymaking process. They concluded that nurse managers needed to use the window of opportunity to participate in health decision making and be informed about health strategies to meet the demands of the changing healthcare environment. 2.3.6 Summary of the Literature The literature review for this study concentrated on studies that discussed managers' use of the strategic management process in their strategic management practices, including environmental scanning, strategy formulation, strategy implementation, evaluation, and control, as well as the difficulties they encountered. The results of SM practices have also been examined in the literature, with findings published appropriately. Strategic management has been a crucial corporate approach for accomplishing organisational goals and preserving a competitive edge over rivals, according to the study of the literature that is now available. Several authors have discussed the benefit of integrating strategic management into routine tasks. A SWOT analysis tool of strategic management was used to prepare for the long term of any firm. It is used to determine the advantages, disadvantages, opportunities, and threats facing a company. It aids managers of organisations in making plans while keeping in mind their working environment and how to blend in seamlessly. In formal and informal meetings where staff members participated in decision-making, effective planning was emphasized. A literature analysis on strategy implementation has shown many ways a manager can guarantee that strategies are used. These methods include delegation, management of organisational culture, incentive, training, supervision, recognizing excellent work, and providing feedback. The review has revealed that all these methods and more must be used for implementation to be successful. On evaluation and control, the literature University of Ghana http://ugspace.ug.edu.gh 37 revealed four distinct components: comprehensiveness, ability to compare evaluated results, measurability of strategic policies, and comparability with goals. Finally, a review on nurse managers' challenges in the practice of SM revealed that many challenges affect the application of SM. These challenges included change resistance, organisational culture, limited staff, and inadequate logistics. University of Ghana http://ugspace.ug.edu.gh 38 CHAPTER THREE RESEARCH METHODOLOGY 3.1 Introduction This chapter looks at the methods used to address the research objectives. It comprises the research design, research setting, target population, sample and sampling method used. Also, it describes the tools used, data collection procedure, data analysis and data management. Additionally, this chapter provides a presentation of how the ethical requirements and trustworthiness of the study were met. 3.2 Research design A qualitative descriptive design was used for this study. According to Zainal (2007), exploratory descriptive design helps the researcher describe a phenomenon and provide a detailed account of its significance. Therefore, the focus lies on an exhaustive understanding of opinions and experiences rather than numbers. Qualitative research methods focus more on individual experiences than general ones (Hammarberg et al., 2016). It also helps a researcher to generate a picture of the world from the participants' perspective, as well as document and describe the phenomena of interest. The exploratory descriptive design was selected because, it efficiently allows researchers to fully understand a given phenomenon while enabling participants to contribute to developing new knowledge (Mccallum & Howes, 2018). Exploratory descriptive design was used since the researcher was interested in obtaining in-depth information from a participant on strategic management practices. Consequently, the study used open-ended questions to explore the SM practices of nurse managers instead of numbers. Previous authors have used the design in similar studies (Hunter et al., 2019; Rizvi & Nabi, 2021). University of Ghana http://ugspace.ug.edu.gh 39 3.3 Research Setting The study was conducted at the Greater Accra Regional Hospital (GARH), situated in the nation‟s capital Accra. It is located at North Ridge in the Korle-Klottey Sub-Metro of the Accra Metropolitan Area, occupying a total land area of about 15.65 acres and currently the regional hospital serving a population of about 4,671,363 (2016) projection based on the 2010 census by the Ghana Statistical Service). It was established in 1928 as the hospital for European expatriates, became a district hospital in 1957 and has now been renovated and transformed into an ultra-modern 470-bed capacity hospital with the full complement of specialist services that reflect the current social aspirations of the rapidly growing capital city of Ghana, Accra. The hospital reports an average bed occupancy of 75% and a daily OPD attendance of 374. The hospital functions as a tertiary hospital drawing its mandate from Ghana Health Service (GHS). The daily administration of the hospital is conferred in the Medical Director, who is supported by 4 directors including the Deputy Director of Nursing Service (DDNS). The DDNS is the Head of the Nursing and Midwifery services (HoNM) in the hospital, GARH has a nursing and midwifery population of one thousand one hundred eighty-one (1,181) representing 60% of the work force of the hospital. Twenty Deputy Directors of Nursing Services support HoNM to oversee nursing departments in the hospital. These departments include Obstetrics and Gynaecology, Child Health, Internal Medicine, Department of Surgery, Emergency and Corporate, antenatal and paediatrics Out Patient Department, Maternity and Day Bays, Intensive Care Unit (ICU) and Recovery, Neonatal and Reproductive Health, Public Health, Allied Surgery, Family Health, Infection Prevention and Control (IPC), Central Sterile Supply Department ( CSSD) and Customer Care unit, Health Promotion, Quality Insurance, In-service Training unit, Auditing Unit and main Out Patient Department (OPD). Each of the departments listed is headed by a DDNS who does University of Ghana http://ugspace.ug.edu.gh 40 daily supervision and coordination of the department through the Principal Nursing Officer (PNO) and Senior Nursing Officers (SNO). The daily activities of the department are carried out by the nurses and midwives. These nurse managers (DDNS and PNO) are responsible for providing leadership for nursing team, effective day-to-day management of the department, coordinating and supervising roster planning and monitoring and documentation of all leave for nurses and midwives in the department, and preparing and submitting monthly, quarterly and annually on nursing and midwifery activities. NMs are also responsible for promoting a positive image of their department and devising improved job methods to increase department efficiency and effectiveness. Greater Accra Regional Hospital was selected as the study site because, it is the regional hospital in the capital city of Ghana. Although GARH is a regional hospital, it is well structured with more specialty departments and a large number of nurse managers to recruit participants. 3.4 Target population The study's target population were all nurse managers working at the Greater Accra Regional Hospital. 3.4.1 Inclusion criteria  Nurse managers who are officially recognised as an administrator of a department.  Nurse managers who have been in their current position for at least 6 months. 3.4.2 Exclusion criteria  Nurse managers who did not consent to participant in the study.  Nurses who are not nurse managers. University of Ghana http://ugspace.ug.edu.gh 41 3.5 Sampling Technique A purposive sampling technique was used to select participants for the study. The researcher adopted this sampling strategy because the population under study was preselected and had the ability to furnish the information needed. Purposive sampling is a non- probability sampling technique for the researcher to draw participant who understand the phenomenon of the study (Ishtiaq, 2019). The type of purposive sampling used was maximum variation sampling, which allowed the researcher to select a diverse range of perspectives relevant to the phenomenon (Sharma, 2017). The participants were purposely selected to be diverse in number of years in management, educational level, age and department. The researcher recruited participants by visiting the departments and informing the nurse managers about the study. All nurse managers who volunteered were noted, their contact numbers taken and an appropriate time and date to meet was established. 3.6 Sample size The sample size for the study was determined by data saturation. The researcher reached data saturation by the 12 th participant. Data saturation is reported at the point where no new information is discovered (Fusch & Ness, 2015). Consequently, the researcher recorded no new information or idea, and an in depth understanding of the strategic management practices of nurse managers at GARH had been attained. Therefore, 12 nurse managers were interviewed at the Greater Accra Regional hospital. 3.7 Data collection tool This study used a semi-structured interview guide constructed in English and consisted of open-ended questions. For each question in the research tool, probing questions were asked to help the researcher gain in-depth information on the strategic management practices of nurse managers. University of Ghana http://ugs