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Leadership competencies offirst-line First-line nursemanagers
nursemanagers: a quantitative study
Yennuten Paarima and Atswei Adzo Kwashie
Department of Research, Education, and Administration,
School of Nursing and Midwifery, University of Ghana, Accra, Ghana
James Avoka Asamani Received 28May 2021
Department of Intercountry Support Team for Eastern and Southern Africa, Revised 11 September 202121 November 2021
Health Workforce Unit, World Health Organization Regional Office for Africa, Accepted 7 December 2021
Harare, Zimbabwe, and
Adelaide Maria Ansah Ofei
Department of Research, Education, and Administration,
School of Nursing and Midwifery, University of Ghana, Accra, Ghana
Abstract
Purpose – This paper aims to examine the leadership competencies of first-line nurse managers (FLNMs) at
the unit level in the eastern region of Ghana.
Design/methodology/approach – The paper is a quantitative cross-section design.
Findings – Nurse managers exhibited a moderate level of knowledge and ability to apply leadership
competencies. Gender, rank, qualification, professional experience, management experience and management
training jointly predicted the leadership competencies of FLNMs [(R2 = 0.158, p = 0.016]. However, only
management training was a significant predictor in the model.
Practical implications – Inappropriate leadership competencies have severe consequences for patients
and staff outcomes. This situation necessitates a call for a well-structured program for the appointment of
FLNMs based on competencies.
Originality/value – This study is the first in Ghana which we are aware of that examined the leadership
competencies at the unit level that identifies predictors of leadership competencies.
Keywords Leadership competencies, Nurse managers, First-line nurse managers
Paper type Research paper
Declarations Ethics: Approval to conduct the study was obtained fromNoguchi Memorial Institute forMedical
Research (CPN 023/17–18) before the start of the research. Official permission to gather data was sought and
received from themanagement of the hospitals. Written informed consent was granted by all the respondents.
The authors wish to sincerely thank the management hospitals and all the nurse managers who
participated in the study.
Funding: The authors received no funding either from individuals, not-for-profit organizations, or
commercial entities.
Conflicting interests: The authors declared no competing interest concerning the authorship, research, and
publication of the article.
Author Contributions statement.
Study conception and design: YP, JAA, AMAO, AAK.
Data collection: YP.
Data analysis and interpretation: YP and JAA.
Draft of the article: YP andAMAO.
Critical revision of article: All authors. Leadership in Health Services
Data availability: The study raw data backing the findings is with the corresponding author and will be © EmeraldPublishingLimited
1751-1879
made available upon request. DOI 10.1108/LHS-05-2021-0047
LHS Background
Health-care systems across the world have become complicated and confronted with several
multifaceted challenges including increasing workload, inadequate staffing and the rising
cost of care (AL-Dossary, 2017; Asamani et al., 2016). As the largest health-care
professionals, nurses are often at the center of these issues. Consequently, health-care
managers are constantly searching for the “best” approach to enhance both staff and patient
outcomes amid these challenges (Asamani et al., 2016). In addressing these challenges and
other health-care-related issues, nurse managers are required to exhibit practical leadership.
Leadership is a process whereby people are influenced by an individual to work toward
the attainment of a mutually agreed goal willingly and enthusiastically (Cummings et al.,
2018). On the other hand, management is defined as “the pursuit of organizational goals
efficiently and effectively by integrating the work of people through planning, organizing,
leading, and controlling the organization’s resources.” (Kinicki and Williams, 2018). Given
the nature of health care, managers are required to provide leadership, as well supervision
and coordination of health-care activities. In this study, leadership is operationally defined
as a process whereby an individual leads a group of people by applying his or her leadership
knowledge and ability to translate organizational goal(s) into action for optimum
performance. To achieve this call for effective display of leadership competencies.
Leadership competencies are “the ability to inspire individual and organizational
excellence, create a shared vision and successfully manage change to attain an
organization’s strategic ends and successful performance”(Hahn and Lapetra, 2019).
According to Chase (2010), leadership competencies are the knowledge and ability to direct
the operations of an organization using skills and behaviors to enlist the support of
individuals or groups in the achievement of a shared goal. Chase (2010) identified leadership
competencies as a significant domain of competencies essential at all levels of management.
Heinen et al. (2019) also acknowledged leadership competencies as an important tool that
frontline nurse managers can use to initiate changes in nursing to affect the attitudes of their
subordinates.
First-line nurse managers (FLNMs) are essential to any health-care organization. Their
functions are complex, vital, and often tricky. FLNMs’ primary duties are to ensure the
delivery of quality and safe care (Ofei et al., 2018) and serve as the bridge between the top
management and nurses. They are also in charge of building and maintaining healthy and
safe working environments, which has a positive impact on both staff and patient outcomes
and reduces mortality rates in all health care systems (Alomairi et al., 2018). This significant
position is characterized by varying degrees of rigor and scope (Erjavec and Starc, 2017),
which require FLNMs to possess the requisite leadership competencies to ensure efficiency
and effectiveness at the unit.
According to Chase (2010), FLNMs need fourteen leadership competencies, that is,
“decision making, power and empowerment, delegation, change process, conflict resolution,
problem-solving, stress management, research process, motivational strategies,
organizational unit work, policy and procedure, staff education, time management, and
interdisciplinary care coordination”. Chase (2010) emphasized that any nurse manager
deficient in knowledge and ability to apply these leadership competencies loses the chance
of being a successful manager as the position is dynamic and challenging.
As asserted by Mosley and Pietri (2015), delegation is essential in managing the unit as
many nurses assume managerial responsibilities without formal training. Delegation allows
FLNMs to distribute and entrust activities and related authority to their subordinates.
However, they retain accountability for the task, ensuring tasks are accomplished safely and
correctly (Yoon et al., 2016). The ability to allow nurses to participate in the management of
the unit actively prepares them adequately for the future, though the process must be well- First-line nurse
structured, done cautiously, and when the right condition prevails with the right supervision managers
(Ofei et al., 2020a, 2020b). Undoubtedly, delegation has the potential to build competencies
and resilience of inexperienced nurses, thus promoting confidence and increased
performance (Dudley et al., 2021). The challenge with delegation is that many FLNMs do not
evaluate and reward performance or give adequate feedback to the delegates, whereas some
also ignore supervision of the delegated tasks (Tompkins, 2016). One obvious challenge with
delegation in Ghana is the blatant lack of well-established organizational methods and
procedures for delegation in the health system (Ofei and Paarima, 2021a, 2021b). Hence, in
most instances, there is lack of a well-structured coordination and communication during
delegation, as well as a lack of properly defined duties and spheres of authority (Ofei and
Paarima, 2021a, 2021b). Again, the act of delegation requires an emotional maturity which
apparently is rare even among successful persons. Due to the absence of policy on
delegation in most institutions, the work experience of FLNMs has not taught them the
practice. Thus, FLNMs are reluctant to take that risk involved in depending on others.
Another challenge with delegation is that the FLNM should be organized to plan work in
advance to delegate appropriately.
Conflict resolution has been identified as a unique leadership competency that FLNMs
require to effectively manage conflicts that may arise at the unit (Mueller and Vogelsmeier,
2013). Conflict feels uncomfortable and awkward to many, it is an inevitable part of life and
is prevalent among nurses at the unit which can negatively affect patient care. FLNMs’
ability to effectively resolve conflicts that ensue at the unit is one endeavor crucial to all
managerial work (Ofei et al., 2020a, 2020b). However, many FLNMs at the unit are not
endowed with conflict resolutions skills to enable them effectively manage conflicts hence,
resorting to ineffective measures such as avoidance and accommodation, which allow other
professionals and junior colleagues alike to brand them as ineffective leaders (Ofei and
Paarima, 2021a, 2021b)
Several studies have also cited decision making as a key leadership competency through
which all the responsibilities and activities of FLNMs are accomplished (Roshanzadeh et al.,
2019; Salmela et al., 2017). Decisions of FLNMs have a significant impact on care
coordination, workflow, patient safety and staff well-being (Chisengantambu-Winters et al.,
2020). Thus, decisions made at the wrong time, and the wrong place are substantial and can
become expensive for health-care delivery (Siirala et al., 2016). Therefore, FLNMs need to
clarify what decisions are made at the unit to elicit the necessary support from their
subordinates. The challenge with decision-making among FLNMs is the lack of
engagement. Decisions are solely made by FLNMs without consultation and colleagues
have to just accept themwithout complaints.
Earlier researchers have reported a positive association between leadership competencies
and improved performance as well as the sustainability of health-care institutions (Lega
et al., 2013). Similarly, Asamani et al. (2016) reported a significant correlation between nurse
managers’ leadership competencies and nurses’ perceived productivity at the unit. Given
this positive impact of leadership competencies, it is essential to strengthen the capabilities
of FLNMs and empower them to develop and maintain these competencies for optimum
health-care delivery (Asamani et al., 2016; Kantanen et al., 2017). However, studies
originating from advanced health-care systems have reported a moderate level of leadership
competency among nurse managers (García et al., 2020; Kantanen et al., 2017). Similarly,
Munyewende et al. (2016) reported moderate leadership competencies score among South
African clinical nurse managers.
LHS In this study, we defined FLNM as a registered nurse or midwife who has officially been
appointed to head a ward/unit irrespective of his/her professional rank. In Ghana’s health
system, they are appointed by executive nurse managers and their duties include
supervising, directing, organizing and coordinating the work of nursing staff at the unit
level. However, because the entry-level of professional nursing in Ghana is a diploma, there
are countless nursing units with nurses in the lower ranks as unit-level managers. Also, due
to the geographical location of some hospitals, nurses with higher certification and ranks
refuse posting to these hospitals therefore, those in the lower ranks who accept posting to
these hospitals assume unit-level managerial positions. Despite their limited management
and professional expertise, they are required to provide effective leadership at the unit level.
To accomplish these essential roles require leadership competencies to navigate and
efficiently manage dwindling health care resources (Paarima et al., 2020b). Despite these
significant roles of FLNMs, it is intriguing to know that most of them are appointed based
on clinical expertise and long service with little or no consideration to competence (Ofei et al.,
2019; Paarima et al., 2020a, 2020b). Also, there is no research information assessing and
measuring the leadership competency of FLNMs in Ghana. Therefore, this study aimed at
examining the leadership competencies of FLNMs at the unit level in the Eastern Region of
Ghana. The study objectives were to examine the leadership competency level of FLNMs at
the unit level and to examine the influence of demographic characteristics on the leadership
competencies of FLNMs at the unit level
Theoretical framework
Though several competencies’ theories exist, we used Katz’s conceptual framework. Katz’s
conceptual framework originally has three distinct dimensions: technical, conceptual and
human relationship competencies (Katz, 1974). Chase used the Katz framework to
investigate nurse managers’ competencies and identified two additional competencies; thus,
leadership and financial management competencies (Chase, 2010). Technical competencies
refer “to the proficiency when working with tools, based on specific knowledge, in a
particular field of work” (Paarima et al., 2020a, 2020b). Technical competencies are
important for “operational level managers, less important for middle managers, and least
important for executive managers”. Human relationship competencies are the “proficiency
when working and relating with people based on one’s knowledge of people and how they
behave, operate in groups, the way to effectively communicate with them, and their feelings,
attitudes, and motives” (Paarima et al., 2020a, 2020b). Human relationship competencies are
vital to all the levels of management (Ofei et al., 2020a, 2020b). Conceptual competencies
are the “ability to think through the ideas or concepts that form the foundation of the
organization, its vision, and goals” (Paarima et al., 2020a, 2020b). These competencies are
essential for executive managers, less significant for middle managers, and least important
for operational-level managers. But lower-level managers need to develop and demonstrate
conceptual competencies to be promoted to higher managerial positions. Leadership
competencies are the “ability to engage and motivate others in followership using personal
mechanisms of strategic planning, significance, relationships, aspirations, and courage”
(Chase, 2010). Leadership competency is ultimately about creating a way for people to
contribute to making something extraordinary happen (Chase, 2010) and is essential at all
levels of management. Financial management competencies are “management related to the
financial structure of the company and therefore to the decisions of source and use of
financial resources, that is reflected in the size of the financial income and/or charges”
(Chase, 2010) and important for all managers. According to Paarima et al. (2020a, 2020b),
any manager deficient in each competency loses the chance of being a successful manager.
Chase’s conceptual framework was used to guide a bigger study that investigated the First-line nurse
managerial competencies of FLNMs in Ghana. The framework was selected over others managers
because its constructs best accommodate the study objectives. It has expansive variables of
assessing the technical, conceptual, human relationship, leadership, and financial
management skills which was the main purpose of the big study. The technical, human,
conceptual and financial management dimensions have already been reported (Paarima
et al., 2020a, 2021). Therefore, this paper is reporting only the leadership domain aspect of
the study to give the full picture of the situations in Ghana. The leadership domain of the
Chase framework has fourteen variables namely decision making, power and
empowerment, delegation, change process, conflict resolution, problem-solving, stress
management, research process, motivational strategies, organizational unit work, policy and
procedure, staff education, timemanagement and interdisciplinary care coordination.
Ghana’s health-care system
Ghana operates a three-level health-care delivery system. At the top (tertiary level) are the
Teaching Hospitals that are autonomous and serve as national referral facilities. They are
mandated to provide excellent services, take care of complex conditions, train health
professionals and conduct research. Each Tertiary Hospital is linked with a public
university to enhance its functions. There are also Regional Hospitals that are mandated to
provide a secondary level of specialized health-care services. They serve as referral facilities
for each of the 16 administrative regions of Ghana. Regional Hospitals are required to
provide health services to about twomillion populaces.
At the district level, is the primary health care made of the district hospitals, health
centers and the community-based health planning and services (CHPS) compounds. The
district hospitals serve as referral centers at the district level. They are mandated to provide
emergency and basic health care to about 200,000 population. The district level is further
divided into subdistricts. Health care at the subdistricts is delivered by the health center,
which provides promotive, preventive and basic curative services. Their catchment area
covers up to about 20,000 inhabitants. At the bottom of the district/primary health,
hierarchy are the community-based health planning and services (CHPS) compounds, whose
key strategy is the provision of basic primary health-care services in the communities
(Asamani et al., 2019). Their principal mandate is to provide preventive services and
treatment of minor ailments using over-the-counter medications to about 750 households or
a population of about 5000. Additionally, there are also government own specialized
hospitals, quasi-government hospitals and private-for-profit health-care facilities (Asamani
et al., 2019).
Nurses are the single largest health professionals constituting about 60% of the total
workforce in Ghana’s health system (Asamani et al., 2019). Nursing administration is
organized at three functional levels: the top level, the middle level and the unit level (Ofei
et al., 2020a, 2020b). The top (executive) nurse managers are responsible for making
organizational strategic decisions and developing strategic plans for the entire organization.
The middle-level nurse managers are heads of departments, that make tactical decisions and
plans for the department as well as manage the work of unit-level nurse managers, whereas
the unit-level nurse managers are in the wards operating as operational managers in the
health-care facility (Ofei and Paarima, 2021a, 2021b). The first-level nurse managers manage
all the activities in the unit, coordinating all the activities of the nurses, other health
professionals and the support staff. They make operational decisions and plans for the
department and are considered first-line managers.
LHS However, FLMNs sometimes feel overwhelmed by competing values and demands
efficiency and quality. Inability to effectively address these competing demands will result
in loss of confidence and trust in them and the organization which can result in staff
dissatisfaction. Given this, FLNMs are required to effectively handle challenges and
problems that arise at the unit level. They need to show responsiveness and support their
staff by ensuring a favorable work environment that will encourage trust and open
communication where the safety and wellbeing of staff are prioritized. Their ability to
develop a friendly environment in which nurses feel valued and supported will enable them
to be inspired and show organizational commitment leading to improved performance. To
accomplish these essential roles, call for effective leadership competencies. Therefore, our
study was centered on the unit-level managers (FLNMs) who constitute the greater
proportion of health-care managers in Ghana’s health system. The FLNMs were
purposefully chosen because of their pivotal role in the delivery of quality health care in
Ghana. While this study with FLNMs, the paper focus is to investigate leadership due to
series of problems that continually occur in the FLNM role.
Methods
Design
The research investigated the leadership competencies of FLNMs using the quantitative
cross-sectional design. This design allows the researcher to collect original data that is
sufficient for generalization to the population of interest (Polit and Beck, 2014).
Setting
We conducted the study in the Eastern Region of Ghana. Ghana is in West Africa and is
bordered to the north by Burkina Faso, to the west by Côte d’Ivoire, to the east by Togo, and
to the south by the Gulf of Guinea and the Atlantic Ocean. Ghana occupies a total landmass
of 92,099 Square miles (238,535 km2). Ghana has 16 administrative regions and 260 district
assemblies with an estimated population of 30,000, 000.
The Eastern is in the southern part of Ghana. The region is the third most populated with
a total population of 3,244,834, representing 10.4% of Ghana’s population in 2019. It is the
sixth-largest region occupying a landmass of 19,323 km2. The region has 26 administrative
districts with Koforidua being the regional capital. We conducted the study in ten public
district hospitals constituting 42% of hospitals in the region (GHS, 2015). The hospitals are
Koforidua Regional Hospital in the New Juaben Municipality, Presbyterian Hospital in the
Kwahu Afram Plains North District, Kwahu Government Hospital in the Kwahu South
District, Holy Family Hospital Kwahu West Municipality, Kibi Government Hospital East
Akim District, Saint Dominic Hospital in the Kwaebibirem district, Nsawam Government
Hospital Nsawam Adoagyire municipality, St. Joseph Hospital in New Juaben municipality,
Suhum Government Hospital Suhum Municipality and Akuse Government Hospital in the
LowerManya Krobo District.
These hospitals comprised one regional hospital, one specialized hospital and eight
district hospitals which were chosen purposefully to represent both primary and secondary
levels of health care in the region. They were also selected to represent the two largest
health-care agencies in the region, Ghana Health Service and the Christian Health
Association of Ghana. We chose the region and the hospitals for the study because most of
these hospitals are in rural and peri-urban towns whose proximities are far from the national
capital with inadequate social amenities.
Population and sampling technique First-line nurse
All FLNMs in the ten hospitals were eligible to participate in the study. FLNMs at least with managers
one year of management experience who agreed to take part in the study were all included.
We excluded top (executive) level managers, trainee nurses, national service personnel and
nurses who were not FLNMs. We used a census approach in administering the
questionnaires. A census approach is a “data collection method that allows the researcher(s)
to collect data from all elements of the accessible population and to investigate one or more
characteristics of those elements” (Polit and Beck, 2014). We chose this approach to enable
us to have an adequate representation of each hospital since FLNMs are not many.
Data collection tool and procedure
We adopted the Nurse Managers Competencies Instrument (Chase, 2010). The instrument
was slightly modified to suit the study’s aim and objectives. The questionnaire has five
dimensions (technical, conceptual, human, leadership and financial management), but this
study adapted only the leadership dimension. The leadership competency dimension had
14-items. The original instrument is measured on a four-point Likert scale (1 to 4) however,
in this study, the authors modified the instrument into a five-point scale (1 = poor, 2 = fair,
3 = Good, 4 = very good 5 = excellent).
We obtained consent to modify the instrument from Linda K. Chase the originator of the
instrument via lindachase2619@gmail.com/Ichase@iuhealth.org. In this study, the fifth
point was added to indicate the highest level of knowledge and ability to apply the
competencies, which is consistent with earlier authors using the instrument in similar
studies (Karathanasi et al., 2014; Paarima et al., 2020, 2021). The questionnaire was clustered
into sections A and B. Section A gathered data on participants’ sociodemographic
characteristics, whereas section B gathered data on the leadership competencies of nurse
managers.
Once official consent was obtained from the management of each hospital, the
researchers proceeded with the data gathering process. We allocated each hospital with a
specific number of questionnaires based on the strength of FLNMs. At the unit/ward level,
each FLNM was approached individually. After an extensive explanation of the study’s
purpose and objectives, those who accepted to take part in the study were given a voluntary
consent form to sign, after which the questionnaires were given out. Due to the busy
schedules of FLNMs, the questionnaires were given to them to complete at their
convenience. The study recorded a 98.4% response rate. We used three months for data
gathering, from January toMarch 2018.
Ethical clearance
The Ethics committee of the Noguchi Memorial Institute for Medical Research (023/17–18)
approved this current study. We also obtained official permission from the hospitals’
management. The study had neither psychological, physical nor emotional harm to
participants as it was nonexperimental, and the questionnaire did not contain variables that
may cause fear or anxiety in participants. Participating in this current study was
exclusively voluntary. Each participant was appropriately briefed on the research purpose.
The right to withdrawal from the study at any time without assigning a reason(s) was
explained. To maintain anonymity, we did not collect any identifying biodata of the study
participants. Participants signed consent before the authors commenced the administration
of the questionnaire. Confidentiality was maintained throughout the study by ensuring that
participants’ rights were protected, and information divulged to researchers was not
disclosed to unauthorized persons.
LHS Validity and reliability
We maintained the validity of the instrument mainly through content and face validity. To
maintain face validity, the questions were arranged to reflect the study objectives. Content
validity was ensured through a thorough conceptualization of the constructs to adequately
capture the content domains. We also made sure research objectives are precise and have
been captured adequately by the questionnaire. Again, the instrument was also validated by
nursing administration and management experts. To safeguard reliability, the instrument
was pre-tested at a different hospital with fifteen FLNMs. The outcome of the pretest was
used to correct grammatical mistakes and to adjust areas of ambiguity. The overall
Cronbach’s alpha coefficient of the original instrument was 0.92 and the overall knowledge
of competency was 0.883 whereas the ability to apply the competency was 0.803. In this
study, the overall Cronbach’s alpha coefficient of instrument was 0.97, knowledge of
competency 0.930, and ability to apply competency 0.944. Because we modified the
instrument to a five-point scale, a psychometric analysis was performed. The Cronbach’s
alpha coefficient of knowledge of competency ranged from between 0.922 and 0.930 whereas
that of the ability to apply competency ranged between 0.751 and 0.758 which is considered
acceptable (Polit and Beck, 2014). Details are presented in Table 1.
Statistical analysis
We analyzed data using descriptive and linear regression analyses. Participants’
characteristics and leadership competencies were summarized, and results presented in
frequencies, percentages, means, and standard deviations using descriptive statistics.
Multiple linear regression analysis was conducted to determine the influence of participant
characteristics (rank, gender, qualification, professional experience, management experience
and management training) on leadership competencies. Scores were interpreted as 1-very
low, 2-low, 3-moderate, 4-high, 5-very high. Higher scores showed a higher level of
leadership competencies among the nurse managers.
Results
Participants’ characteristics
Females accounted for 73.6% (n = 89) of the 121 (100%) nurse managers, while males
accounted for 24.7% (n= 30). Most of the participants (n= 66, 54.6%) were between the ages
of 30 and 39. In addition, 38.8% (n = 47) of the participants had the title of Nursing Officer.
Furthermore, first-degree holders made up 47.9% (n= 58) of the participants, while master’s
degree holders made up just 7.4% (n = 9). Finally, most of the participants (n = 21, 17.4%)
work in specialist units/wards. Table 2 provides more details.
Leadership competencies of first-line nurse managers
The average score of knowledge of leadership competencies was 3.91 (SD = 0.60) and the
ability to apply the competencies was 3.76 (SD = 0.66). The highest-rated leadership
competency was knowledge of delegation (mean = 4.15, SD = 0.73) and ability to apply
delegation (mean = 4.03, SD = 0.83). This competency was followed by knowledge of conflict
resolution (mean = 4.09 SD = 0.68) and the ability to apply conflict resolution (mean = 4.03,
SD = 0.06). The lowest score of leadership competency was knowledge of research process
(mean = 3.35, SD = 0.96) and ability to apply the research process (mean = 3.18, SD = 0.95).
Details are illustrated in Table 3.
First-line nurse
Statement
Knowledge of Scale mean if item Scale variance if item Corrected item-total Cronbach’s alpha if item managers
competency deleted deleted correlation deleted
Decision-making 50.63 60.938 0.731 0.924
Power and
empowerment 50.82 59.429 0.767 0.922
Delegation 50.6 62.984 0.497 0.930
Change process 50.92 59.095 0.724 0.924
Conflict
resolution 50.71 58.487 0.762 0.922
Problem solving 50.66 59.911 0.744 0.923
Stress
management 50.98 60.333 0.589 0.928
Research process 51.38 60.941 0.530 0.930
Motivational
strategies 50.96 58.536 0.715 0.924
Organizational
unit work 50.66 61.041 0.622 0.927
Policy and
procedure 50.92 60.873 0.701 0.925
Staff education 50.66 60.356 0.717 0.924
Time
management 50.72 60.238 0.693 0.925
Interdisciplinary
care coordination 51.05 59.044 0.683 0.925
Leadership
knowledge 54.74 69.396 1.000 0.930
Ability to apply
competency
Decision making 100.99 325.953 0.779 0.757
Power and
empowerment 101.3 321.815 0.796 0.753
Delegation 101 326.774 0.630 0.758
Change process 101.33 318.505 0.807 0.751
Conflict
resolution 101.19 323.021 0.759 0.755
Problem solving 101.14 325.046 0.709 0.756
Stress
management 101.5 322.516 0.700 0.755
Research process 101.84 325.456 0.618 0.757
Motivational
strategies 101.42 318.944 0.798 0.751
Organizational
unit work 101.12 322.108 0.765 0.754
Policy and Table 1.
procedure 101.36 324.533 0.793 0.756 Cronbach’s alpha
Staff education 101.12 323.504 0.760 0.755 coefficient of
Time knowledge and
management 101.15 321.883 0.781 0.753
Interdisciplinary ability to apply
care coordination 101.42 320.284 0.717 0.753 leadership
Leadership ability 52.51 86.724 1.000 0.923 competencies
LHS
Variable Frequency (n) (%)
Gender
Male 30 24.7
Female 89 73.6
Missing values 2 1.8
Total 121 100
Age
20–29 10 8.3
30–39 66 54.6
40–49 10 8.3
50–59 25 20.7
#60 1 0.8
Rank
Staff Nurse 4 3.3
Senior Staff Nurse 17 14
Nursing Officer 47 38.8
Senior Nursing Officer 30 24.9
Principal Nursing Officer 23 19
Total 121 100
Qualification
Certificate 15 12.4
Diploma 20 16.5
Post Basic 19 15.7
First degree 58 47.9
Masters 9 7.4
Total 121 100
Unit
Emergency 6 5
Maternity 16 13.2
Surgical 11 9.1
Medical 23 19
Theatre 10 8.8
Out-patient department 10 8.8
Children 9 9.4
Specialized unit 21 17.4
Others 15 12.4
Table 2. Total 121 100
Participants
characteristics Source: Field data, 2018
The influence of leadership competencies of first-line nurse managers
The results in Table 4 shows that, participant characteristics (gender, rank, qualification,
professional experience, management experience and management training) together
accounted for 15.8% of the variance in leadership competencies [R2 = 0.158, F (6, 95) = 2.781,
p = 0.016]. However, a more detailed examination of the predictors showed that only
management training was statistically significant (p= 0.001) in the regression model.
Discussion
Participant characteristics
Participants within the age group of 30–39 years bracket constituted the majority. Our
finding agrees with the average age of nurses in Ghana, which is projected to be between the
First-line nurse
Knowledge of Ability to apply
competency competency managers
Statement N Mean SD Mean SD Mean difference
Leadership competencies
(Mean score) 117 3.91 0.60 3.76 0.66 0.15
Decision-making 121 4.09 0.68 4.03 0.70 0.06
Power and empowerment 121 3.89 0.80 3.72 0.84 0.17
Delegation 121 4.15 0.73 4.03 0.83 0.12
Change process 119 3.82 0.86 3.72 0.95 0.10
Conflict resolution 121 4.03 0.88 3.84 0.85 0.19
Problem solving 120 4.08 0.76 3.88 0.81 0.20
Stress management 121 3.75 0.90 3.53 0.92 0.22
Research process 121 3.35 0.96 3.18 0.95 0.17
Motivational strategies 121 3.79 0.93 3.62 0.96 0.17
Organizational unit work 121 4.07 0.78 3.90 0.85 0.17
Policy and procedure 120 3.82 0.74 3.66 0.76 0.17
Staff education 121 4.07 0.77 3.91 0.82 0.16 Table 3.
Time management 121 4.00 0.80 3.86 0.87 0.14 List of nurse
Interdisciplinary care manager leadership
coordination 121 3.72 0.92 3.64 0.99 0.08 competencies (Chase,
Source: Field data 2018 2010)
age of 25–40 years (Asamani et al., 2019, 2020). This finding suggests a young cohort of
nurses in Ghana’s health-care system. It implies that these FLNMs might possess limited or
no leadership competencies. This may stem from the fact that some FLNMs are in the Staff
Nurse and Senior Staff Nurse ranking with limited management and professional
experience. Furthermore, 73.6% of the participants were female which reinforced the
assertion that nursing is a women-dominated profession. This view is gradually shifting,
with manymales in Ghana preferring nursing as a career.
Most of the participants were in the Nursing Officer’s designations. This suggests that,
depending on their starting grade, most of the participants have served for 3 to 5 years or
more. This contradicts the findings of Ofei et al. (2018), who found that most participants
were Senior Staff Nurses. Even though both studies were performed in Ghana’s Eastern
Region, Ofei et al. (2018) conducted their research in three hospitals with 45 nurse managers,
Unstandardized Standardized 95.0% Confidence
Predictors coefficients coefficients t p-value Interval for B
Model B Std. Error Beta Lower Upper
(Constant) 134.829 11.764 11.46 <0.000 111.454 158.205
Gender 
3.696 4.212 
0.093 
0.88 0.383 
12.065 4.673
Rank 2.063 2.256 0.122 0.914 0.363 
2.42 6.545
Qualification 
2.932 2.994 
0.111 
0.98 0.330 
8.881 3.018 Table 4.
Professional experience 0.16 0.35 0.082 0.458 0.648 
0.536 0.857 The influence of
Management experience 
0.853 0.62 
0.197 
1.38 0.172 
2.084 0.378
Management training 
12.624 3.497 
0.355 
3.61 0.001 
19.573 
5.676 nurse manager
R2 = 0.158, F characteristics on(6, 95) = 2.781, p = 0.016
leadership
Notes: Dependent variable: Total leadership competencies, Criterion level: 0.05 competencies
LHS while this current study used 121 FLNMs in ten health-care facilities. The finding is also
inconsistent with the Ghana Health Service job description of nursing and midwifery staff
which requires that a nurse manager should be at least a Senior Nursing Officer (Ghana
Health Service, 2005). This means that most of the participants in this study are not
qualified to be occupying these key positions. However, because of the prevailing
environment, they are forced to assume the responsibilities of FLNM without the necessary
experience and competencies. The situation can have severe consequences on patient and
staff outcomes. The study found a different level of educational background which
illustrates the entry-level of professional nursing in Ghana. As asserted by Ofei et al. (2020a,
2020b) and Paarima et al. (2020a, 2020b), the educational level of FLNMs can greatly affect
their appreciation of leadership at the unit level.
Leadership competencies of first-line nurse managers
Leadership is a critical concept in nursing since health-care delivery even at the small unit is
immeasurably complex (Asamani et al., 2016; Paarima et al., 2020a, 2020b) and the
appropriate leadership competencies are required to avoid errors, waste and confusion. The
study found a moderate level of leadership competencies among FLNMs. This finding
means that the FLNMs exhibited satisfactory leadership competencies at the unit. FLNMs in
Ghana are faced with several challenges including poor work environment, inadequate
remuneration, and leadership challenges. This information partially explains the moderate
leadership competencies among participants in this current study. Several studies have
reported similar findings (Asamani et al., 2016; Ofei et al., 2014; Karathanasi et al., 2014).
These studies attributed the moderate level of leadership competencies to a lack of
mentorship, coaching, leadership training and experiential learning.
The current study further revealed a high knowledge and ability to apply delegation.
This implies that FLNMs in this recent study effectively delegate responsibilities to their
subordinates in the unit. The researchers observed that FLNMs do delegate with the
appropriate authority and resources, but improvement would be appreciated. Delegation in
nursing is crucial in managing the unit as most nurses assume management roles without
formal training. Therefore, FLNMs must allow subordinates to take active roles in
managing the unit to prepare them adequately for the future, though the process must be
structured and done cautiously (Paarima et al., 2020b). Delegation can effectively be used as
a form of succession planning for nurses if managed well. FLNMs should be encouraged to
delegate when the prevailing conditions are right. Researchers in Denmark and Saudi
Arabia have reported similar findings (Sabri Gassas, 2017; Riisgaard et al., 2016).
Also, nurse managers had high knowledge and ability to apply conflict resolution at the
unit. This finding suggests that nurse managers have the needed skills in conflict resolution.
As nursing units are human societies, conflicts are inevitable. However, poor management
of conflict has been linked to low morale, decreased productivity, job dissatisfaction,
financial loss for organizations and poor workflow (Moeta and Du Rand, 2019). Therefore,
resolving conflicts that arise at the unit level is an essential endeavor critical to all FLNMs.
In dealing with challenges that occur at the unit, FLNMs must be competent, experienced
and able to relate well with their staff. Ganz et al. (2014) reported a similar finding in Israel.
However, the result is inconsistent with the work of Moeta and Du Rand (2019) in which
unit-level FLNMs in South Africa appeared to have challenges in dealing with conflict
between individuals or generally in the unit and intervened inappropriately.
Effective decision-making is an essential leadership competency in nursing. FLNMs’
ability to make effective clinical decisions is the most crucial factor affecting the staff and
patient outcomes (Chisengantambu-Winters et al., 2020). FLNMs in this current study
showed higher decision-making skills. This finding implies that FLNMs can effectively First-line nurse
gather, process and prioritize critical patient information to choose the best nursing actions, managers
implement and evaluate the outcomes. If nurses can participate in the decision process, it
would enhance their confidence, competence, improve care and increase their organizational
commitment. Participating in decision-making deepens democratic values, increases team
spirit, stimulates the work environment as well as improves staff satisfaction and
productivity. This finding conforms to the work of Asiri et al. (2016) which affirmed that an
effective decision-making process significantly predicted nurses’ commitment and
performance among Saudi nurses.
Research has a tremendous impact on professional nursing practice, thus rendering it an
essential component of the FLNMs competencies (Tingen et al., 2009). Even though research
is critical in nursing care, participants in this current study showed moderate knowledge
and ability to apply the research process. The finding suggests that nurse managers exhibit
a satisfactory level of the research process. It is, therefore, essential that FLNMs acquire the
necessary skills, knowledge, and attitudes towards research to enable them to lead their
staff in conducting and utilizing research findings in health-care delivery. This information
calls for future directions to help nurses build and maintain research skills. The finding is
inconsistent with the work of Lehane et al. (2019) and Migliore et al. (2020) which reported a
high level of clinical research competencies among nurses.
The current study revealed that participant characteristics (gender, rank, qualification,
professional experience, management experience, and management training) accounted for
15.8% of differences in the leadership competencies of FLNMs. However, only management
training statistically contributed to the model. This finding implies that training in
management improves leadership competencies. Thus, management training build-up
FLNM competence and confidence. Periodic training of FLNMs and adequate preparation
for this position are very relevant and hospitals must be encouraged to provide systematic
training. A structured in-service training, as well as mentorship and coaching, should be
encouraged at the unit level to help young nurses build their leadership competencies by
learning from experienced nurses. Also, hospitals should support current and potential
nurse managers to take leadership andmanagement courses as approved by the GHS.
Although this finding may not be new in the advanced health-care settings, it is a vital
finding in the context of Ghana where the appointment of nurse managers is based on
clinical expertise and long service with little or no consideration to competencies and
management/leadership training.
This finding is congruent with a US study by Anderson (2016) in which attending a
management academy significantly predicted the managerial knowledge and skills of
military nurse managers. The call for nurses to receive leadership and management training
before they assume management positions are in the right direction as well as the
development of better remuneration packages to boost their worth to the hospital. In
addition, all the predictors identified only 15.8% of the variance, a greater proportion of the
variance remains unknown. This calls for further studies to establish whether other factors
may account for FLNMs’ leadership competencies.
Conclusion
The study investigated the leadership competencies of FLNMs in the Eastern Region of
Ghana. The study identified that FLNMs are essential stakeholders in addressing the
myriad of nursing and health-care challenges. Therefore, FLNMs must possess the relevant
and appropriate leadership competencies to enable them to address these challenges. The
findings showed that FLNMs exhibited all the leadership competencies of the Nurse
LHS Managers Competency Instrument. The results also demonstrated that age, gender,
qualification, professional experience, managerial experience, and training in management
explained a substantial proportion of the leadership competencies of FLNMs. However, only
managerial training contributed to the model. A well-structured educational, experiential,
and mentorship programs are required to provide a framework for leadership development
for FLNMs.
Implications for nursing management
Generally, we found a satisfactory level of leadership competencies among FLNMs. This
finding implies a need for improvement in these competencies to effectively create a
favorable work environment for quality and safe patient care. Training in management
explained a significant portion of FLNMs’ leadership competencies. This implies that nurses
need training in management before or after their appointment as FLNMs. This training will
equip them with adequate knowledge, abilities, and skills to navigate the increasingly
complex health-care environments. This situation necessitates the identification of potential
nurse managers and their adequate preparation through regular training in leadership and
management.
Study strength and limitation
As far as the author knows, this is the first study to investigate the leadership competencies of
FLNMs in Ghana. However, due to its limitations, the research results should be interpreted
with caution. The study was conducted only in the Eastern Region of Ghana using a
self-reported questionnaire. Therefore, the results may vary in other regions of Ghana.
However, the selected hospital has the characteristics of Ghanaian health-care facilities.
Like all other theories and models of leadership, the Chase framework has some
weaknesses. First, the framework lacks key skills such as inspiration, innovations,
teamwork and goal(s) setting among other critical skills needed for effective leadership. The
lack of these critical skills may be due to the fact; the framework is not a leadership
framework but rather nurse managers competency framework. Therefore, the findings of
this study should be interpreted in the context of nurse managers’ competencies as outlined
in Chase Nurse Managers Competencies (Chase, 2010).
Recommendation for future studies
The authors recommend future studies to consider using mixed-method and other
theoretical approaches in examining leadership competencies in health care.
References
Al-Dossary, R.N. (2017), “Leadership in nursing”, Contemporary Leadership Challenges, pp. 252-264,
doi: 10.1016/j.colsurfa.2011.12.014.
Alomairi, S.B., Seesy, N., El. and Rajab, A.A. (2018), “Managerial and leadership competencies of first-
line nurse managers in Makkah city: mixed-method approach”, Journal of Nursing and Health
Science, Vol. 7 No. 1, pp. 53-60, doi: 10.9790/1959-0701055360.
Anderson, R. (2016),Assessing NurseManager Competencies in aMilitary Hospital, Walden University.
Asamani, J.A., Naab, F. and Ofei, A.M.A. (2016), “Leadership styles in nursing management:
implications for staff outcomes”, Journal of Health Sciences, Vol. 6 No. 1, pp. 23-36.
Asamani, J.A., Amertil, N.P., Ismaila, H., Akugri, F.A. and Nabyonga-Orem, J. (2020), “The imperative
of evidence-based health workforce planning and implementation: lessons from nurses and
midwives unemployment crisis in Ghana”, Human Resources for Health, Vol. 18 No. 1, pp. 1-6, First-line nurse
doi: 10.1186/s12960-020-0462-5. managers
Asamani, J.A., Amertil, N.P., Ismaila, H., Francis, A.A., Chebere, M.M. and Nabyonga-Orem, J. (2019),
“Nurses and midwives demographic shift in Ghana - the policy implications of a looming crisis”,
Human Resources for Health, Vol. 17 No. 1, pp. 1-5, doi: 10.1186/s12960-019-0377-1.
Asiri, S.A., Rohrer, W.W., Al-Surimi, K., Da, O.O. and Ahmed, A. (2016), “The association of leadership
styles and empowerment with nurses’ organizational commitment in an acute health care
setting: a cross-sectional study”, BMC Nursing, Vol. 15 No. 1, pp. 1-10, doi: 10.1186/s12912-016-
0161-7.
Chase, L. (2010),NurseManager Competencies, University of IA.
Chisengantambu-Winters, C., Robinson, G.M. and Evans, N. (2020), “Developing a decision-making
dependency (DMD) model for nurse managers”, Heliyon, Vol. 6 No. 1, p. e03128, doi: 10.1016/j.
heliyon.2019.e03128.
Cummings, G.G., Tate, K., Lee, S., Wong, C.A., Paananen, T., Micaroni, S.P.M. and Chatterjee, G.E.
(2018), “Leadership styles and outcome patterns for the nursing workforce and work
environment: a systematic review”, International Journal of Nursing Studies, Vol. 85 No. April,
pp. 19-60, doi: 10.1016/j.ijnurstu.2018.04.016.
Dudley, N., Miller, J., Breslin, M., Lou Chapman, S.A. and Spetz, J. (2021), “The impact of nurse
delegation regulations on the provision of home care services: a Four-State case study”,Medical
Care Research and Review, Vol. 78 No. 1_suppl, pp. 47S-56S, doi: 10.1177/1077558720960902.
Erjavec, K. and Starc, J. (2017), “Competencies of nurse managers in Slovenia: a qualitative and
quantitative study”, Central European Journal of Nursing and Midwifery, Vol. 8 No. 2,
pp. 632-640, doi: 10.15452/CEJNM.2017.08.0012.
Ganz, F.D., Wagner, N. and Toren, O. (2014), “Nurse Middle manager ethical dilemmas and moral
distress”,Nursing Ethics, Vol. 22 No. 1, doi: 10.1177/0969733013515490.
García, A.G., Pinto-Carral, A., Villorejo, J.S. and Marqués-S
anchez, P. (2020), “Nurse manager core
competencies: a proposal in the Spanish health system”, International Journal of Environmental
Research and Public Health, Vol. 17 No. 9, doi: 10.3390/ijerph17093173.
Ghana Health Service (2005), Restructuring the Additional Duty Hours Part I of Volume II Job
Descriptions for Clinical, Nursing andMidwifery, Vol. II, Ghana Health Service
Hahn, C.A. and Lapetra, M.G. (2019), “Development and use of the leadership competencies for
healthcare services managers assessment”, Frontiers in Public Health, Vol. 7 No. FEB, pp. 1-7,
doi: 10.3389/fpubh.2019.00034.
Heinen, M., van Oostveen, C., Peters, J., Vermeulen, H. and Huis, A. (2019), “An integrative review of
leadership competencies and attributes in advanced nursing practice”, Journal of Advanced
Nursing, Vol. 75 No. 11, pp. 2378-2392, doi: 10.1111/jan.14092.
Kantanen, K., Kaunonen, M., Helminen, M. and Suominen, T. (2017), “Leadership and management
competencies of head nurses and directors of nursing in Finnish social and health care”, Journal
of Research in Nursing, Vol. 22 No. 3, pp. 228-244, doi: 10.1177/1744987117702692.
Karathanasi, K., Prezerakos, P., Maria, M., Siskou, O. and Kaitelidou, D. (2014), “Operating room nurse
manager competencies in Greek hospitals”, Clinical Nursing Studies, Vol. 2 No. 2, pp. 16-29,
doi: 10.5430/cns.v2n2p16.
Katz, R.L. (1974), “Skills of an effective administrator”,Havard Business Review, Vol. 52 No. September,
pp. 90-102.
Kinicki, A. and Williams, B.K. (2018), Management: A Practical Introduction, 8th ed., McGraw-Hill
Education.
Lega, F., Prenestini, A. and Spurgeon, P. (2013), “Is management essential to improving the performance
and sustainability of health care systems and organizations? A systematic review and a roadmap
for future studies”,Value in Health, Vol. 16 No. 1, pp. S46-S51, doi: 10.1016/j.jval.2012.10.004.
LHS Lehane, E., Leahy-Warren, P., O’Riordan, C., Savage, E., Drennan, J., O’Tuathaigh, C., O’Connor, M.,
Corrigan, M., Burke, F., Hayes, M., Lynch, H., Sahm, L., Heffernan, E., O’Keeffe, E., Blake, C.,
Horgan, F. and Hegarty, J. (2019), “Evidence-based practice education for healthcare professions:
an expert view”, BMJ Evidence-Based Medicine, Vol. 24 No. 3, pp. 103-108, doi: 10.1136/bmjebm-
2018-111019.
Migliore, L., Chouinard, H. and Woodlee, R. (2020), “Clinical research and practice collaborative: an
Evidence-Based nursing clinical inquiry expansion”, Military Medicine, Vol. 185
No. Supplement_2, pp. 35-42, doi: 10.1093/milmed/usz447.
Moeta, M.E. and Du Rand, S.M. (2019), “Using scenarios to explore conflict management practices of
nurse unit managers in public hospitals”, Curationis, Vol. 42 No. 1, pp. e1-e11, doi: 10.4102/
curationis.v42i1.1943.
Mosley, D.C. and Pietri, P.H. (2015), Supervisory Management: The Art of Inspiring, Empowering, and
Developing People, 7th ed., South-Western College.
Mueller, C. and Vogelsmeier, A. (2013), “Effective delegation: understanding responsibility, authority,
and accountability”, Journal of Nursing Regulation, Vol. 4 No. 3, pp. 20-27, doi: 10.1016/S2155-
8256(15)30126-5.
Munyewende, P.O., Levin, J. and Rispel, L.C. (2016), “An evaluation of the competencies of primary
health care clinic nursing managers in two South African provinces”, Global Health Action,
Vol. 9 No. 1, p. 32486, doi: 10.3402/gha.v9.32486.
Ofei, A.M.A. and Paarima, Y. (2021a), “Exploring the governance practices of nurse managers in the
Greater Accra region of Ghana”, Journal of Nursing Management, Vol. 29 No. 6, pp. 1-10, doi:
10.1111/jonm.13288.
Ofei, A.M.A. and Paarima, Y. (2021b), “Perception of nurse managers ‘care coordination practices
among nurses at the unit level”, International Journal of Care Coordination, Vol. 24 No. 1,
pp. 1-11, doi: 10.1177/2053434521999978
Ofei, A.M., Ansah Paarima, Y., Barnes, T. and Kwashie, A.A. (2019), “Planning practices of nurse
managers in Ghana”, IJRDO - Journal of Health Sciences and Nursing, Vol. 4 No. 10, pp. 1-23.
Ofei, A.M., Ansah Sakyi, E.K., Buabeng, T., Mwini-Nyaledzigbor, P. and Asiedua, E. (2014), “Nurses’
perception of planning practices of nurse managers in the Greater Accra region”, Ghana.
Wudpecker Journal of Medical Sciences, Vol. 3 No. September, pp. 33-45.
Ofei, A.M.A., Paarima, Y. and Barnes, T. (2020a), “Exploring the management competencies of nurse
managers in the Greater Accra region, Ghana”, International Journal of Africa Nursing Sciences,
Vol. 13, p. 100248, doi: 10.1016/j.ijans.2020.100248.
Ofei, A.M.A., Paarima, Y., Barnes, T. and Kwashie, A.A. (2020b), “Stress and coping strategies among
nurse managers”, Journal of Nursing Education and Practice, Vol. 10 No. 2, pp. 38-48,
doi: 10.5430/jnep.v10n2p39.
Ofei, A.M., Ansah Kwashie, A.A., Asiedua, E., Twum, N.S. and Akotiah, A.N. (2018), “Stress and coping
strategies among nurse managers at three district hospitals in the Eastern region of Ghana.
NUMID HORIZON”, An International Journal of Nursing and Midwifery Original, Vol. 2 No. 1,
pp. 1-13.
Paarima, Y., Kwashie, A.A. and Ofei, A.M.A. (2021), “Financial management skills of nurse managers
in the Eastern region of Ghana”, International Journal of Africa Nursing Sciences, Vol. 14, pp. 1-6,
doi: 10.1016/j.ijans.2020.100269.
Paarima, Y., Ofei, A.M.A. and Kwashie, A.A. (2020a), “Managerial competencies of nurse managers in Ghana”,
Africa Journal ofNursing andMidwifery, Vol. 22No. 2, pp. 1-20, doi: 10.25159/0256-8853/6969.
Paarima, Y., Ofei, A.M.A. and Kwashie, A.A. (2020b), “Managerial competencies of nurse managers in
Ghana”,Africa Journal of Nursing andMidwifery, Vol. 22 No. 2, doi: 10.25159/0256-8853/6969.
Polit, D.F. and Beck, C.T. (2014), Essentials of Nursing Research: Appraising Evidence for Nursing
Practice, 7th ed.,Wolters Kluwer Health/LippincottWilliams andWilkins.
Riisgaard, H., Nexøe, J., Le, J.V., Søndergaard, J. and Ledderer, L. (2016), “Relations between task First-line nurse
delegation and job satisfaction in general practice: a systematic literature review”, BMC Family
Practice, Vol. 17 No. 1, pp. 1-8, doi: 10.1186/s12875-016-0565-1. managers
Roshanzadeh, M., Vanaki, Z. and Sadooghiasl, A. (2019), “Sensitivity in ethical decision-making: the
experiences of nurse managers”, Nursing Ethics, Vol. 27 No. 5, pp. 1-13, doi: 10.1177/
0969733019864146.
Sabri Gassas, R. (2017), “Nurse managers’ attitude and competency towards delegation in Jeddah city”,
American Journal of Nursing Science, Vol. 6 No. 2, p. 72, doi: 10.11648/j.ajns.20170602.11.
Salmela, S., Koskinen, C. and Eriksson, K. (2017), “Nurse leaders as managers of ethically sustainable
caring cultures”, Journal of Advanced Nursing, Vol. 73 No. 4, pp. 871-882, doi: 10.1111/jan.13184.
Siirala, E., Peltonen, L.M., Lundgrén-Laine, H., Salanterä, S. and Junttila, K. (2016), “Nurse managers’
decision-making in daily unit operation in peri-operative settings: a cross-sectional descriptive
study”, Journal of NursingManagement, Vol. 24 No. 6, pp. 806-815, doi: 10.1111/jonm.12385.
Tingen, M.S., Burnett, A.H., Murchison, R.B. and Zhu, H. (2009), “The importance of nursing research”,
Journal of Nursing Education, Vol. 48 No. 3, pp. 167-170, doi: 10.1038/jid.2014.371.
Tompkins, F. (2016), “Delegation in correctional nursing practice”, Journal of Correctional Health Care,
Vol. 22 No. 3, pp. 218-224, doi: 10.1177/1078345816654229.
Yoon, J., Kim, M. and Shin, J. (2016), “Confidence in delegation and leadership of registered nurses in
long-term-care hospitals”, Journal of Nursing Management, Vol. 24 No. 5, pp. 676-685,
doi: 10.1111/jonm.12372.
Corresponding author
Adelaide Maria Ansah Ofei can be contacted at: adelaideaofei@yahoo.com or aansahofei@ug.edu.gh
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