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International Journal of Healthcare Management
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Self-Perceived performance-based training needs among middle-level nursing managers in Jordan
Mohammad Abo Jalghef, Nidal Eshah, Islam Al-Oweidat & Abdulqadir J.
Nashwan
To cite this article: Mohammad Abo Jalghef, Nidal Eshah, Islam Al-Oweidat & Abdulqadir J.
Nashwan (03 Jul 2023): Self-Perceived performance-based training needs among middle- level nursing managers in Jordan, International Journal of Healthcare Management, DOI:
10.1080/20479700.2023.2231205
To link to this article: https://doi.org/10.1080/20479700.2023.2231205
© 2023 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group
Published online: 03 Jul 2023.
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Self-Perceived performance-based training needs among middle-level nursing managers in Jordan
Mohammad Abo Jalghefa, Nidal Eshaha, Islam Al-Oweidataand Abdulqadir J. Nashwan b
aFaculty of Nursing, Zarqa University, Zarqa, Jordan;bNursing Department, Hamad Medical Corporation, Doha, Qatar
ABSTRACT
Background:Nurse managers need to possess specific knowledge, skills, and attitudes to fulfil their roles and responsibilities and exemplify that they are competent to do their jobs.
However, there is a paucity of data on the performance-based training needs of middle- level nurse managers in Jordan.
Aim: To identify the performance-based training needs of middle-level nursing managers working in Jordanian governmental hospitals and to evaluate the differences in perceived performance-based training needs based on their socio-demographic and professional characteristics.
Methods:A descriptive cross-sectional design was utilized. The study recruited 132 nurses from three governmental hospitals in Jordan using convenience sampling. An online survey included the Hennessy-Hicks Training Needs Questionnaire was used for data collection.
Ethical approvals were obtained to conduct the study. Data were analysed using descriptive and inferential statistics using SPSS version 28.
Results:‘Designing a research study’item had the highest perceived need for training (M = 2.5, SD ± 2.5), while‘establishing a relationship with patients’item had the lowest (M = 0.4, SD ± 1.2). Nurses with more experience (F = 2.9, df = 131, P< 0.05), and nurses who worked in specialized units (F = 2.3, df = 131, P< 0.05) had significantly lower training needs than nurses with lesser years of experience, and nurses who worked in outpatient departments.
In addition, age, gender, prior training in nursing management, and years of experience as middle-level nurse managers significantly predicted the levels of training needed (R2= 0.23, P< 0.001).
Conclusion:Thefindings reflected the need for training on several managerial competencies.
Future research can help identify other personal and organizational factors affecting performance-based training needs.
ARTICLE HISTORY Received 22 February 2023 Accepted 23 June 2023 KEYWORDS Training needs;
performance-based;
competency; nurse; Jordan
Introduction
The ability of healthcare organizations to provide safe and high-quality nursing care to their clients and their families depends not only on the abilities of staff nurses but also on the competencies of nurse man- agers [1]. With competent nurse managers, manage- rial tasks will be completed, which can significantly impact patients, families, and other stakeholders [2].
In addition, determining competence based on per- formance and addressing gaps in competence by measuring needs can help nurse managers meet their roles’demands and expectations [3].
Tsang and colleagues [3] defined nurse managerial competence based on the quality of performance of job expectations. Nurse managerial competence can be described according to three performance charac- teristics, namely general, managerial, and professional categories. Furthermore, the authors broke down the three performance characteristics into sub-categories, namely organizing, problem-solving and decision-
making, innovation, communication, teamwork, com- mitment to quality service, relations with the public and patients, leadership, supervision, and manage- ment of staff, planning and control, use of resources, professional development and technical expertise, and mentorship [3].
Despite the significance of nurse managerial compe- tence, there is no standard method to measure it [4]. Fur- thermore, the lack of a standard measure may lead to wide variations in how nurse managerial competence is viewed by different healthcare settings in different country-specific or culture-specific contexts [4].
The results of the current study can benefit patients, families, managers, and other stakeholders of health- care organizations. Well-trained, competent, knowl- edgeable, and skilful nursing managers can lead the nursing and wider multidisciplinary team in providing safe, effective, and high-quality care.
The results of the current study can also help nurse educators in the assessment, planning,
© 2023 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrest- ricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The terms on which this article has been published allow the posting of the Accepted Manuscript in a repository by the author(s) or with their consent.
CONTACT Abdulqadir J. Nashwan [email protected] Nursing Department, Hamad Medical Corporation, P.O. Box 3050, Doha, Qatar https://doi.org/10.1080/20479700.2023.2231205
implementation, and evaluation of training sessions and workshops for nurse managers. Besides, middle- level nursing managers can have insight and self- awareness regarding the quality of their performance, the level of training they need to complete, the content of training they need to complete, and the methods with which they will be assessed if they meet their training needs or not.
Obviously, many previous research studies were conducted addressing the same theme of the current study both regionally and internationally. However, the current study and its emerging results create the urgency among policy makers and executive nurse managers to enforce the continuous training culture among nurse managers at all levels in healthcare institutions.
So, based on the detected gap in the literature, the current study aimed to identify the performance- based training needs of middle-level nursing managers working in Jordanian governmental hospitals and to evaluate the differences in perceived performance- based training needs based on the sociodemographic and professional characteristics of the middle–level nurse managers.
Research questions
1. What are the performance-based training needs of the middle-level nursing managers working in Jor- danian governmental hospitals?
2. Are there significant differences in middle –level nurse managers’ performance-based training needs based on sociodemographic characteristics?
3. Which of the socio-demographic of work-related factors predict the level of middle – level nurse managers’performance-based training needs?
A conceptual framework has been formulated that shows the variables of interest at play that might affect the formulation of programmes to improve managerial competence (Figure 1).
In a previous systematic review study was con- ducted by Kakemam and colleagues [5] to synthesize a best-fit framework that will elucidate current evi- dence on hospital managers’leadership and manage- ment competencies. Searching through 4 databases for studies were published between 2000 and 2020, the investigators identified 12 studies thatfit the eligi- bility criteria of the systematic review. The systematic review showed similar results of the understanding that competency and performance-based assessment of managerial training needs is an emerging concept and that even across countries, there is a lack of con- sensus on what constitutes competence of healthcare managers. Pooling results of different studies, the best-fit framework produced by the investigators
centred on 6 dimensions that composed managerial competence. These dimensions were communication, change, professionalism, evidence, resources, and knowledge. In addition, the study emphasized the sig- nificance of identifying training needs based on nurse manager competence because an objective framework or structure can be used to guide programme develop- ment [5].
Additionally, Gunawan and colleagues [6] devel- oped an instrument to measure the managerial com- petence of nursing managers using a competence and performance-based human resource management framework. The instrument was developed based on a literature review, pilot testing, validity and reliability tests, and field testing, which involved the partici- pation of 300 nurses. The resulting instrument con- sisted of 34 items arranged into 5 domains against which managerial competence was to be measured.
Training and evaluation was thefirst domain that con- sisted of developing nursing managers’ knowledge, skills, and attitudes using workshops, courses, and training programmes. Career planning and develop- ment was the second domain composed of creating opportunities to support the progression of nursing managers based on their career goals and aspirations.
The rewards scheme was the third dimension which consisted of monetary and non-monetary based com- pensation to reward the quality of work and support the livelihood and well-being of nursing managers.
The fourth dimension was recruitment and selection, which focused on the ability to put the right person on the right job based on experience and competence.
Lastly, the fifth dimension was the appraisal system which consisted of the ability of nursing managers to formally evaluate job performance [6].
In the same vein, Naranjee et al. [7] performed a qualitative study to explore the financial component of management competencies of nursing managers in eight public hospitals in South Africa. In-depth interviews were conducted to elicit responses regard- ing thefinancial management roles of nursing man- agers in their work environment, identify training needs regarding financial management competence, and develop a framework to improve nursing man- agers’skills in this area. Findings showed that nurse managers did not have the skills and competencies necessary to fulfil roles and responsibilities related to financial management. However, nurse managers felt they were indirectly involved in financial decision- making with upper management in budgeting, oper- ational planning, procurement, human resource plan- ning, skill mix requirement, costing of required nursing staff, and cashflow monitoring [7].
Besides, Al Makkouk [8] performed a literature review to develop training via continuing professional development (CPD) for nursing managers in Leba- non. The investigator recommended that nursing
managers be assessed on a set of competencies to evaluate the value and impact of training. As a result, a list of 22 competencies was identified which included (1) the ability to assess and identify staff and unit needs, (2) developing yearly plans for the unit, (3) fol- low-up on daily unit operations, (4) being role model for junior staff, (5) support staff performance improvement, (6) motivate and empower staff, (7) del- egate tasks to the right staff, (8) help the staffto man- age their time effectively, (9) solve daily unit problems and issues, (10), make right decisions for unit and staff, (11) enhance teamwork, (12) support staffpro- fessional development, (13) utilize positive discipline for better performance, (14) evaluate outcomes of nur- sing interventions, (15) lead quality initiatives, (17) manage own time effectively, (18) utilize evidence- based practice, (19) use effective communication, (20) coordinate patient care, (21) collaborate with other nursing managers to enhance the outcome, and (22) maintain positive relationships with other departments in the hospital [8].
Moreover, in Egypt, Ahmed and colleagues [9]
asked nursing managers about the competencies they felt were most important and were most frequently implemented in practice. A total of 55 nursing man- agers from 4 hospitals participated in the study. Nur- sing managers were asked about their perceptions of 7 core competencies, namely (1) assessment and inter- vention skills, (2) communication skills, (3) critical thinking skills, (4) humanistic caring and relationship skills, (5) management skills, (6) leadership skills, and (7) teaching skills. The highest scores were obtained from management, teaching, critical thinking, and lea- dership skills [9].
In regard to the predictors that might affect man- agers’ competencies; in Ghana, Ofei et al. [10]
explored socio-demographic factors that might influ- ence managerial competencies. Analyses of results from a cross-sectional survey of 121 nursing managers in 10 hospitals in the eastern region of Ghana showed that experience as a nurse, experience as a nurse man- ager, previous qualifications, and management train- ing were significant predictors of their technical and conceptual skills. In addition, improving educational attainment was more likely to improve technical and managerial competencies [11].
Likewise, Castro [12] recommended implementing and institutionalizing individualized training and orientation to better prepare nursing managers to carry out the roles and responsibilities attached to their jobs. A survey on nurse manager self-assessment and mentorship revealed 17 themes that would pro- mote training and learning, such as the provision of guidance and support, more customization of train- ing, evidence-based standardization, decrease in the learning curve, more meaningful orientation experi- ence, mentorship, assurance of expectations being met, and provision of experience-based training. As such, it is necessary to look at socio-demographic and other specific personally-related variables to better formulate individualized strategies to approach nur- sing managers’identified training needs [12].
The researchers do believe that the current study is a further step in the literature which is based on what is already known, such as the study that was conducted in the samefield by Babaeinesami and Ghasmi in 2021 in which the mentioned study shows the features of learning organizations and the current study aimed to assess the perceived level of performance-based training needs among nurse managers in which the continuous training is a milestone in learning organiz- ations [13].
Figure 1.Conceptual framework.
A paucity of studies performed in Jordan looked at the application of performance-based training needs assessment in developing training courses and programmes.
Methodology
Research procedure and sample
The study employed a descriptive correlation, cross- sectional design to identify the performance-based training needs of middle-level nursing managers working in governmental hospitals in Jordan.
The study was conducted in three governmental tertiary-level hospitals in Jordan. These hospitals are (1) Al Bashir Hospital, (2) Zarqa Hospital, and (3) Prince Hamza Hospital. Al Bashir Hospital comprises four distinct hospitals within its main campus: the Medical Hospital, Surgical Hospital, Maternity and Paediatric Hospital, and Emergency Hospital. First, Al Bashir Hospital has a total capacity of 1,088 beds, 70 middle-level nursing managers with a total number of 1800 nurses, making it the largest governmental and referral hospital in Jordan [14]. Second, Zarqa Hospi- tal has a total capacity of 494 beds, 24 middle-level nursing managers with a total number of 550 staff nurses. Finally, Prince Hamza Hospital has a total capacity of 436 beds, 30 middle-level managers with a total number of 450 staffnurses [14]. These hospitals were chosen because of the large number of patients treated there, which reflects the healthcare demand that must be met by competent, safe, and quality nur- sing management. In addition, these hospitals were chosen because of the relatively high number of middle-level nursing managers who compose the organizational structure of the hospitals. Moreover, these hospitals were chosen because they reflect a representative cohort of nursing managers across all areas of Jordan.
The study used a convenience sampling technique to recruit eligible nursing managers. Participants’
inclusion criteria were: (1) a middle-level nurse man- ager (i.e. nursing units’ manager or head nurses), (2) managing a clinical area providing direct bedside care and services to patients. On the other hand, exclusion criteria were: (1) administrative duties to areas that have no direct patient care responsibilities and (2) hav- ing a disability that might affect their performance.
The minimum required sample size was calculated using Cohen power tables and setting α= 5%, confi- dence interval at 95%, medium effect size for associ- ation (0.3), and power 0.8. The required minimum sample size is 85 participants. Because the study is cross-sectional, there is no need to adjust for attrition, but the sample size was increased to compensate for the possibility of incomplete data entry [15], so the final sample size was 132 participants.
Ethical considerations
Ethical approval from the institutional review board (IRB) of the Faculty of Nursing at Zarqa University and the selected hospitals was obtained prior to data collection. Participant autonomy was respected by providing them with full information about the study and gaining their signed informed consent before collecting any data from them. An online ver- sion of the informed consent was used and was signed electronically. Participants were ensured that they could withdraw without any need for explanation.
Confidentiality was ensured throughout the study, and no personally identifiable information was col- lected. Questionnaires were assigned code numbers matched to the master list of names only to prevent mismatching during data analysis. All collected data were stored securely, and soft copies were encrypted with a password. Encoded data were kept in pass- word-protected computers for data protection purposes.
There was no risk with participation in the study.
The participants did not undergo any experimentation or intervention. Survey questionnaires are short and only take 10–15 minutes to answer. There was no monetary benefit to joining the study. However, it was explained to participants that the study could con- tribute to building the evidence base around the use of performance-based training needs assessment among middle-level nursing managers working in govern- mental hospitals in Jordan. It was ensured that partici- pants could access the study results by requesting this if they wished.
Research instruments
The researcher developed the participant information sheet to collect data regarding socio-demographic and work-related variables. Data collected included age, gender, educational level, years working as a registered nurse, years working as a nurse manager, experience in the current hospital, and previous history of train- ing in nursing management.
Hennessy-Hicks training needs questionnaire The Hennessy Hicks Training Needs questionnaire was originally developed in 1996 to identify the devel- opment needs of nurse practitioners when the pro- fessional role was only beginning to be introduced as an advanced form of nursing practice.
The tool is made up of 44 items that cover five dimensions of nurse manager competency, namely (1) research/audit (items 3,6,7,9,15,21,25,26, and 27), (2) administrative/technical (items 2,20, and 29), (3) communication/teamwork (items 1,5,8,13,14 and 27), (4) management/supervisory (items 4,11,16,19,23 and 30), and (5) clinical activities (items 10,12,17,18,22
and 24). Each item can be rated on a 7-point scale according to responses based on two questions, namely (1) how critical the task is to the successful performance of the respondent’s job and (2) how well the respondent is currently performing the task. Hence, in this way, the tool also allows for analysis scores based on expec- tations and realities around competence and task per- formance [16]. Part C of the tool was no longer included because these were items that measured indi- vidualized training needs rather than group or unit requirements [16]
The tool has acceptable psychometric properties in the original development study [17]. For example, reliability measured by internal consistency demon- strated Cronbach alpha scores of 0.71–0.91 for each subscale and the overall scale. Also, the instrument demonstrated acceptable face and criterion validity [17].
Because the tool was originally intended for nurse practitioners who are more involved with direct patient care, the authors have developed 8 additional questions that made the tool specifically for nursing managers. Each item was given a score of 1–7 along a Likert scale, and then scores were summed for responses to thefirst and second questions. The total score of responses for thefirst question is called the critical Index, while the total score for the second question is called the skill index. After calculating the critical and skill indices, the critical index score should be subtracted from the score of the skill index. The resulting difference is called the training need index. The training need Index provides a numerical interpretation of the training needed in that particular competency [16].
The highest score for the critical and skill indices is 308 (score of 7 multiplied by 44 items). The lowest score for both is 44 (score of 1 multiplied by 44 items). Therefore, the range of scores is 44–308 with scores nearer 44 indicating low levels while scores nearer 308 indicating high levels of critical and skill indices. A respondent can obtain a training need index of 0, representing a perfect score (i.e. no training is needed) for each and all questionnaire items [18].
On the other hand, a positive training index score indicates the need for training (high critical but low skill indices). While a negative training index score can also be obtained, which means no training is needed, a negative training index score indicates that the participant does not give high levels of importance to the competency (low critical but high skill index) [18].
Because of the difference in the perceived impor- tance and level of actual performance of a skill, it was possible that (1) a skill was perceived as highly important and the participant had a high level of per- formance (reflected as a positive training need index score but score is near zero; the participant needs little
training in this area), (2) a skill was perceived as highly important but the participant had a low level of per- formance (reflected as a positive training need index score but score is nearer 6; the participant needs more training in this area), (3) a skill was perceived as not important and the participant had a high level of performance (reflected as a negative training need index score but score is near −6; the participant needs little training in this area), and (4) a skill was perceived as not important and the participant had a low level of performance (reflected as a negative train- ing need index score but score is near zero; participant may or may not need training in this area depending on how important the skill is in the participant’s roles and responsibilities).
The Hennessy -Hicks Training Needs Question- naire was translated into Arabic to make the questions more comprehensible to the study participants and cross-culturally adapted to the Jordanian community.
The tool was sent to a certified professional translator who translated it from English to Arabic, then was given to another certified professional translator who worked on back translation to English to see the clarity and accuracy of the translation process, i.e. the for- ward- and backward translation of the tool which was originally in English. Once compatibility of the forward and backward translated versions was estab- lished, the cross-culturally translated tool was sent to 3 nursing administration professors who decided on the semantic, idiomatic, experiential, and conceptual equivalent of the tool. The Arabic version was adjusted as appropriate, and equivalence with the original Eng- lish tool was ensured, the Cronbach’s alpha for this scale in the current study was 0.97.
Data collection
Once ethical approvals had been obtained, the researcher approached the nursing directors of hospi- tals that participated in the study to ensure support to access the middle-level nursing managers and direct shift supervisors. A master list was created for nursing managers eligible to participate using the inclusion- exclusion criteria. Afterward, the investigator approached the nursing managers individually and invited them to participate in the study. Online informed consent forms were sent via email to demonstrate participants’willingness to join. Recruit- ment continued until the target sample size was reached.
Nursing managers who accepted to participate were asked to answer (1) the participant information sheet that collected data about socio-demographic and work-related variables and (2) the Hennessy-Hicks Training Needs questionnaire. Data collection was done using the online survey method because it is more practical and convenient for nurses. First, the
questionnaires were made available through online versions using google sheets. Then, they were distrib- uted to participants through emails from their hospital departments. A reminder email was sent a week after the initial email to ensure a higher response rate.
Data collection was initiated on October 1st and ended on 25 October 2022.
Data analysis
Data were coded, entered, and analyzed using the Statistical Package for the Social Sciences (SPSS) ver- sion 26 software. SPSS is the most suitable pro- gramme to analyse quantitative data. Descriptive statistics were used to describe the study sample and the professional characteristics of the participat- ing nursing managers. Frequencies and percentages were computed for nominal and ordinal level vari- ables. Means and standard deviations were computed for continuous variables.
The independent t-test, one-way ANOVA, and Pearson’s r-test were used as appropriate. Multiple regression analysis was used to identify factors that could significantly predict performance-based training needs. Assumptions for every statistical test were checked and assured prior to conducting data analysis.
The significance criterion was set asP< 0.05.
Results
Sample characteristics
A total of 170 questionnaires were distributed to the study sample, out of which 132 participants returned the filled questionnaires (124 were middle-level nur- sing managers and 8 were direct shift supervisors in which they are considered middle-level managers), reflecting a response rate of 78% of nurse managers who participated in the study. Table 1 shows the socio-demographic characteristics of the participants.
The mean age of participants was 35 years old (SD ± 7 years), and more than half were males (n= 73, 55.3%). In terms of the years of experience as a regis- tered nurse, the majority of the participants have more than 10 years of experience (n= 70, 53.0%), and the majority of the participants have more than 10 years of experience in the current department (n= 56, 42.4%). On the other hand, regarding the years of experience working in a managerial position, the majority have less than 5 years of experience (n= 71, 53.8%).
More than half of the participants did not receive any previous training in nursing management (n= 73, 55.3%). Participants were recruited from different workplaces; inpatient floors (n= 43, 32.6%), outpati- ent departments (n= 44, 33.3%), and specialized units (n= 45, 34.1%).
Performance-based training needs
Table 2 shows all questionnaire items’ critical, skill, and training need indices. Tables 3–5 show items with the highest scores on each Index. In terms of the critical Index, item no. 5,‘getting on with your col- leagues’, item no. 19,‘organizing your own time effec- tively’, and item no. 27,‘working as a member of the team’, were rated as the items with the highest impor- tant item for training (m = 6.4, SD ± 0.7). In contrast, item 23,‘making do with limited resources’, was rated as the least important item for training (m = 2.9, SD ± 2.1). The total critical index score for the whole scale was 260, indicating high critical index levels. On the other hand, in terms of the skill index, item no. 1
‘establishing a relationship with patients’ and item no. 4 ‘appraising your own performance’ were rated as the items with the highest level of skill performed in the actual practice (m = 5.9, SD ± 0.9), while item no.‘designing a research study’was rated as the item with the lowest level of skill performed in the actual practice (m = 2.8, SD ± 1.8). The total skill index score for the whole scale was 219, indicating high levels of skill index. Taken together, the critical Index is higher than the skill index, thus resulting in a positive score for the training needs Index or the need for performance-based training.
When a participant does not need any training on a particular skill, the training need index score is zero (After calculating the criticality and skill indices, the score of the critical Index should be subtracted from the score of the skill index. The resulting difference Table 1. Socio-demographic characteristics of the study participants (n= 132).
Variables Mean (m) SD
Age 35 years old 7 years
Variables Frequency
(n)
Percentage (%) Gender
Male 73 55.3
Female 59 44.7
Years of Experience as a Registered Nurse
< 5 year 19 14.4
5–10 years 43 32.6
> 10 years 70 53.0
Years of Experience in the Current Place of Work
< 5 year 27 20.5
5–10 years 49 37.1
> 10 years 56 42.4
Years of Experience in the Current Place of Work
< 5 year 71 53.8
5–10 years 24 18.2
> 10 years 37 28.0
History of Training in Nurse Management
Yes 59 44.7
No 73 55.3
Department
Inpatient 43 32.6
Outpatient 44 33.3
Specialized Units 45 34.1
is called the training need index) indicating a perfect level of perceived importance and a perfect level of actual skill performance. For example, the item with the highest perceived need for training was‘designing a research study’(m = 2.5, SD ± 2.5) (high importance, low performance), while the lowest two items in terms of the need for training were‘establishing a relation- ship with patients’ (m = 0.4, SD ± 1.2) (high
importance, high performance) and‘making do with limited resources’ (m =−2.0, SD ± 2.2) (low impor- tance, high performance). The total training need index was 41.Table 2 shows all questionnaire items’
critical, skill, and training need indices.
Performance-based training needs sub- domains
The questionnaire allowed the measurement of the critical, skill, and training needs indices of 5 sub- domains of nurse management roles, namely (1) Table 2. Performance-based training needs of the middle nursing managers–individual items.
Items of Hennessy Hicks Training Needs Questionnaire Critical Index Skill Index Training Need Index
1. Establishing a relationship with patients. 6.3 5.9 0.4
2. Doing paperwork and/or routine data inputting. 5.9 5.4 0.5
3. Critically evaluating published research. 5.2 3.1 2.1
4. Appraising your own performance. 6.3 5.5 0.8
5. Getting on with your colleagues. 6.4 5.9 0.5
6. Interpreting your own researchfindings. 5.4 3.2 2.2
7. Applying research results to your own practice. 5.6 3.8 1.8
8. Communicating with patients face-to-face. 6.3 5.8 0.5
9. Identifying viable research topics. 5.6 3.6 2.0
10. Treating patients. 6.3 5.7 0.5
11. Introducing new ideas at work. 6.3 5.6 0.7
12. Accessing relevant literature for your clinical work. 5.6 3.6 2.0
13. Providing feedback to colleagues. 6.3 5.6 0.7
14. Giving information to patients and/or carers. 6.3 5.7 0.6
15. Statistically analyzing your own data. 5.6 3.3 2.3
16. Showing colleagues and/or students how to do things. 6.3 5.6 0.6
17. Planning and organizing an individual patient’s care. 6.1 5.6 0.5
18. Evaluating patients’psychological and social needs. 6.1 5.5 0.6
19. Organizing your own time effectively. 6.4 5.7 0.6
20. Using technical equipment including computers. 6.2 5.7 0.5
21. Writing reports of your research studies. 5.6 3.5 2.0
22. Undertaking health promotion studies. 5.6 3.5 2.0
23. Making do with limited resources. 2.9 4.9 −2.0
24. Assessing patients’clinical needs. 6.2 5.7 0.5
25. Collecting and collating relevant research information. 5.4 3.7 1.7
26. Designing a research study. 5.3 2.8 2.5
27. Working as a member of a team. 6.4 5.8 0.6
28. Accessing research resources (e.g. time, money, information, equipment). 5.9 4.5 1.4
29. Undertaking administrative activities. 6.1 5.0 1.0
30. Personally coping with change in the health service. 6.3 5.6 0.6
31. Dealing with personnel management issues. 6.0 5.1 0.9
32. Providing performance feedback to staff. 6.0 5.2 0.8
33. Controllingfinancial resources. 5.8 4.7 1.1
34. Planning and organizing workload. 6.2 5.4 0.8
35. Writing management reports. 5.9 4.9 0.9
36. Generating income for your organization. 5.9 4.8 1.1
37. Designing and implementing an audit. 5.9 5.1 0.8
38. Consulting with colleagues to discuss service provision. 6.1 5.5 0.6
39. Accessing available resources for organizational development. 6.1 5.5 0.6
40. Developing joint working arrangements with others. 6.1 5.5 0.6
41. Actively facilitate organizational improvements. 6.2 5.6 0.6
42. Undertaking business planning activities. 6.2 5.6 0.5
43. Developing a shared vision of organizational goals. 6.2 5.6 0.6
44. Converting organizational goals into personal action plans. 5.7 5.5 0.2
Table 3.Top scoring items of the Critical Index–the perceived importance of the skill.
Items of Hennessy Hicks Training Needs Questionnaire
Criticality Index
5. Getting on with your colleagues. 6.4
19. Organizing your own time effectively. 6.4
27. Working as a member of a team. 6.4
1. Establishing a relationship with patients. 6.3
4. Appraising your own performance. 6.3
8. Communicating with patients face-to-face. 6.3
10. Treating patients. 6.3
11. Introducing new ideas at work. 6.3
13. Providing feedback to colleagues. 6.3
14. Giving information to patients and/or carers. 6.3 16. Showing colleagues and/or students how to do
things.
6.3 30. Personally coping with change in the health service. 6.3
Table 4.Top-scoring items of the Skill Index–evaluating how well a skill is performed.
Items of Hennessy Hicks Training Needs Questionnaire Skill Index
5. Getting on with your colleagues. 5.9
4. Appraising your own performance. 5.9
11. Introducing new ideas at work. 5.8
2. Doing paperwork and/or routine data inputting. 5.8 14. Giving information to patients and/or carers. 5.7
24. Assessing patients’clinical needs. 5.7
17. Planning and organizing an individual patient’s care. 5.7 18. Evaluating patients’psychological and social needs. 5.7
research/audit, (2) communication/teamwork, (3) clinical activities, (4) administrative/technical, and (5) management/supervisory. In terms of the critical Index, communication/teamwork was perceived as the sub-domain with the highest importance for train- ing (µ = 6.3, SD ± 0.7), while research/audit was per- ceived as the sub-domain with the lowest importance (µ = 5.6, SD ±1.3). In terms of the skill index, communication/teamwork was the sub-domain with the highest level of performance (µ = 5.8, SD
±0.9), while research/audit was the sub-domain with the lowest level of performance (µ = 3.6, SD ± 1.4).
Lastly, in terms of the training needs Index, research/audit was the domain with the need for the most training (high importance, low performance) (µ = 1.9, SD ±1.9), while management/supervisory was the domain with the least need for training (high importance, high performance) (µ = 0.2, SD
±0.7).Tables 6–8shows the critical, skill, and training need indices for the sub-domains.
Socio-demographic characteristics and performance-based training needs
Pearson’s r was used to assess whether a significant relationship existed between age and training need index. The results showed a weak negative, but signifi- cant relationship between age and training need indi- ces for research/audit (r=−0.17, P< 0.05), clinical activities (r=−0.21, P< 0.05), and administrative/
technical (r=−0.28, P< 0.01) sub-domains. These
results feed into the overall training need index, which has a weak negative but significant relationship with age (r=−0.29,P< 0.01). In addition, a weak posi- tive but significant relationship was found between age and skill index (r= 0.24,P< 0.01) skills. No significant correlations were found between age, communication/
teamwork, management/supervisory domains, or age and the overall critical Index (Table 7).
The Independentt-testwas used to test whether sig- nificant differences existed in performance-based training needs based on gender. All the needed assumptions were met and not violated in order to run the statistical analysis as well as normality and normal distribution of data was assured in which data were checked and screened for outliers. The results showed that female nurses (µ = 204.2, SD ± 36.1) had significantly higher scores than male nurses (µ = 190.5, SD ± 31.8) on overall skill index (t =−2.41, P< 0.05). This result is matching with thefindings on the overall training need index, with male nurses (µ = 43.9, SD ± 42.3) having higher scores in this area than female nurses (µ = 33.5, SD ± 33.1) (t =1.53,P< 0.05).
No other significant differences were found in training need indices of each sub-domain based on gender.
The One-way ANOVA was used to determine whether any significant differences existed in perform- ance-based training needs based on years of experience as a registered nurse. Post hoc tests showed that nurses who had less than 5 years of experience as a registered nurse had significantly higher training need index on the research/audit domain than nurses who had 5–10 years of experience (F = 2.09, df = 131,P< 0.05), on the administrative/technical domain than nurses who had more than 10 years of experience (F = 3.56, df = 131, P< 0.05), on overall training need index than nurses who had more than 10 years of experience (F = 2.9, df
= 131, P< 0.05). Consequently, nurses with less than 5 years of experience as registered nurses had significantly lower overall skill index than nurses with more than 10 years of experience (F = 2.5. df = 131,P< 0.05). No other significant differences were found (Table 8).
One-way ANOVA was also used to determine whether any significant differences existed in perform- ance-based training needs based on years of experi- ence in the current workplace. The results showed that nurses with less than 5 years of experience in the current workplace had a significantly higher train- ing need index than nurses with more than 10 years of experience (F = 0.44, df = 131,P< 0.05). No other sig- nificant differences were found.
One-way ANOVA was used to determine whether any significant differences existed in performance- based training needs based on years of experience as a middle-level nurse manager. No significant differ- ences were found.
An Independentt-test was performed to determine whether any significant differences existed in Table 5.Top scoring items of the Training Needs Index–the
numerical interpretation of the amount of training needed in that skill.
Items of Hennessy Hicks Training Needs Questionnaire
Training need index 32. Providing performance feedback to staff. 0.8
34. Planning and organizing workload. 0.8
8. Communicating with patients face-to-face. 0.5
27. Working as a member of a team. 0.6
13. Providing feedback to colleagues. 0.7
30. Personally coping with change in the health service.
0.7 29. Undertaking administrative activities. 1 38. Consulting with colleagues to discuss service
provision.
0.6
Table 6. Performance-Based Training Needs of the middle nursing managers – critical index, skill index and training needs index.
Rank Item
Critical Index
Skill Index
Training Need Index
1. Research/audit 5.6 3.6 2.0
2. Clinical activities 6.0 5.0 1.0
3. Administrative/
technical
6.0 5.4 0.6
4. Communication/
teamwork
6.3 5.8 0.5
5. Management/
supervisory
5.7 5.5 0.2
performance-based training needs based on whether any prior nurse management training was received.
No significant differences were found.
One-way ANOVA was used to determine whether any significant differences existed in performance- based training needs based on the ward or department where the participant worked. The results showed that middle-level nurse managers from the outpatient department had a significantly higher training need index on the research/audit domain than nurses from inpatientfloors (F = 2.3, df = 131,P< 0.05). In addition, middle-level nurse managers from the outpatient department had significantly higher training needs Index on the administrative/technical domain than nurses from specialized units (F = 2.1, df = 131, P<
0.05). Also, middle-level nurse managers from the out- patient department had significantly higher overall critical Index than nurses from other departments (F
= 6.2, df = 131, P< 0.01) and an overall skill index than nurses from specialized units (F = 2.6, df = 131, P< 0.05). No other significant differences were found.
Perceived importance and actual level of performance
Pearson’srcorrelation was used to determine whether a significant relationship existed between the per- ceived importance of a skill and the actual level of per- formance of that skill. The results showed a weak positive but significant relationship (r= 0.34, P<
0.001). Further analysis was done to identify corre- lations between the sub-domains of criticality and skill indices. There was a moderate positive significant relationship between the perceived importance and actual level of performance for each of communi- cation/teamwork (r= 0.552, P< 0.001), clinical tasks (r= 0.34, P< 0.001), administration (r= 0.45, P<
0.001), management/supervisory tasks (r = 0.58, P<
0.001), while there was no significant relationship between the perceived importance and actual level of performance for research/audit (r= 0.03,P= 0.779).
Predictors of performance-based training needs Stepwise linear regression was performed to deter- mine factors that can predict the overall training need index. Technically, all the needed assumptions for the regression analysis to be executed were checked and not violated. Specifically, data were assessed for outliers, multicollinearity, singularity, normality, homoscedasticity, linearity and indepen- dence of residuals as well. Furthermore, all variables were checked for multicollinearity and some issues had been picked up from the correlation matrix;
among all entered independent variables, there was no high relationship above (0.7) between them;
that’s why all the independent variables were retained. The whole regression model significantly predicted the level of performance-based training needs (P< 0.001). In specific, age (B =−2.3, P<
0.01), gender (B =−18.0, P< 0.01), years of experi- ence working as a middle-level nurse manager (B = 22.7, P< 0.001), and prior training in nursing man- agement (B =−33.3, P< 0001) significantly predicted training need index (R2= 0.23, P< 0.001), which means that 23% of the variation in the training needs index can be explained by the socio-demo- graphic variables in the regression model (Table 9).
Priorities for training based on participants’ perceptions
The total score as the top priority for each of the eight topics concerning the training needs based on Table 7.Relationship between age and training needs Index.
Variable Category R/A C/T CA A/T M/S CI SI TNI
Age r −0.17 −0.13 −0.21 −0.28 −0.08 −0.08 0.24 −0.29
P-value 0.05* 0.15 0.01* 0.001* 0.34 0.36 0.01* 0.001*
Notes: Legend: R/A–research/audit, C/T–communication/teamwork, CA–clinical activities, A/T–administrative/technical, M/S–management/super- visory, CI–criticality index, SI–skill index, TNI–training need index, *significant atP< 0.0.
Table 8.Differences in the performance-based training needs based on socio-demographic characteristics.
Variable Category R/A C/T CA A/T M/S CI SI TNI
Gender t 1.42 2.18 2.40 −0.29 1.47 −0.73 −2.41 1.53
P-value 0.40 0.07 0.11 0.10 0.50 0.53 0.05* 0.03*
Years of Experience as Registered Nurse F 2.09 0.58 1.54 3.56 0.87 0.10 2.61 3.08
P-value 0.05* 0.33 0.09 0.02* 0.22 0.91 0.08 0.05*
Years of Experience in the Current Department F 0.35 0.47 0.01 3.52 0.55 0.22 1.63 0.56
P-value 0.55 0.65 0.93 0.04* 0.83 0.80 0.20 0.57
Years of Experience as a Middle Level Nurse Manager F 0.29 0.12 0.17 1.54 0.62 1.17 4.10 0.77
P-value 0.45 0.95 0.76 0.64 0.45 0.31 0.02* 0.47
History of receiving Prior training t −3.12 −1.98 −2.96 −3.67 −0.10 −0.83 3.50 −4.00
P-value 0.14 0.46 0.42 0.92 0.97 0.61 0.24 0.70
Area of practice F 2.26 0.83 0.04 2.12 1.82 6.82 3.23 0.43
P-value 0.05* 0.47 0.85 0.05* 0.07 0.002* 0.04* 0.65
participants’perceptions was counted to identify and rank priority areas. The item for which the highest number of participants voted as a top priority was quality improvement skills (total scores = 22), fol- lowed by human resources staffing, recruitment, and retention (total scores = 20), then each of the evi- dence-based practice skills, research and implemen- tation (total scores = 17), and financial skills, finances, cash flow, and resource allocation (total scores = 17) (Table 10).
Discussion
Performance-based training needs
The results showed that middle-level nurse managers had a high critical index (i.e. perceived importance of training on a competency) and skill index (i.e.
expression about the level of actual performance) based on scoring instructions [3]. However, the overall critical Index was higher than the skill index, represent- ing a perceived need for training to improve the level of all performance (i.e. training index). Unfortunately, there is a scarcity of studies in Jordan about perform- ance-based training needs among middle-level nurse managers. Hence, the results of the current study are unique empirical data on the performance-based train- ing needs of middle-level nurse managers, especially when considering that previous studies assessing train- ing needs in Jordan did not offer a comprehensive pic- ture of the nurse manager competencies [19].
The results showed that middle-level nurse man- agers had the highest training need Index for
‘research/audit competencies’, which supports the findings of previous studies showing the need to improve the knowledge and skills of nurse managers in the development, implementation, and translation of research evidence [20,21]. Meeting the training needs of middle-level nurse managers in research and audit is essential not only because they play a critical role in the utilization of research evidence and incor- porating it with the clinical expertise of the multidisci- plinary team but also because nurse managerial support and leadership is a key ingredient in the implemen- tation of evidence-based practice among staff nurses who provide direct bedside care [22,23]. Moreover, improving audit skills increases the ability of nurse managers to implement quality improvements efforts, evaluate the effectiveness of nursing services, monitor and measure whether key organizational outcomes are met, and ensure that standards and benchmarks are achieved [24]. A quality audit modeled and implemented by competent nurse managers has signifi- cantly influenced the effectiveness of healthcare deliv- ery systems and feedback from service users and the wider community [25].
On the other hand, the results indicated that middle-level nurse managers felt the least need for training on‘management and supervisory competen- cies’. This might be an expected result since reacting management occurs daily, as it is the core responsibil- ity of nurse managers. However, this does not mean that nurse managers should not receive any more training. Instead, the result implies the need for nurse managers to continue receiving regular training and educational sessions to keep their competencies at the same high level of functioning as they were at the data collection time.
The results showed that female, older middle-level nurse managers and nurses with longer experience had significantly higher skill indices and lower training need indices compared to their counterparts. Other studies found similar results that looked at factors that might affect nurse manager competence [21,26].
These results support the idea that competence increases and improve with experience and thus under- line the significance of investing in junior nurses’pro- fessional growth and development. As noted by Castro [12], to enable junior nurses to train, learn and adapt increasingly to their roles and responsibilities, hospital administrators and higher-level nurse managers should focus on removing barriers to learning, provid- ing a meaningful orientation, and settling-in experi- ence, setting appropriate and realistic expectations, providing guidance and support, individualization and customization of training, and providing a mentor- ing network. Moreover, there should be a drive towards implementing effective retention strategies to reduce Table 9. Predicting the training need Index middle nursing
managers by certain socio-demographic variables.
Variable
Beta
coefficient P Model
R2
Model P
Age −2.3 0.002* 0.23 0.000*
Gender −18.0 0.007*
Prior training as nursing manager
−33.3 0.000*
Years of Experience as Nurse Manager
22.7 0.000*
*Significant atP< 0.01.
Table 10.Priority rank for training needs according to certain proposed topics.
Rank Topic
Total scores as the top priority 1. Quality Improvement Skills–Monitoring,
Evaluation
22 2. Human Resources Staffing, Recruitment,
Retention
20 3. Evidence-Based Practice Skills–Research,
Implementation
17 4. Financial Skills–Finances, Cash Flow,
Resource Allocation
17 5. Leadership Skills–Motivation, Inspiration,
Role Modelling
14 6. Personal Skills–Coping, Time
Management, Attitudes
14 7. Interpersonal Skills–Communication,
Listening
14 8. Clinical Skills–Skill mix, staffallocation,
clinical expertise
14
the intention to leave among junior nurse managers because, as results showed, it is only through their role that they will gain a significant performance in their expected competencies [27].
On the other hand, the study did not generate ade- quate data to justify why female middle-level nurse man- agers would have a higher performance and lesser need for training than their male counterparts. However, this might be because of a larger proportion of female par- ticipants in the sample, but this is not an adequate reason to justify why this might be so. Other studies did notfind significant differences in nurse manager competence based on gender [28,29]. Whether or not innate charac- teristics based on gender influence the performance- based training needs of middle-level nurse managers can be explored in future studies.
Lastly, middle-level nurse managers working in specialized units (e.g. intensive care units) had signifi- cantly lesser training need indices than nurses work- ing in outpatient departments. Patients admitted to specialized units not only possess complex and often life-threatening conditions but also highly depend on advanced medical equipment, supplies, and technol- ogies. As such, nurses must possess high levels of knowledge and skills in order to be able to meet patient and family demands in highly stressful and emotive situations [30]. Nurses in outpatient depart- ments do not deal with such patient types and acuities.
Therefore, they would not be expected to have the same competencies as nurses in specialized units.
However, the results underscore the need to keep nurses working in outpatient departments up to date with the expected competencies.
Predictors of performance-based training needs Identification of the predictors of performance-based training needs among middle-level nurse managers using stepwise multiple regression analysis reflects the results of the exploration of socio-demographic characteristics except for prior receipt of training in nurse management. The regression model indicated that the variables of age, gender, years of experience as a nursing manager, and prior management training significantly predicted the training needs Index. In addition, other studies reported the predictive influ- ence of age and years of experience on nurse manager competence [26,31].
However, it should be noted that the regression analysis model only explained 23% of the observed variance on the training need index. This suggests that other unexplored factors contribute to the remaining variance [15]. These factors might be out- side socio-demographic characteristics, such as those pertaining to the profession, organization, or nurse- sensitive outcomes. Future research can help in iden- tifying these factors.
Limitations
Despite the strength of this study; it has some limitations such as adopting convenience sampling that might affect the generalizability of the results to all middle level nursing managers. Additionally, the small sample size that was recruited in the current study might affect the representation aspect of the participant.
Thus, it is recommended to do further studies recruiting large numbers of middle level nursing manegers in gov- ernmental hospitals in Jordan. Additionally, the study used a self-report questionnaire to assess the perform- ance level of middle-level nurse managers. While self- assessment might coincide with the perceived level of importance, a separate, independent performance measurement would have provided a more objective measure. Moreover, the study involved middle-level nurse managers in a limited sample of hospitals in Jor- dan. Therefore, the generalizability of results is restricted to middle-level nurse managers whose socio-demo- graphic characteristics and hospital type are similar to those of study participants. Finally, the study was limited by its exploration of several socio-demographic charac- teristics. The regression model only showed a variance of 23%, suggesting that other unexplored factors con- tributed to the remaining unexplained variance. Thus, future research can aid in identifying the role of such factors and how gaps in training needs might be more effectively addressed in the future.
Implications
Results can be used to ensure that middle-level nurse managers meet the competencies required for them to be able to carry out their roles and responsibilities.
Nurse manager competence is associated with positive patient- and organizational outcomes such as better patient satisfaction, improved staff job satisfaction, more responsive care, lesser rates of intention to leave and turnover, better teamwork, and assurance of the quality and safety of patient care. Moreover, results can be used to ensure that training and edu- cational workshops are designed in accordance with the training needs of middle-level nurse managers and not randomly chosen based on objectives set by the hospital or education department.
Besides, interventions targeted at resolving gaps in training should give more emphasis on younger, less experienced nurses who demonstrated significantly lower scores on skill indices and higher scores on training need indices. Compared to older nurses who perceived less need for training to achieve their competencies, younger middle-level nurse managers may require more support to increase their level of actual performance.
Academically, paradigm shift in building curricula is needed for the academicians, which means nursing
students should be encountered with the training con- cepts and continuous professional development strat- egies as well as to be prepared well to their career positions.
Future research should be conceptualized and implemented in better understanding the perform- ance-based training needs of middle level nurse man- agers. Research studies can take the form of (1) a qualitative exploration of the beliefs, feelings, emotions and experiences of middle level nurse man- agers regarding their competencies, (2) longitudinal measurement of performance-based training needs as they change over time.
Conclusion
Effective interventions for addressing training needs are crucial for organizations looking to improve the per- formance of their workforce. These interventions should be tailored to the competencies perceived as most important by the individuals and teams who will be impacted. By aligning the training with the specific skills and knowledge needed, organizations can ensure that the resources invested in training are being used effec- tively and achieving the desired outcomes.
However, it is also important to consider the broader context in which training needs occur. For example, personal and organizational factors can sig- nificantly impact performance-based training needs.
For example, factors such as employee motivation, organizational culture, and team dynamics can all play a role in shaping the training needs of an individ- ual or team. Therefore, organizations can design inter- ventions that take a holistic approach to address training needs by identifying and understanding these factors.
In conclusion, interventions for addressing training needs should be targeted and effective, aligned with the perceived importance of the competencies, and also taking into account other personal and organiz- ational factors affecting performance-based training needs. Future research should focus on identifying these factors to support organizations in their efforts to improve the performance of their workforce.
Declarations
Acknowledgements
MAJ: Conceptualization. MAJ, NE, IO, AJN: Research design, Data collection, Analysis, Literature search, Manu- script preparation. All authors have accepted responsibility for the entire content of this manuscript and approved its submission.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Funding
The Qatar National Library funded the publication of this article.
Ethics approval
The Institutional Review Board at the Faculty of Nur- sing, Zarqa University (Zarqa, Jordan) approved the study. Informed consent was obtained from all partici- pants. All methods were carried out following relevant guidelines and regulations or the Declaration of Helsinki.
Data availability
All data generated or analyzed during this study are included in this published article.
Notes on contributors
Mohammad Abo Jalghefis a post graduate student in the nursing administration program at Zarqa University.
Prof. Nidal Eshahis a vice president of Zarqa University.
Dr. Islam Al-Oweidatis an assistant professor of nursing administration at Zarqa University.
Dr. Abdulqadir J. Nashwanis a researcher at Hamad Medi- cal Corporation in Qatar.
ORCID
Abdulqadir J. Nashwan http://orcid.org/0000-0003-4845- 4119
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