Economic and social changes have led to an adaptation of healthcare management at all levels and a change in the way in which services are provided [1
]. The relationship between the economy and sustainability should be causes that make it necessary to develop management competencies with a high level of development, because these competencies are related to higher performance and outcomes [7
]. To address these changes, nurses need to be part of the core of healthcare [2
]. This claim is justified because the nurse is a professional with a high degree of leadership in many healthcare processes [13
], because of their closeness to patients, families and the community [14
]. Multiple research programs are led by nurses, including oncology, mental health, patient safety, palliative care and childcare, among others, which shows the importance of the nurse in the healthcare system [15
]. For this reason, the participation of the nurse in the governance of healthcare organizations is recognized as fundamental, both for health outcomes and the sustainability of the health system [20
The American Institute of Medicine, in its report entitled “The future of nursing: leading change in health”, already identified nursing in 2010 as a key player in critical decision making and in the transformation of healthcare [24
]. In the same way, Weber et al. [25
] and McClaringan et al. [20
] express themselves by stating that nursing is fundamental to the implementation of shared governance, because their commitment and participation is essential for the sustainability and improvement of health. Panayotou et al. [26
] emphasizes nursing within strategic plans, so that their key actions are focused on the creation of a culture of good practice. Brooks-Cleator et al. [27
], in his studies on transculturality and governance, focus on the importance of the nurse in establishing a culture of safety. The involvement of nurses in social action committees has achieved a great impact on the everyday problems of people [28
], highlighting the importance of their participation in decision making [29
]. When the nurse is involved in the different parts of the healthcare process (management and nursing care), better results are achieved [30
], communication is enhanced, together with collaboration between the different professional groups, innovation, organizational commitment and retention of staff [23
Nurse leaders and nurse manager are different roles, although there is a natural overlap of the required competencies [1
]. To develop the role of the nurse in the governance of healthcare organizations, the Global Nursing Leadership Institute (GNLI) in the actions of Nursing Now (2020) has developed a nurse preparation program designed to promote leaders for change, focused on new policies to improve the health of the population [18
]. Thus, to identify, mentor and train nurse leaders, the management competencies are an essential resource [31
]. Furthermore, for the integration of nurses at different levels of organizational management and governance, the nurse should develop management competencies that go beyond the scope of nursing [33
The nurse manager is responsible for planning and managing resources, organizing nursing care, supporting teamwork, evaluating the services provided, and contributing to the achievement of optimal results for the both the organization and the patients [36
]. Based on the literature review, it is necessary to increase the knowledge of the role of the nurse manager [36
], because the necessary competencies are often not clearly defined [35
], which would explain this lack of conceptualization of the nurse manager’s role. This same absence is evident in the Spanish context since there are no core competencies for carrying out management functions.
Core competencies are the collective learning of the organization, especially with regard to skills related to the generation of a product or service, so that all necessary knowledge and technologies are integrated [43
]. The core competencies in nursing management are associated with the success of the healthcare organization [45
]. Therefore, the core competencies for nurse managers are the set of fundamental competencies needed to ensure their work effectiveness [46
]. There are three functional roles within nursing management, the operational nurse manager (performs his or her function at unit level), the logistic nurse manager (performs his or her function at the department level), and the top nurse manager (performs his or her function at the organizational level); all of them should develop the core competencies to help improve the quality of healthcare. [46
Hence, the main objective of this study is to propose the core competencies to be developed by the nurse manager in the Spanish health system. To achieve this objective, the following specific objectives were set:
To determine core competencies for each functional level of nursing management by expert consensus;
To describe the level of development of competencies for each functional level of nursing management by expert consensus;
To describe the training needed to develop each of the required competencies by expert consensus;
To evaluate the structural validity of the proposed core competencies.
This paper is laid out as follows: first, the current state of knowledge about the nurse manager is described. The second part explains the research methods. Next, the results are presented and interpreted. Finally, the paper includes a discussion and conclusion.
This paper reports on the findings of the core competencies to be developed by the nurse manager in the Spanish health system. Decision making, relationship management, communication skills, listening, leadership, conflict management, ethical principles, collaboration and team management skills were seen as the core competencies for nurse managers. These findings are consistent with the findings from previous studies [47
]. Kantanen et al. [42
] emphasizes competency in decision making as a critical competency. McCarthy [58
] highlights core competencies that are aligned with our research in communication, relationship management, ethical values and decision making. Our research is also aligned with Pillay [59
] and with Gunawan [60
], when he described relationship management, conflict management and collaboration and team management as basic competencies.
To emphasize the strength of the core competencies identified in this research, we should say that this were also identified through a scoping review of the literature, with the exception of the listening skills and ethical principles, which were not found among the most frequent results in the review. It should be noted that the frequency of citation in the selected articles was used as a criterion for identifying the core competencies in the literature review.
This study identified that all the core competencies are needed independent of the functional level of nurse managers (executive management, logistics and operational management). Although each functional level requires different levels of competency development to be reached. There was a consensus between the experts in Delphi rounds 3 and 4. These findings are consistent with findings from previous studies (e.g., [47
]). McCarthy et al. [58
] highlighted that core competencies should be common to all three levels of management at different degrees of development. The AONE [61
] has shown shared competencies in their different models (“Nurse Manager Competency”, “Nurse Executive Competencies” and “Nurse Executive Competencies: CNE system”), and in the Nurse Executive Competency Assessment Tool, which differentiates the degree of development of each competency. In another sense, the AONE also defined non-shared competencies in their models.
With regard to the development of competencies, an agreement was reached in Delphi rounds 3 and 4. The experts agreed that competencies should be developed at “competent” (this was considered to have been reached when there is a strong demonstration of competency), “very competent” (level reached when there is a significant demonstration of competency) and “expert” level (level reached when it demonstrates the behavior of the competency model). This proposal is in agreement with AONE, who use the levels competent, proficient and expert for the development of competencies, emphasizing how these levels are reached through master’s degree studies or a Ph.D. [62
]. In contrast, in other studies such as “Nurse manager competencies”, the focus is on the degree to which the competencies contribute to the nurse manager’s work (minimally, moderately, significantly and essentially) [48
]. Furthermore, the results of the current study emphasize the need for a high level of competence development, in the same way that Crawford et al. [64
] demonstrated by indicating how executive practice would require a high degree of specialization and a specific development of competencies.
During Delphi rounds 3 and 4, the expert panel achieved a consensus about the training to be developed by the nurse manager on the three competency levels (“expert”, “very competent” and “competent”). The “competent” level is reached through continuing education, University Expert and University specialization diploma. With regard to the “very competent” level, the consensus was reached with University expert, University specialization diploma or master’s degree. Finally, the “expert” level is reached through master’s and Ph.D. studies. We should keep in mind how work experience and education significantly influence the development of competencies of nurse managers [65
]. However, experience as a nurse manager does not prepare them for the wide range of skills needed, requiring specialized training and work experience in concrete situations [33
]. Learning experientially as a nurse manager should be accompanied by prior planning and close mentoring [67
]. Previous studies show that the quality and level of training are responsible for orienting nurse managers towards good governance and the acquisition of the global vision of the organization [33
]. Furthermore, the results of the current study emphasize how it is possible to appreciate differences between nurse managers who have completed advanced management programs with respect to others who have not participated in this type of training program, adding evidence to previous studies [68
]. We share the recommendations given by the Joint Commission for Accreditation of Healthcare Organizations regarding the development of different career levels for nurses according to their level of education, training and experience [71
]. In addition, and just like Fralic [72
] affirmed, our results suggest that the training received by nurse managers would be one of the key aspects, because they are responsible for managing the area with the largest number of people, to make decisions about resource management and other areas such as quality of care, patient safety, research, training, expenditure or investment. The present study, along with other previous studies such as the research carried out by Herrin et al. [73
], support that the master’s degree training allows the nurse manager to be able to carry out adequate decision making, as well as for the effective management of health processes. In the same way, Rizani et al. [74
] point out that the average competence of nurses is higher when they have developed advanced studies (master’s degree or Ph.D.), increasing with time their level of competency to a higher degree than those nurses who have not developed advanced training.
The PCA verified the core competencies by defining three principal components named communication (communication skills, relationship management, conflict management), leadership (leadership and team management skills) and decision making (decision making and ethical principles), which would therefore constitute the competency factors to develop the role of a nurse manager in Spain (Table 6
). The strength of the eigenvalue confirms the importance of the relationship between decision making and ethical principles [75
], the need for strong leadership in working groups [76
] and communication as a fundamental element in conflict resolution [77
]. By comparing the core competencies emerging from our research with the most relevant international studies into core competencies for nurse managers, we would find a shared factor with communication, which should indeed be presented as a shared factor [25
The communication ability that would be expected from the nurse manager should include the ability to convey critical thinking and generate reflection in nurse teams prior to action [36
]. In the same way, it should, for example, facilitate conflict resolution and shared decision making, as well as creation, participation and team management [80
]. The differences that would arise between all the core competencies could be related to the different health contexts in which management practice takes place [58
The purpose of this study was to determine the core competencies for each functional level of nursing management by expert consensus. Our research contributes strong and important evidence to the nursing management field. Firstly, we provide a baseline of competencies for nurses who intend to carry out functions as nurse managers. Secondly, our study is also useful as a tool for evaluating and detecting areas for improvement for nurse managers. Finally, the core competencies should be useful for planning the professional development of nurse managers.
With regard to the limitations of this research, we should mention the different healthcare contexts from which the body of research knowledge is derived. Nursing management has specific characteristics for each of these contexts.
This study found core competencies for nurse managers in Spain. The successful nurse manager should develop all these competencies (as relevant to their practice) in today’s rapidly evolving healthcare system. In conclusion, this study yielded a consensus on eight core competencies for nurse managers in Spain: decision making, relationship management, communication skills, listening, leadership, conflict management, ethical principles, collaboration and team management skills, oriented towards leadership and good governance of health organizations, and on the basis of the social responsibility of health professionals. The nurse manager is responsible for the largest area of a healthcare organization, managing large budgets and large numbers of nurses. Therefore, a nurse should not be promoted to the role of a nurse manager without advanced management training.
Our research shows the precise level of development of each competency for the different functional levels of nurse manager. The nurse manager at any functional level should develop these core competencies before being promoted to other roles as a nurse manager.
Any nurse who wishes to develop his or her professional career as a nurse manager should first develop the core competencies shown here.
Moreover, our research shows the necessary education required to acquire the competency development necessary for each different nursing management role. Both nurses who want to be promoted to nurse managers and current nurse managers should follow the educational programs shown in order to adapt their knowledge to the requirements of the role.
These core competencies may have implications for practice, organizational policy, and education related to nursing management. The proposed core competencies may contribute to nurse manager role design, selection processes, and nurse manager curriculum design for traditional academic institutions and organizational continued professional development programs. Further understanding of core competencies is likely to inform interventions, which may improve nurses’ work environment, patient care, patient safety and organizational outcomes.
The following research should develop the characteristics corresponding to each of these competencies and training situations.