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Abstract

Purpose This paper aims to examine the leadership competencies of �rst- 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, quali�cation, professional experience, management experience and management training jointly predicted the leadership competencies of FLNMs [(R = 0.158, p = 0.016]. However, only management training was a signi�cant predictor in the model.

Practical implications Inappropriate leadership competencies have severe consequences for patients and sta� 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 �rst in Ghana which we are aware of that examined the leadership competencies at the unit level that identi�es predictors of leadership competencies.

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Abstract

Background

Theoretical framew

Ghana’s health-car system

Methods

Results

Discussion

Conclusion

Implications for nu management

Study strength and limitation

Recommendation future studies

Leadership competencies of �rst-line nurse managers: a quantitative study

Yennuten Paarima, Atswei Adzo Kwashie, James Avoka Asamani, Adelaide Maria Ansah Ofei

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Leadership in Health Services : 1751-1879

Article publication date: 3 January 2022

Issue publication date: 28 June 2022

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1/18/23, 2:49 AM Leadership competencies of first-line nurse managers: a quantitative study | Emerald Insight

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Keywords

Leadership competencies Nurse managers

First-line nurse managers

Citation Paarima, Y., Kwashie, A.A., Asamani, J.A. and Ofei, A.M.A. (2022), "Leadership competencies of �rst-line nurse managers: a quantitative study", Leadership in Health Services, Vol. 35 No. 3, pp. 338-354. https://doi-org.lopes.idm.oclc.org/10.1108/LHS-05-2021- 0047

Publisher: Emerald Publishing Limited Copyright © 2021, Emerald Publishing Limited

Background Health-care systems across the world have become complicated and confronted with several multifaceted challenges including increasing workload, inadequate sta�ng 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 sta� 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 in�uenced 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 de�ned as “the pursuit of organizational goals e�ciently and e�ectively 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 de�ned 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 e�ective 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

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behaviors to enlist the support of individuals or groups in the achievement of a shared goal. Chase (2010) identi�ed leadership competencies as a signi�cant 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 a�ect 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 sta� and patient outcomes and reduces mortality rates in all health care systems (Alomairi et al., 2018). This signi�cant 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 e�ciency and e�ectiveness at the unit.

According to Chase (2010), FLNMs need fourteen leadership competencies, that is, “decision making, power and empowerment, delegation, change process, con�ict resolution, problem-solving, stress management, research process, motivational strategies, organizational unit work, policy and procedure, sta� education, time management, and interdisciplinary care coordination”. Chase (2010) emphasized that any nurse manager de�cient 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-structured, done cautiously, and when the right condition prevails with the right supervision (Ofei et al., 2020a, 2020b). Undoubtedly, delegation has the potential to build competencies and resilience of inexperienced nurses, thus promoting con�dence 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 de�ned duties and spheres of authority (Ofei and Paarima, 2021a, 2021b). Again, the act of delegation requires an emotional maturity which apparently is rare even

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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.

Con�ict resolution has been identi�ed as a unique leadership competency that FLNMs require to e�ectively manage con�icts that may arise at the unit (Mueller and Vogelsmeier, 2013). Con�ict feels uncomfortable and awkward to many, it is an inevitable part of life and is prevalent among nurses at the unit which can negatively a�ect patient care. FLNMs' ability to e�ectively resolve con�icts 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 con�ict resolutions skills to enable them e�ectively manage con�icts hence, resorting to ine�ective measures such as avoidance and accommodation, which allow other professionals and junior colleagues alike to brand them as ine�ective 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 signi�cant impact on care coordination, work�ow, patient safety and sta� 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 them without 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 signi�cant 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.

In this study, we de�ned FLNM as a registered nurse or midwife who has o�cially 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

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supervising, directing, organizing and coordinating the work of nursing sta� 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 certi�cation 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 e�ective leadership at the unit level.

To accomplish these essential roles require leadership competencies to navigate and e�ciently manage dwindling health care resources (Paarima et al., 2020b). Despite these signi�cant 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 in�uence 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 identi�ed two additional competencies; thus, leadership and �nancial management competencies (Chase, 2010). Technical competencies refer “to the pro�ciency when working with tools, based on speci�c knowledge, in a particular �eld 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 “pro�ciency when working and relating with people based on one’s knowledge of people and how they behave, operate in groups, the way to e�ectively 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 signi�cant 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

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planning, signi�cance, 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 �nancial structure of the company and therefore to the decisions of source and use of �nancial resources, that is re�ected in the size of the �nancial income and/or charges” (Chase, 2010) and important for all managers. According to Paarima et al. (2020a, 2020b), any manager de�cient 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 managerial competencies of FLNMs in Ghana. The framework was selected over others because its constructs best accommodate the study objectives. It has expansive variables of assessing the technical, conceptual, human relationship, leadership, and �nancial management skills which was the main purpose of the big study. The technical, human, conceptual and �nancial 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, con�ict resolution, problem-solving, stress management, research process, motivational strategies, organizational unit work, policy and procedure, sta� education, time management 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 two million 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

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(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- pro�t 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 �rst- level nurse managers manage all the activities in the unit, coordinating all the activities of the nurses, other health professionals and the support sta�. They make operational decisions and plans for the department and are considered �rst- line managers.

However, FLMNs sometimes feel overwhelmed by competing values and demands e�ciency and quality. Inability to e�ectively address these competing demands will result in loss of con�dence and trust in them and the organization which can result in sta� dissatisfaction. Given this, FLNMs are required to e�ectively handle challenges and problems that arise at the unit level. They need to show responsiveness and support their sta� by ensuring a favorable work environment that will encourage trust and open communication where the safety and wellbeing of sta� 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 e�ective 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 su�cient for generalization to the population of interest (Polit and Beck, 2014).

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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 km ). 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 km . 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 Lower Manya 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 All FLNMs in the ten hospitals were eligible to participate in the study. FLNMs at least with 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.

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Data collection tool and procedure We adopted the Nurse Managers Competencies Instrument (Chase, 2010). The instrument was slightly modi�ed to suit the study's aim and objectives. The questionnaire has �ve dimensions (technical, conceptual, human, leadership and �nancial 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 modi�ed the instrument into a �ve-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 [email protected]/[email protected]. In this study, the �fth 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 o�cial consent was obtained from the management of each hospital, the researchers proceeded with the data gathering process. We allocated each hospital with a speci�c 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 to March 2018.

Ethical clearance The Ethics committee of the Noguchi Memorial Institute for Medical Research (023/17–18) approved this current study. We also obtained o�cial 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. Con�dentiality was maintained throughout the study by ensuring that participants’ rights were protected, and information divulged to researchers was not disclosed to unauthorized persons.

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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 re�ect 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 di�erent hospital with �fteen FLNMs. The outcome of the pretest was used to correct grammatical mistakes and to adjust areas of ambiguity. The overall Cronbach’s alpha coe�cient 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 coe�cient of instrument was 0.97, knowledge of competency 0.930, and ability to apply competency 0.944. Because we modi�ed the instrument to a �ve-point scale, a psychometric analysis was performed. The Cronbach’s alpha coe�cient 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 in�uence of participant characteristics (rank, gender, quali�cation, 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 O�cer. Furthermore, �rst-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.

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Leadership competencies of �rst-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 con�ict resolution (mean = 4.09 SD = 0.68) and the ability to apply con�ict 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.

The in�uence of leadership competencies of �rst-line nurse managers The results in Table 4 shows that, participant characteristics (gender, rank, quali�cation, professional experience, management experience and management training) together accounted for 15.8% of the variance in leadership competencies [R = 0.158, F

= 2.781, p = 0.016]. However, a more detailed examination of the predictors showed that only management training was statistically signi�cant (p = 0.001) in the regression model.

Discussion

Participant characteristics Participants within the age group of 30–39 years bracket constituted the majority. Our �nding agrees with the average age of nurses in Ghana, which is projected to be between the age of 25–40 years (Asamani et al., 2019, 2020). This �nding 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 Sta� Nurse and Senior Sta� 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 many males in Ghana preferring nursing as a career.

Most of the participants were in the Nursing O�cer’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 �ndings of Ofei et al. (2018), who found that most participants were Senior Sta� 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, while this current study used 121 FLNMs in ten health-care facilities. The �nding is also inconsistent with the Ghana Health Service job description of nursing and midwifery sta� which requires that a nurse manager should be at least a Senior Nursing O�cer (Ghana Health Service, 2005). This means that most of the participants in this study are not quali�ed to be occupying these key positions.

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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 sta� outcomes. The study found a di�erent 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 a�ect their appreciation of leadership at the unit level.

Leadership competencies of �rst-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 �nding 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 �ndings (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 e�ectively 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 e�ectively 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 �ndings (Sabri Gassas, 2017; Riisgaard et al., 2016).

Also, nurse managers had high knowledge and ability to apply con�ict resolution at the unit. This �nding suggests that nurse managers have the needed skills in con�ict resolution. As nursing units are human societies, con�icts are inevitable. However, poor management of con�ict has been linked to low morale, decreased productivity, job dissatisfaction, �nancial loss for organizations and poor work�ow (Moeta and Du Rand, 2019). Therefore, resolving con�icts 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 sta�. Ganz et al. (2014) reported a similar �nding in Israel. However, the result is inconsistent with the work of Moeta and Du

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Rand (2019) in which unit-level FLNMs in South Africa appeared to have challenges in dealing with con�ict between individuals or generally in the unit and intervened inappropriately.

E�ective decision-making is an essential leadership competency in nursing. FLNMs' ability to make e�ective clinical decisions is the most crucial factor a�ecting the sta� and patient outcomes (Chisengantambu-Winters et al., 2020). FLNMs in this current study showed higher decision-making skills. This �nding implies that FLNMs can e�ectively gather, process and prioritize critical patient information to choose the best nursing actions, implement and evaluate the outcomes. If nurses can participate in the decision process, it would enhance their con�dence, 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 sta� satisfaction and productivity. This �nding conforms to the work of Asiri et al. (2016) which a�rmed that an e�ective decision-making process signi�cantly 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 �nding 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 sta� in conducting and utilizing research �ndings in health-care delivery. This information calls for future directions to help nurses build and maintain research skills. The �nding 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, quali�cation, professional experience, management experience, and management training) accounted for 15.8% of di�erences in the leadership competencies of FLNMs. However, only management training statistically contributed to the model. This �nding implies that training in management improves leadership competencies. Thus, management training build-up FLNM competence and con�dence. 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 and management courses as approved by the GHS.

Although this �nding may not be new in the advanced health-care settings, it is a vital �nding in the context of Ghana where the appointment of nurse managers is based on clinical expertise and

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long service with little or no consideration to competencies and management/leadership training.

This �nding is congruent with a US study by Anderson (2016) in which attending a management academy signi�cantly 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 identi�ed 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 identi�ed 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 �ndings showed that FLNMs exhibited all the leadership competencies of the Nurse Managers Competency Instrument. The results also demonstrated that age, gender, quali�cation, 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 �nding implies a need for improvement in these competencies to e�ectively create a favorable work environment for quality and safe patient care. Training in management explained a signi�cant 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 identi�cation 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 �rst 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

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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 e�ective 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 �ndings 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.

Cronbach's alpha coe�cient of knowledge and ability to apply leadership competencies

Statement Knowledge of competency

Scale mean if item deleted

Scale variance if item deleted

Corrected item-total correlation

Cron alph item dele

Decision- making

50.63 60.938 0.731 0.92

Power and empowerment

50.82 59.429 0.767 0.92

Participants characteristics

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

Table 1.

Table 2.

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List of nurse manager leadership competencies (Chase, 2010)

Statement

Knowledge of competency

Ability to apply competency

N Mean SD Mean SD M di

Leadership competencies (Mean score)

117 3.91 0.60 3.76 0.66 0.

Decision 121 4 09 0 68 4 03 0 70 0 0

The in�uence of nurse manager characteristics on leadership competencies

Predictors Unstandardized coe�cients

Standardized coe�cients t

Model B Std. Error Beta

(Constant) 134.829 11.764 11.46 Gender −3.696 4.212 −0.093 −0.88 Rank 2.063 2.256 0.122 0.914 Q li� ti 2 932 2 994 0 111 0 98

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Acknowledgements Declarations Ethics: Approval to conduct the study was obtained from Noguchi Memorial Institute for Medical Research (CPN 023/17–18) before the start of the research. O�cial permission to gather data was sought and received from the management 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-pro�t organizations, or commercial entities.

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Con�icting 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 and AMAO.

Critical revision of article: All authors.

Data availability: The study raw data backing the �ndings is with the corresponding author and will be made available upon request.

Corresponding author Adelaide Maria Ansah Ofei can be contacted at: [email protected] or [email protected]

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