Journal of Nursing Management, 2014, 22, 192–200
Identifying nurse managers’ essential communication skills: an analysis of nurses’ perceptions in Oman RUBY A. ROUSE
PhD
1
and MAJID AL-MAQBALI
RN, PhD
2
Associate Faculty, School of Advanced Studies, University of Phoenix, San Antonio, Texas, USA and 2Director of Nursing and Midwifery Affairs, Ministry of Health, Muscat, Sultanate of Oman 1
Correspondence Ruby A. Rouse Associate Faculty School of Advanced Studies University of Phoenix 15319 Rompel Trail San Antonio Texas 78232 USA E-mail: [email protected]
ROUSE R.A. & AL-MAQBALI M.
(2014) Journal of Nursing Management 22, 192–200. Identifying nurse managers’ essential communication skills: an analysis of nurses’ perceptions in Oman Aim(s) The aim of the present study was to analyse nurses’ perceptions of the communication qualities that are essential for nurse managers to carry out their jobs effectively. Background An examination of effective communication may help to identify nurse manager behaviours that promote dignity and respect. Method(s) A paper-and-pencil survey collected open-ended data from 1526 nursing professionals (RNs) representing 22 hospitals in Oman. Qualitative content analysis was conducted first, followed by a quantitative descriptive analysis. Results The participants reported frustration with nurse managers who seemed overly focused on mistakes. Many participants felt there was little to no appreciation for tasks that were well done. Nurses also disliked being disciplined openly in front of colleagues or patients. Conclusion(s) The participants stressed that nurse manager feedback should be shared privately and framed in a positive and constructive tone. Active listening, team collaboration and the avoidance of discrimination/favouritism were also emphasised. Implications for nursing management A supportive and communicative work environment promotes nurses’ dignity and respect. Embarrassing nurses in front of other health care professionals may be counterproductive. Instead, the study results suggested privately discussing concerns in a positive, constructive tone is more likely to foster nurse trust and dignity. Keywords: bullying, communication, dignity, lateral violence, nurse managers, respect
Accepted for publication: 9 January 2014
Introduction Nurse-to-nurse bullying has been documented in the literature for more than 20 years (Embree & White 2010). Rowell (2008) described lateral violence as any behaviour that ‘humiliates, degrades, or otherwise indicates a lack of respect or dignity and worth of an individual’ (p. 9). Common types of nurseto-nurse aggression include verbal assaults, profanity, 192
condescending language, withholding information, unreasonable demands, excessive criticism – even physical aggression (Embree & White 2010). One U.S. study found 85% of staff nurses experienced workplace incivility, with approximately 37% admitting that they instigated such behaviour (Lewis & Malecha 2011). Over time, working in a toxic environment takes a toll on nurses as well as their organisations. Nurse-to-nurse DOI: 10.1111/jonm.12222 ª 2014 John Wiley & Sons Ltd
Identifying essential communication skills
bullying has been reported to be particularly upsetting for new nurses, with 60% leaving their first organisation within 6 months due to concerns about lateral violence (Embree & White 2010). While workplace incivility has been estimated to cost organisations $11581 per nurse per year (Lewis & Malecha 2011), Hutton (2006) reported lateral violence costs organisations over $4.2 million annually. While health care leaders underscore the importance of respecting patient dignity (Shotton & Seedhouse 1998, Lawless & Moss 2007, Lawless 2009, Khademi et al. 2012), significantly less emphasis is placed on respecting the dignity of nurses. Pope (2010) suggested nurse-to-nurse bullying is often tolerated as a rite of passage for new nurses. Working in high-pressure situations, nurses are socialised to ‘toughen up’ if they want to succeed. Consistent with this culture, researchers note that some nurses intentionally exhibit bullying behaviours to help them fit into a nursing unit (Embree & White 2010, Hutchinson et al. 2010). Hutchinson et al. (2006a) suggested bullying has become so normalised within the health care culture that ‘it is almost invisible’ (p. 118). Lawless (2009) suggested nurses who are forced to work in an environment without dignity and respect are unlikely to respect themselves or the people around them. Unfortunately, research about nurse dignity has received little attention in the literature. Lawless and Moss (2007) explained, ‘the value of dignity in the work-life of nurses has been under-explored and there is a critical need for further theoretical work and research’ (p. 225).
Background Importance of maintaining nurse dignity In their review of the literature concerning nurse dignity, Lawless and Moss (2007) indicated that supporting a nurse’s self-worth advances individual as well as organisational goals. Khademi et al. (2012) found that a nurse’s work environment influenced both their dignity and job satisfaction. The study suggested humanistic models that allow for open dialogue, balance of power, autonomy and privacy are more likely to nurture a culture of nurse dignity and respect (Khademi et al. 2012). Laschinger et al. (2006) similarly reported a strong correlation between respect and perceived organisational support, job satisfaction and trust. Other researchers found workplace civility improved nurse engagement and productivity, while also reducing absenteeism and turnover (Lewis & Malecha 2011). ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2014, 22, 192–200
Dimensions essential to nurse dignity The subjective nature of nurse dignity makes understanding and operationalising the construct difficult. According to Mairis (1994), dignity exists ‘when an individual is capable of exerting control over his or her behaviour, surroundings and the way in which he or she is treated by others. He or she should be capable of understanding information and making decisions’ (p. 952). In a patient context, dignity is maintained when individuals understand their conditions and are empowered to make knowledgeable choices about their treatment. Conversely, individuals lack dignity when they find themselves in situations where they ‘feel foolish, incompetent, inadequate or unusually vulnerable’ (Shotton & Seedhouse 1998 pp. 246–247). Pope’s (2010) analysis of nursing students confirmed the importance of dignity-supporting behaviours. Nurses preferred instructors who treated students as responsible individuals. Students also favoured instructors who exhibited inviting behaviours such as being, polite, welcoming, respectful and enthusiastic. In contrast, disliked educators often insulted, teased, ridiculed and/or devalued nursing students (Pope 2010).
Key role of nurse managers After leaving school, nurses are socialised to the health care workforce through interactions with nurse managers and co-workers. Lewis (2009) suggested that nurse leaders play a particularly pivotal role in the development of a healthy work environment. Serving as role models, nurse supervisors often set the tone and expectations for health care organisations. Unfortunately, 68% of staff nurses report experiencing incivility from their supervisors (Lewis & Malecha 2011). Consistent with literature about nurse bullying, supervisor incivility and cynicism have been found to be predictors of job dissatisfaction, organisational commitment and turnover (Lewis & Malecha 2011). In their study, Hutchinson et al. (2010) concluded that the organisational tolerance of bullying socialises nurses to accept workplace aggression as normal. In contrast, Lewis and Malecha (2011) found nurse leaders who proactively manage incivility were noticed and appreciated by staff nurses. Kramer and Schmalenberg (2008) suggested that nurses want a collaborative relationship based on mutual trust and respect. As a result, the use of a professional code of conduct, interdisciplinary governance councils and/or quality 193
R. A. Rouse and M. Al-Maqbali
improvement teams may help to promote a healthy work environment (Lewis & Malecha 2011). Consistent with such recommendations, Ceravolo et al. (2012) used a series of workshops to improve communication about lateral violence in nursing. Over a 3 year period, they conducted 203 workshops with over 4000 U.S. nurses. The sessions focused on an increased awareness of lateral violence and improved assertive communication to create a more respectful workplace culture. At the conclusion of their study, Ceravolo et al. found that nurse-to-nurse verbal abuse dropped by 14%, while turnover declined by 3% and vacancy rates decreased by about 6%. Stagg et al. (2013) similarly found that participation in a cognitive rehearsal programme decreased workplace bullying by nurses. Six months after attending a two-hour programme designed to increase nurses’ awareness of bullying, 70% of nurses indicated they changed their behaviour. Another 40% reported a decline in the bullying behaviours. In their study, Ceravolo et al. (2012) found the use of effective communication skills significantly improved the perceived dignity and respect in health care organisations.
Challenges when measuring nurse dignity It is challenging to research the importance of dignity to nurses because of the sensitivity of the topic and the elusive nature of the construct. To date, a variety of quantitative survey instruments have been used by researchers interested in nurse-to-nurse bullying. Unfortunately, data collection instruments that rely on closed questions may inadvertently sensitise participants to the issues being investigated (Reja et al. 2003). For instance, the Incivility in Healthcare Survey, used by Lewis and Malecha (2011), asked nurses to provide information about incivility. Likewise the Negative Acts Questionnaire, used by Pope (2010), prompted evaluations of nurse educators’ negative behaviours. Similar issues are evident in other studies of nurse bullying (Hutchinson et al. 2006b, Lewis 2009). While some nurse-to-nurse bullying researchers used qualitative methods, such as observation (Lawless & Moss 2007), interviews (Mairis 1994, Lawless 2009, Khademi et al. 2012) and open-ended questions (Pope 2010), samples tend to be small and frequently direct participants to discuss specific issues of interest to the researcher.
Purpose and research questions To evaluate the importance of dignity to nurses objectively, the current study examined nursing professionals’ 194
(RNs) perceptions of the essential communication skills of nursing managers in Oman. Our assumption was that if dignity and respect are highly valued, nurses should describe dignity-related communication behaviours in response to a nondirective open-ended inquiry about nurse managers. Our research questions were: ●
Research question 1: What communication skills are essential for nurse managers to carry out their jobs effectively? ● Research question 2: How, if at all, do perceptions of essential nurse manager communication skills differ by nursing professionals’ years of experience?
Method The data analysed in the current study were collected as part of a larger research project that investigated the effectiveness of nurse managers in Oman. Omani nursing professionals completed a descriptive survey about the effectiveness of their nurse managers’ leadership and communication skills. Participants were also asked to describe, in their own words, the communication characteristics that are essential for nurse managers to complete their jobs effectively. An open-ended question was used to collect the data and to minimise bias that might occur if multiple choice responses were used (American Association Public Opinion Research 2013). Reja et al. (2003) suggested, ‘Close-ended questions limit the respondent to the set of alternatives being offered, while openended questions allow the respondent to express an opinion without being influenced by the researcher’ (p. 161). Takemura et al. (2005) similarly argued that nondirective questions allow respondents to discuss concerns freely. While open-ended questions tend to be more cognitively demanding and require more effort from participants (Reja et al. 2003), Riiskjær et al. (2012) found 76% of participants provided comments to openended questions. In health care studies, open-ended questions can be particularly effective. Takemura et al. (2005) found nondirective questions elicited significantly more patient information. Likewise, 80.7% of health care management teams in Riiskjær et al.’s study (2012) characterised open-ended data as useful or very useful. When statistically compared with data collected from closed questions, Reja et al. (2003) found openended inquires generate significantly more diverse responses. Geer (1991) suggested that open-ended ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2014, 22, 192–200
Identifying essential communication skills
questions are particularly effective when measuring attitudes, with 80% of participants accurately identifying salient issues in their responses. It should be noted that participants who are most and least satisfied may be more prone to respond to open-ended questions (Riiskjær et al. 2012). Nevertheless, very high correlations (r = +0.67 to r = +0.85) have been detected between the frequency rankings of open and closed data (Reja et al. 2003).
IRB approval The study was approved by the Research and Ethical Review and Approve Committee for the Directorate of Research and Studies in Oman’s Ministry of Health (R. Alhinai, personal communication, 1 December 2012). Prior to any data collection, the participants were provided with information about the purpose of the study and data collection process. No identifying information was collected and participants were assured their responses were confidential and anonymous.
Sample Approximately 65% of the total nursing workforce (n = 10594) in the Ministry of Health (MoH) is Omani (n = 6887). To access the population of Omani nursing professionals, a stratified random sampling design collected data from approximately 23% of Omani nursing professionals at 22 MoH hospitals. Three MoH researchers visited each of the 22 hospitals to administer the survey. After completing the surveys, the participants placed their responses in a locked box that could only be accessed by the principal investigator. After one month of data collection, 1526 Omani staff returned surveys. Assuming a 95% confidence level, the margin of error was 2.32 (American Research Group 2013). As shown in Table 1, 88% nursing professionals in the study were women (n = 1327). Most participants reported their highest level of education was a diploma in general nursing (70%; n = 1054). About 67% of the sample reported being either a bedside nurse (39%; n = 549) or a mixed role nursing professional (28%; n = 395). About a third of the sample (27%; n = 412) had less than 5 years of experience as a nurse; while 39% (n = 594) indicated they had 6–10 years of experience.
Instrumentation At the end of a questionnaire that measured perceptions of their specific supervisors’ leadership ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2014, 22, 192–200
and communication, Omani nursing professionals were asked to respond to the open-ended question: What do you believe are the essential communication qualities that nursing managers must have to be able to carry out their job effectively? Participants were encouraged to write as much, or as little, as they chose and were not restricted to a specific number of comments. While some nurses shared several thoughts, others chose not to respond. The study’s 1526 nursing professionals shared 3323 open-ended comments about the essential communication skills of nurse managers.
Analysis Nurses’ handwritten responses were typed to ensure participant anonymity. Before coding the open-ended comments, two doctoral-trained individuals reviewed all the transcripts and identified preliminary categories. A qualitative content analysis initially explored and categorised nurses responses to an open-ended question about their nurse managers’ communication skills; a descriptive analysis then quantified the frequency of each category (Mayring 2000, Elo & Kyng€as 2008). Each coder independently classified 100 responses to test the robustness of the categories. Frequencies were then tallied to produce intervalscaled category scores for each coder. To assess the reliability of the coders’ frequencies a Cronbach’s
Table 1 Sample demographics
Gender (n = 1513) Male Female Highest education (n = 1509) Diploma in general nursing Bachelor’s in nursing sciences Post basic degree in a specialty Master’s in nursing sciences Doctorate/PhD Other Nursing role (n = 1416) Bedside nurse Charge nurse Clinical facilitator Mixed role Nurse managers Senior management Other Years of nursing experience (n = 1515) Less than 5 years 6–10 years 11–15 years More than 15 years
n
%
186 1327
12 88
1054 94 321 2 1 37
70 6 21 0 0 2
549 123 45 395 73 153 78
39 9 3 28 5 11 6
412 594 333 176
27 39 22 12
Some participants did not respond to all the demographic questions.
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alpha was computed in the Statistical Package for Social Sciences (SPSS, Inc., Chicago, IL, USA) for Windows 16.0. The alpha for a subset of 100 responses was 0.91. Since both coders’ category frequencies were significantly similar, the remainder of the data were content analysed by only one coder. Using comments as the unit of analysis, category frequencies were computed for all of the open-ended comments (n = 3323) to evaluate Research question 1. In Research question 2 nursing professionals (n = 1526) were used as the unit of analysis. A dichotomous, dummy variable was computed to differentiate nurses who shared a written response (coded 1) from those who left the question blank (coded 0). The proportions of written and blank responses were compared, crosstabulated and statistically tested with chi-squared analysis to examine the differences by years of experience.
Results Essential communication skills for nurse managers Participants provided 3323 comments about the essential communication qualities of nurse managers. Many respondents described a series of effective behaviors. For instance, one participant wrote:
To be a good leader, a supervisor must set an example to his/her subordinates. In solving problems, he/she must listen to all sides and avoid discrimination and favoritism. A supervisor must cooperate in problem solving and be a part of the team instead of just making orders to be followed. Before implementing rules and new policies, a supervisor must also know the situation of the staff and hear from them personally through meetings. A supervisor should be a motivator. He/she should not only look for flaws or mistakes but also give recognition to the staff’s good deeds. As indicated in Figure 1, the ability to explain and teach (17.1%; n = 569) was the most frequently mentioned essential communication skill for nurse managers. Several participants described effective supervisors as valuable sources of information. For instance, one nurse wrote, ‘[At my hospital] there is good communication between nurses and supervisors. My manager is like my sister. She helps find solutions to my problems.’ Another participant shared, ‘If we make mistakes, nurse managers should guide us. If we do well, they should praise us. We are a team and need each other.’ Face-to-face communication with nurse managers was strongly preferred. One participant wrote, ‘A
Figure 1 Frequency of open-ended comments about the essential communication qualities needed by nurse supervisors.
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ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2014, 22, 192–200
Identifying essential communication skills
Table 2 Frequency of participants’ open-ended comments by years of nursing experience Years of nursing experience
Essential nurse manager characteristics Feedback Problem solving Confidentiality Collaborate Positive tone Explain Negative tone Fairness Trust Knowledge Listen Other Role model
Less than 5 years (n = 412)
5–10 years (n = 594)
No comment
No comment
Comment
10–15 years (n = 333) Comment
No comment
More than 15 years (n = 176) Comment
No comment
Comment
n
%
n
%
n
%
n
%
n
%
n
%
n
%
n
%
v2
df
P
356 316 387 263 300 252 400 377 390 351 310 398 387
86.4 76.7 93.9 63.8 72.8 61.2 97.1 91.5 94.7 85.2 75.2 96.6 93.9
56 96 25 149 112 160 12 35 22 61 102 14 25
13.6 23.3 6.1 36.2 27.2 38.8 2.9 8.5 5.3 14.8 24.8 3.4 6.1
486 480 560 415 450 408 564 534 572 490 420 579 559
81.8 80.8 94.3 69.9 75.8 68.7 94.9 89.9 96.3 82.5 70.7 97.5 94.1
108 114 34 179 144 186 30 60 22 104 174 15 35
18.2 19.2 5.7 30.1 24.2 31.3 5.1 10.1 3.7 17.5 29.3 2.5 5.9
294 283 318 236 267 220 323 315 320 266 246 327 307
88.3 85.0 95.5 70.9 80.2 66.1 97.0 94.6 96.1 79.9 73.9 98.2 92.2
39 50 15 97 66 113 10 18 13 67 87 6 26
11.7 15.0 4.5 29.1 19.8 33.9 3.0 5.4 3.9 20.1 26.1 1.8 7.8
164 152 176 132 144 121 173 160 174 150 131 169 165
93.2 86.4 100.0 75.0 81.8 68.8 98.3 90.9 98.9 85.2 74.4 96.0 93.8
12 24 0 44 32 55 3 16 2 26 45 7 11
6.8 13.6 0.0 25.0 18.2 31.3 1.7 9.1 1.1 14.8 25.6 4.0 6.3
17.43 11.75 11.29 8.86 8.59 6.80 6.27 6.13 5.94 4.42 2.95 2.85 1.44
3 3 3 3 3 3 3 3 3 3 3 3 3
0.00 0.01 0.01 0.03 0.04 0.08 0.10 0.11 0.12 0.22 0.40 0.42 0.70
nurse supervisor should be someone who really thinks about patient care and is comfortable making a plan with the staff to deliver quality care – not somebody sitting in an office with papers all the time.’ Another staff member suggested, ‘Discuss issues with staff nurses – but not by merely writing comments and asking the staff to read the information. Sit with the staff and take their points and ideas into consideration.’ Nursing professionals’ comments also indicated that collaborating (16.1%; n = 536), using an appropriate tone (14.8%; n = 492), and listening (14.1%, n = 470) were essential communication skills for nurse managers (see Figure 1). Participants often simultaneously described these skills. Numerous participants complained about nurse managers with inappropriate tone who also failed to collaborate and listen. Several participants also mentioned communication skills related to the nurse managers’ critical thinking. Participants explained that being knowledgeable (9.2%; n = 306), solving problems (9.1%; n = 302) and providing feedback (7.0%; n = 233) were important for nurse managers to communicate effectively. The importance of being fair (4.2%; n = 139), behaving as a role model (2.9%; n = 98), maintaining confidentiality (2.3%; n = 76), and trusting (1.8%; n = 60) were also mentioned. While mentioned less frequently, nursing professionals from various hospitals expressed dissatisfaction with disrespectful managers. One nurse observed, ‘Some supervisors feel they’re more important than us and they have the right to shout and deal with us badly’. Another participant commented, ‘Supervisors ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2014, 22, 192–200
should work with us like colleagues – as a sister or brother – not as children’. Rather than belittling nurses, several participants urged a balanced approach that respects the staff member’s dignity and confidentiality. If a staff nurse makes a mistake, the nurse manger should not embarrass her in front of other in-charges and colleagues as this may affect job productivity. There should be a trusting relationship between supervisors and staff. There should not be gossiping and talking behind the backs of the staff. The nurse manager should not have favorites on the staff – everyone should be treated equally.
Differences by years of experience Since data were collected within the context of a larger written survey, some participants did not respond to the open-ended question about essential nurse manager communication skills. Using the nursing professional as the unit of analysis (n = 1526), the frequency of responses to the open-ended question were dummy-coded (0, no written comment; 1, written comment). Chi-squared analysis then compared the expected and observed frequencies of each category to test for significant differences in the proportions of written and blank responses. In this portion of the analysis, the ‘appropriate tone’ category was divided into positive and negative tone to differentiate sub-categories.
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When analysed by years of experience, no significant differences were detected in the participants’ comments about 8 of the 13 essential nurse manager communication categories (see Table 2). However, the frequency of comments about feedback (v2 = 17.43, df = 3, P = 0.00), problem solving (v2 = 11.75, df = 3, P = 0.01), confidentiality (v2 = 11.29, df = 3, P = 0.01), collaboration (v2 = 8.86, df = 3, P = 0.03) and positive tone (v2 = 8.59, df = 3, P = 0.04) differed significantly by nursing professionals’ years of experience (see Table 2). As shown in Figure 2, 18% of nurses with 5–10 years of experience (n = 108) shared in open-ended comments that feedback is an essential communication skill for nurse managers. Only 7% of participants with more than 15 years of experience (n = 12) expressed similar remarks. In every other category with statistically significant differences (problem solving, collaboration and positive tone), participants with less than 5 years had the highest percentage of open-ended comments, while nursing professionals with 15 or more years of experience had the lowest percentage. For instance, 23% of participants with the least nursing experience (n = 96) shared remarks that nurse managers need problem solving skills, while only 14% of the most experienced nurses (n = 24) made similar observations. Likewise, 36% of inexperienced nurses (n = 149) felt nursing supervisors needed collaboration skills, while only 25% of highly experienced nurses (n = 44) expressed similar beliefs. Inexperienced nurses (27%, n = 112) also had a significantly higher percentage of comments about the importance of nurse managers’ use of a positive tone, compared with 18% of highly experienced nurses (n = 32).
Discussion Effective communication Participants identified a variety of effective communication strategies that nurse managers can use to foster a culture of dignity and respect. Nursing professionals said approachable and affirming behaviours are essential communication skills for nurse managers. According to Pope (2010), approachable behaviours make nurses feel comfortable asking for help or clarification. Numerous open-ended comments from participants described the importance of managers explaining/ teaching, being knowledgeable, solving problems and providing feedback. Such communication skills foster an ‘inviting’ culture where nurses feel comfortable asking questions and/or seeking help (Pope 2010). 198
Similarly, affirming behaviours, which communicate the nurse is valued (Pope 2010), were also described as essential for nurse managers. Participants emphasised that collaboration, appropriate tone and listening help support nurses’ self-esteem and improve patient outcomes.
Ineffective communication Ineffective nurse manager communication was also described in the open-ended data. Consistent with Pope’s (2010) results, criticising behaviours were perceived as emotionally demeaning and discouraging by the study’s nursing professionals. Participants disliked managers who spoke harshly, showed favouritism or disciplined nurses publicly. Interestingly, however, there were significantly fewer comments about the criticising behaviours of nurse managers. Only 14.8% of participants’ open-ended comments described the importance of nursing supervisors using an appropriate tone (13.1% mentioned the use of a positive tone, while 1.7% commented about use of a negative tone). A nurse manager’s fairness (4.2%), confidentiality (2.3%) and trust (1.8%) were mentioned even less frequently (see Figure 1).
Socialisation trends These trends are consistent with prior researchers who concluded that nurses are socialised to expect relational violence (Hutchinson et al. 2006a, Hutchinson et al. 2010, Pope 2010). Over time, it appears that nurses learn bullying behaviour is an expected and accepted part of nursing (Pope 2010). In a work environment where such behaviour is overlooked or trivialised, nurses may perceive nurse-to-nurse violence is an inherent part of job (Hutchinson et al. 2010). Evidence of this phenomenon was detected when participants’ responses were cross-tabulated by their years of experience. New nurses, with
Identifying nurse managers’ essential communication skills: an analysis of nurses’ perceptions in Oman RUBY A. ROUSE
PhD
1
and MAJID AL-MAQBALI
RN, PhD
2
Associate Faculty, School of Advanced Studies, University of Phoenix, San Antonio, Texas, USA and 2Director of Nursing and Midwifery Affairs, Ministry of Health, Muscat, Sultanate of Oman 1
Correspondence Ruby A. Rouse Associate Faculty School of Advanced Studies University of Phoenix 15319 Rompel Trail San Antonio Texas 78232 USA E-mail: [email protected]
ROUSE R.A. & AL-MAQBALI M.
(2014) Journal of Nursing Management 22, 192–200. Identifying nurse managers’ essential communication skills: an analysis of nurses’ perceptions in Oman Aim(s) The aim of the present study was to analyse nurses’ perceptions of the communication qualities that are essential for nurse managers to carry out their jobs effectively. Background An examination of effective communication may help to identify nurse manager behaviours that promote dignity and respect. Method(s) A paper-and-pencil survey collected open-ended data from 1526 nursing professionals (RNs) representing 22 hospitals in Oman. Qualitative content analysis was conducted first, followed by a quantitative descriptive analysis. Results The participants reported frustration with nurse managers who seemed overly focused on mistakes. Many participants felt there was little to no appreciation for tasks that were well done. Nurses also disliked being disciplined openly in front of colleagues or patients. Conclusion(s) The participants stressed that nurse manager feedback should be shared privately and framed in a positive and constructive tone. Active listening, team collaboration and the avoidance of discrimination/favouritism were also emphasised. Implications for nursing management A supportive and communicative work environment promotes nurses’ dignity and respect. Embarrassing nurses in front of other health care professionals may be counterproductive. Instead, the study results suggested privately discussing concerns in a positive, constructive tone is more likely to foster nurse trust and dignity. Keywords: bullying, communication, dignity, lateral violence, nurse managers, respect
Accepted for publication: 9 January 2014
Introduction Nurse-to-nurse bullying has been documented in the literature for more than 20 years (Embree & White 2010). Rowell (2008) described lateral violence as any behaviour that ‘humiliates, degrades, or otherwise indicates a lack of respect or dignity and worth of an individual’ (p. 9). Common types of nurseto-nurse aggression include verbal assaults, profanity, 192
condescending language, withholding information, unreasonable demands, excessive criticism – even physical aggression (Embree & White 2010). One U.S. study found 85% of staff nurses experienced workplace incivility, with approximately 37% admitting that they instigated such behaviour (Lewis & Malecha 2011). Over time, working in a toxic environment takes a toll on nurses as well as their organisations. Nurse-to-nurse DOI: 10.1111/jonm.12222 ª 2014 John Wiley & Sons Ltd
Identifying essential communication skills
bullying has been reported to be particularly upsetting for new nurses, with 60% leaving their first organisation within 6 months due to concerns about lateral violence (Embree & White 2010). While workplace incivility has been estimated to cost organisations $11581 per nurse per year (Lewis & Malecha 2011), Hutton (2006) reported lateral violence costs organisations over $4.2 million annually. While health care leaders underscore the importance of respecting patient dignity (Shotton & Seedhouse 1998, Lawless & Moss 2007, Lawless 2009, Khademi et al. 2012), significantly less emphasis is placed on respecting the dignity of nurses. Pope (2010) suggested nurse-to-nurse bullying is often tolerated as a rite of passage for new nurses. Working in high-pressure situations, nurses are socialised to ‘toughen up’ if they want to succeed. Consistent with this culture, researchers note that some nurses intentionally exhibit bullying behaviours to help them fit into a nursing unit (Embree & White 2010, Hutchinson et al. 2010). Hutchinson et al. (2006a) suggested bullying has become so normalised within the health care culture that ‘it is almost invisible’ (p. 118). Lawless (2009) suggested nurses who are forced to work in an environment without dignity and respect are unlikely to respect themselves or the people around them. Unfortunately, research about nurse dignity has received little attention in the literature. Lawless and Moss (2007) explained, ‘the value of dignity in the work-life of nurses has been under-explored and there is a critical need for further theoretical work and research’ (p. 225).
Background Importance of maintaining nurse dignity In their review of the literature concerning nurse dignity, Lawless and Moss (2007) indicated that supporting a nurse’s self-worth advances individual as well as organisational goals. Khademi et al. (2012) found that a nurse’s work environment influenced both their dignity and job satisfaction. The study suggested humanistic models that allow for open dialogue, balance of power, autonomy and privacy are more likely to nurture a culture of nurse dignity and respect (Khademi et al. 2012). Laschinger et al. (2006) similarly reported a strong correlation between respect and perceived organisational support, job satisfaction and trust. Other researchers found workplace civility improved nurse engagement and productivity, while also reducing absenteeism and turnover (Lewis & Malecha 2011). ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2014, 22, 192–200
Dimensions essential to nurse dignity The subjective nature of nurse dignity makes understanding and operationalising the construct difficult. According to Mairis (1994), dignity exists ‘when an individual is capable of exerting control over his or her behaviour, surroundings and the way in which he or she is treated by others. He or she should be capable of understanding information and making decisions’ (p. 952). In a patient context, dignity is maintained when individuals understand their conditions and are empowered to make knowledgeable choices about their treatment. Conversely, individuals lack dignity when they find themselves in situations where they ‘feel foolish, incompetent, inadequate or unusually vulnerable’ (Shotton & Seedhouse 1998 pp. 246–247). Pope’s (2010) analysis of nursing students confirmed the importance of dignity-supporting behaviours. Nurses preferred instructors who treated students as responsible individuals. Students also favoured instructors who exhibited inviting behaviours such as being, polite, welcoming, respectful and enthusiastic. In contrast, disliked educators often insulted, teased, ridiculed and/or devalued nursing students (Pope 2010).
Key role of nurse managers After leaving school, nurses are socialised to the health care workforce through interactions with nurse managers and co-workers. Lewis (2009) suggested that nurse leaders play a particularly pivotal role in the development of a healthy work environment. Serving as role models, nurse supervisors often set the tone and expectations for health care organisations. Unfortunately, 68% of staff nurses report experiencing incivility from their supervisors (Lewis & Malecha 2011). Consistent with literature about nurse bullying, supervisor incivility and cynicism have been found to be predictors of job dissatisfaction, organisational commitment and turnover (Lewis & Malecha 2011). In their study, Hutchinson et al. (2010) concluded that the organisational tolerance of bullying socialises nurses to accept workplace aggression as normal. In contrast, Lewis and Malecha (2011) found nurse leaders who proactively manage incivility were noticed and appreciated by staff nurses. Kramer and Schmalenberg (2008) suggested that nurses want a collaborative relationship based on mutual trust and respect. As a result, the use of a professional code of conduct, interdisciplinary governance councils and/or quality 193
R. A. Rouse and M. Al-Maqbali
improvement teams may help to promote a healthy work environment (Lewis & Malecha 2011). Consistent with such recommendations, Ceravolo et al. (2012) used a series of workshops to improve communication about lateral violence in nursing. Over a 3 year period, they conducted 203 workshops with over 4000 U.S. nurses. The sessions focused on an increased awareness of lateral violence and improved assertive communication to create a more respectful workplace culture. At the conclusion of their study, Ceravolo et al. found that nurse-to-nurse verbal abuse dropped by 14%, while turnover declined by 3% and vacancy rates decreased by about 6%. Stagg et al. (2013) similarly found that participation in a cognitive rehearsal programme decreased workplace bullying by nurses. Six months after attending a two-hour programme designed to increase nurses’ awareness of bullying, 70% of nurses indicated they changed their behaviour. Another 40% reported a decline in the bullying behaviours. In their study, Ceravolo et al. (2012) found the use of effective communication skills significantly improved the perceived dignity and respect in health care organisations.
Challenges when measuring nurse dignity It is challenging to research the importance of dignity to nurses because of the sensitivity of the topic and the elusive nature of the construct. To date, a variety of quantitative survey instruments have been used by researchers interested in nurse-to-nurse bullying. Unfortunately, data collection instruments that rely on closed questions may inadvertently sensitise participants to the issues being investigated (Reja et al. 2003). For instance, the Incivility in Healthcare Survey, used by Lewis and Malecha (2011), asked nurses to provide information about incivility. Likewise the Negative Acts Questionnaire, used by Pope (2010), prompted evaluations of nurse educators’ negative behaviours. Similar issues are evident in other studies of nurse bullying (Hutchinson et al. 2006b, Lewis 2009). While some nurse-to-nurse bullying researchers used qualitative methods, such as observation (Lawless & Moss 2007), interviews (Mairis 1994, Lawless 2009, Khademi et al. 2012) and open-ended questions (Pope 2010), samples tend to be small and frequently direct participants to discuss specific issues of interest to the researcher.
Purpose and research questions To evaluate the importance of dignity to nurses objectively, the current study examined nursing professionals’ 194
(RNs) perceptions of the essential communication skills of nursing managers in Oman. Our assumption was that if dignity and respect are highly valued, nurses should describe dignity-related communication behaviours in response to a nondirective open-ended inquiry about nurse managers. Our research questions were: ●
Research question 1: What communication skills are essential for nurse managers to carry out their jobs effectively? ● Research question 2: How, if at all, do perceptions of essential nurse manager communication skills differ by nursing professionals’ years of experience?
Method The data analysed in the current study were collected as part of a larger research project that investigated the effectiveness of nurse managers in Oman. Omani nursing professionals completed a descriptive survey about the effectiveness of their nurse managers’ leadership and communication skills. Participants were also asked to describe, in their own words, the communication characteristics that are essential for nurse managers to complete their jobs effectively. An open-ended question was used to collect the data and to minimise bias that might occur if multiple choice responses were used (American Association Public Opinion Research 2013). Reja et al. (2003) suggested, ‘Close-ended questions limit the respondent to the set of alternatives being offered, while openended questions allow the respondent to express an opinion without being influenced by the researcher’ (p. 161). Takemura et al. (2005) similarly argued that nondirective questions allow respondents to discuss concerns freely. While open-ended questions tend to be more cognitively demanding and require more effort from participants (Reja et al. 2003), Riiskjær et al. (2012) found 76% of participants provided comments to openended questions. In health care studies, open-ended questions can be particularly effective. Takemura et al. (2005) found nondirective questions elicited significantly more patient information. Likewise, 80.7% of health care management teams in Riiskjær et al.’s study (2012) characterised open-ended data as useful or very useful. When statistically compared with data collected from closed questions, Reja et al. (2003) found openended inquires generate significantly more diverse responses. Geer (1991) suggested that open-ended ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2014, 22, 192–200
Identifying essential communication skills
questions are particularly effective when measuring attitudes, with 80% of participants accurately identifying salient issues in their responses. It should be noted that participants who are most and least satisfied may be more prone to respond to open-ended questions (Riiskjær et al. 2012). Nevertheless, very high correlations (r = +0.67 to r = +0.85) have been detected between the frequency rankings of open and closed data (Reja et al. 2003).
IRB approval The study was approved by the Research and Ethical Review and Approve Committee for the Directorate of Research and Studies in Oman’s Ministry of Health (R. Alhinai, personal communication, 1 December 2012). Prior to any data collection, the participants were provided with information about the purpose of the study and data collection process. No identifying information was collected and participants were assured their responses were confidential and anonymous.
Sample Approximately 65% of the total nursing workforce (n = 10594) in the Ministry of Health (MoH) is Omani (n = 6887). To access the population of Omani nursing professionals, a stratified random sampling design collected data from approximately 23% of Omani nursing professionals at 22 MoH hospitals. Three MoH researchers visited each of the 22 hospitals to administer the survey. After completing the surveys, the participants placed their responses in a locked box that could only be accessed by the principal investigator. After one month of data collection, 1526 Omani staff returned surveys. Assuming a 95% confidence level, the margin of error was 2.32 (American Research Group 2013). As shown in Table 1, 88% nursing professionals in the study were women (n = 1327). Most participants reported their highest level of education was a diploma in general nursing (70%; n = 1054). About 67% of the sample reported being either a bedside nurse (39%; n = 549) or a mixed role nursing professional (28%; n = 395). About a third of the sample (27%; n = 412) had less than 5 years of experience as a nurse; while 39% (n = 594) indicated they had 6–10 years of experience.
Instrumentation At the end of a questionnaire that measured perceptions of their specific supervisors’ leadership ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2014, 22, 192–200
and communication, Omani nursing professionals were asked to respond to the open-ended question: What do you believe are the essential communication qualities that nursing managers must have to be able to carry out their job effectively? Participants were encouraged to write as much, or as little, as they chose and were not restricted to a specific number of comments. While some nurses shared several thoughts, others chose not to respond. The study’s 1526 nursing professionals shared 3323 open-ended comments about the essential communication skills of nurse managers.
Analysis Nurses’ handwritten responses were typed to ensure participant anonymity. Before coding the open-ended comments, two doctoral-trained individuals reviewed all the transcripts and identified preliminary categories. A qualitative content analysis initially explored and categorised nurses responses to an open-ended question about their nurse managers’ communication skills; a descriptive analysis then quantified the frequency of each category (Mayring 2000, Elo & Kyng€as 2008). Each coder independently classified 100 responses to test the robustness of the categories. Frequencies were then tallied to produce intervalscaled category scores for each coder. To assess the reliability of the coders’ frequencies a Cronbach’s
Table 1 Sample demographics
Gender (n = 1513) Male Female Highest education (n = 1509) Diploma in general nursing Bachelor’s in nursing sciences Post basic degree in a specialty Master’s in nursing sciences Doctorate/PhD Other Nursing role (n = 1416) Bedside nurse Charge nurse Clinical facilitator Mixed role Nurse managers Senior management Other Years of nursing experience (n = 1515) Less than 5 years 6–10 years 11–15 years More than 15 years
n
%
186 1327
12 88
1054 94 321 2 1 37
70 6 21 0 0 2
549 123 45 395 73 153 78
39 9 3 28 5 11 6
412 594 333 176
27 39 22 12
Some participants did not respond to all the demographic questions.
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alpha was computed in the Statistical Package for Social Sciences (SPSS, Inc., Chicago, IL, USA) for Windows 16.0. The alpha for a subset of 100 responses was 0.91. Since both coders’ category frequencies were significantly similar, the remainder of the data were content analysed by only one coder. Using comments as the unit of analysis, category frequencies were computed for all of the open-ended comments (n = 3323) to evaluate Research question 1. In Research question 2 nursing professionals (n = 1526) were used as the unit of analysis. A dichotomous, dummy variable was computed to differentiate nurses who shared a written response (coded 1) from those who left the question blank (coded 0). The proportions of written and blank responses were compared, crosstabulated and statistically tested with chi-squared analysis to examine the differences by years of experience.
Results Essential communication skills for nurse managers Participants provided 3323 comments about the essential communication qualities of nurse managers. Many respondents described a series of effective behaviors. For instance, one participant wrote:
To be a good leader, a supervisor must set an example to his/her subordinates. In solving problems, he/she must listen to all sides and avoid discrimination and favoritism. A supervisor must cooperate in problem solving and be a part of the team instead of just making orders to be followed. Before implementing rules and new policies, a supervisor must also know the situation of the staff and hear from them personally through meetings. A supervisor should be a motivator. He/she should not only look for flaws or mistakes but also give recognition to the staff’s good deeds. As indicated in Figure 1, the ability to explain and teach (17.1%; n = 569) was the most frequently mentioned essential communication skill for nurse managers. Several participants described effective supervisors as valuable sources of information. For instance, one nurse wrote, ‘[At my hospital] there is good communication between nurses and supervisors. My manager is like my sister. She helps find solutions to my problems.’ Another participant shared, ‘If we make mistakes, nurse managers should guide us. If we do well, they should praise us. We are a team and need each other.’ Face-to-face communication with nurse managers was strongly preferred. One participant wrote, ‘A
Figure 1 Frequency of open-ended comments about the essential communication qualities needed by nurse supervisors.
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Identifying essential communication skills
Table 2 Frequency of participants’ open-ended comments by years of nursing experience Years of nursing experience
Essential nurse manager characteristics Feedback Problem solving Confidentiality Collaborate Positive tone Explain Negative tone Fairness Trust Knowledge Listen Other Role model
Less than 5 years (n = 412)
5–10 years (n = 594)
No comment
No comment
Comment
10–15 years (n = 333) Comment
No comment
More than 15 years (n = 176) Comment
No comment
Comment
n
%
n
%
n
%
n
%
n
%
n
%
n
%
n
%
v2
df
P
356 316 387 263 300 252 400 377 390 351 310 398 387
86.4 76.7 93.9 63.8 72.8 61.2 97.1 91.5 94.7 85.2 75.2 96.6 93.9
56 96 25 149 112 160 12 35 22 61 102 14 25
13.6 23.3 6.1 36.2 27.2 38.8 2.9 8.5 5.3 14.8 24.8 3.4 6.1
486 480 560 415 450 408 564 534 572 490 420 579 559
81.8 80.8 94.3 69.9 75.8 68.7 94.9 89.9 96.3 82.5 70.7 97.5 94.1
108 114 34 179 144 186 30 60 22 104 174 15 35
18.2 19.2 5.7 30.1 24.2 31.3 5.1 10.1 3.7 17.5 29.3 2.5 5.9
294 283 318 236 267 220 323 315 320 266 246 327 307
88.3 85.0 95.5 70.9 80.2 66.1 97.0 94.6 96.1 79.9 73.9 98.2 92.2
39 50 15 97 66 113 10 18 13 67 87 6 26
11.7 15.0 4.5 29.1 19.8 33.9 3.0 5.4 3.9 20.1 26.1 1.8 7.8
164 152 176 132 144 121 173 160 174 150 131 169 165
93.2 86.4 100.0 75.0 81.8 68.8 98.3 90.9 98.9 85.2 74.4 96.0 93.8
12 24 0 44 32 55 3 16 2 26 45 7 11
6.8 13.6 0.0 25.0 18.2 31.3 1.7 9.1 1.1 14.8 25.6 4.0 6.3
17.43 11.75 11.29 8.86 8.59 6.80 6.27 6.13 5.94 4.42 2.95 2.85 1.44
3 3 3 3 3 3 3 3 3 3 3 3 3
0.00 0.01 0.01 0.03 0.04 0.08 0.10 0.11 0.12 0.22 0.40 0.42 0.70
nurse supervisor should be someone who really thinks about patient care and is comfortable making a plan with the staff to deliver quality care – not somebody sitting in an office with papers all the time.’ Another staff member suggested, ‘Discuss issues with staff nurses – but not by merely writing comments and asking the staff to read the information. Sit with the staff and take their points and ideas into consideration.’ Nursing professionals’ comments also indicated that collaborating (16.1%; n = 536), using an appropriate tone (14.8%; n = 492), and listening (14.1%, n = 470) were essential communication skills for nurse managers (see Figure 1). Participants often simultaneously described these skills. Numerous participants complained about nurse managers with inappropriate tone who also failed to collaborate and listen. Several participants also mentioned communication skills related to the nurse managers’ critical thinking. Participants explained that being knowledgeable (9.2%; n = 306), solving problems (9.1%; n = 302) and providing feedback (7.0%; n = 233) were important for nurse managers to communicate effectively. The importance of being fair (4.2%; n = 139), behaving as a role model (2.9%; n = 98), maintaining confidentiality (2.3%; n = 76), and trusting (1.8%; n = 60) were also mentioned. While mentioned less frequently, nursing professionals from various hospitals expressed dissatisfaction with disrespectful managers. One nurse observed, ‘Some supervisors feel they’re more important than us and they have the right to shout and deal with us badly’. Another participant commented, ‘Supervisors ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2014, 22, 192–200
should work with us like colleagues – as a sister or brother – not as children’. Rather than belittling nurses, several participants urged a balanced approach that respects the staff member’s dignity and confidentiality. If a staff nurse makes a mistake, the nurse manger should not embarrass her in front of other in-charges and colleagues as this may affect job productivity. There should be a trusting relationship between supervisors and staff. There should not be gossiping and talking behind the backs of the staff. The nurse manager should not have favorites on the staff – everyone should be treated equally.
Differences by years of experience Since data were collected within the context of a larger written survey, some participants did not respond to the open-ended question about essential nurse manager communication skills. Using the nursing professional as the unit of analysis (n = 1526), the frequency of responses to the open-ended question were dummy-coded (0, no written comment; 1, written comment). Chi-squared analysis then compared the expected and observed frequencies of each category to test for significant differences in the proportions of written and blank responses. In this portion of the analysis, the ‘appropriate tone’ category was divided into positive and negative tone to differentiate sub-categories.
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When analysed by years of experience, no significant differences were detected in the participants’ comments about 8 of the 13 essential nurse manager communication categories (see Table 2). However, the frequency of comments about feedback (v2 = 17.43, df = 3, P = 0.00), problem solving (v2 = 11.75, df = 3, P = 0.01), confidentiality (v2 = 11.29, df = 3, P = 0.01), collaboration (v2 = 8.86, df = 3, P = 0.03) and positive tone (v2 = 8.59, df = 3, P = 0.04) differed significantly by nursing professionals’ years of experience (see Table 2). As shown in Figure 2, 18% of nurses with 5–10 years of experience (n = 108) shared in open-ended comments that feedback is an essential communication skill for nurse managers. Only 7% of participants with more than 15 years of experience (n = 12) expressed similar remarks. In every other category with statistically significant differences (problem solving, collaboration and positive tone), participants with less than 5 years had the highest percentage of open-ended comments, while nursing professionals with 15 or more years of experience had the lowest percentage. For instance, 23% of participants with the least nursing experience (n = 96) shared remarks that nurse managers need problem solving skills, while only 14% of the most experienced nurses (n = 24) made similar observations. Likewise, 36% of inexperienced nurses (n = 149) felt nursing supervisors needed collaboration skills, while only 25% of highly experienced nurses (n = 44) expressed similar beliefs. Inexperienced nurses (27%, n = 112) also had a significantly higher percentage of comments about the importance of nurse managers’ use of a positive tone, compared with 18% of highly experienced nurses (n = 32).
Discussion Effective communication Participants identified a variety of effective communication strategies that nurse managers can use to foster a culture of dignity and respect. Nursing professionals said approachable and affirming behaviours are essential communication skills for nurse managers. According to Pope (2010), approachable behaviours make nurses feel comfortable asking for help or clarification. Numerous open-ended comments from participants described the importance of managers explaining/ teaching, being knowledgeable, solving problems and providing feedback. Such communication skills foster an ‘inviting’ culture where nurses feel comfortable asking questions and/or seeking help (Pope 2010). 198
Similarly, affirming behaviours, which communicate the nurse is valued (Pope 2010), were also described as essential for nurse managers. Participants emphasised that collaboration, appropriate tone and listening help support nurses’ self-esteem and improve patient outcomes.
Ineffective communication Ineffective nurse manager communication was also described in the open-ended data. Consistent with Pope’s (2010) results, criticising behaviours were perceived as emotionally demeaning and discouraging by the study’s nursing professionals. Participants disliked managers who spoke harshly, showed favouritism or disciplined nurses publicly. Interestingly, however, there were significantly fewer comments about the criticising behaviours of nurse managers. Only 14.8% of participants’ open-ended comments described the importance of nursing supervisors using an appropriate tone (13.1% mentioned the use of a positive tone, while 1.7% commented about use of a negative tone). A nurse manager’s fairness (4.2%), confidentiality (2.3%) and trust (1.8%) were mentioned even less frequently (see Figure 1).
Socialisation trends These trends are consistent with prior researchers who concluded that nurses are socialised to expect relational violence (Hutchinson et al. 2006a, Hutchinson et al. 2010, Pope 2010). Over time, it appears that nurses learn bullying behaviour is an expected and accepted part of nursing (Pope 2010). In a work environment where such behaviour is overlooked or trivialised, nurses may perceive nurse-to-nurse violence is an inherent part of job (Hutchinson et al. 2010). Evidence of this phenomenon was detected when participants’ responses were cross-tabulated by their years of experience. New nurses, with
