Validation of the Nurse Managers' Work Content Questionnaire and Factors―A Structural Equation Modeling Study

Introduction

The POSDCORB (planning, organizing, staffing, directing, coordinating, reporting, and budgeting) model, first introduced in 1937 by Gulick and Urwick, is still considered highly relevant to organization managers (Mintzberg, 1973) and is widely used to structure managerial work (Chalekian, 2016). The POSDCORB model may also be used to classify nurse managers' work content. Although management and leadership strategies and their effectiveness (Cummings et al., 2018; McCay et al., 2018) have been widely studied, the reality of the work performed by nurse managers has remained a neglected topic. Recent research into the work of nurse managers has focused mainly on leadership styles (e.g., Boamah et al., 2018; Cummings et al., 2018) and the perspective of roles (e.g., Townsend et al., 2015; Weaver & Lindgren, 2016). However, it is equally important to describe the work content of nurse managers in the clinical setting. In this study, the POSDCORB model is used as the theoretical framework.

The process of planning involves listing and organizing the activities required to achieve an organization's goals. Nurse managers are responsible for the strategic planning of their unit, which includes both operational and financial planning (Omery et al., 2019). However, strategic activities may also comprise a limited portion of nurse managers' daily work (Bjerregård Madsen et al., 2016).

In addition, nurse managers must be adept at organizing, that is, allocating certain tasks and resources among departments and employees to achieve goals. Nurse managers must be competent at organizing because their daily work mainly consists of administrative routines and human resources management (Ericsson & Augustinsson, 2015; Rankin et al., 2016;Townsend et al., 2015).

Staffing describes a process that begins with recruitment and selection and finishes with orientation and integration into an organization. Nurse managers influence the quality of care by recruiting competent staff (Aiken et al., 2017; Gunawan et al., 2019) and ensuring their unit is adequately staffed (Squires et al., 2017).

While directing, managers instruct, guide, and counsel their staff in a way that will help achieve organizational goals. Nurse managers must be visible and accessible, provide regular feedback to their staff (Omery et al., 2019; Stevanin et al., 2020), and lead by example (Pegram et al., 2015) to improve care.

Through good coordination, managers guarantee that available resources are efficiently used to meet specific goals. In recent years, nurse managers have taken on more administrative tasks in terms of being increasingly responsible for the hiring of temporary staff, participating in administrative meetings, and following financial, sick leave, and quality indicators (Kristiansen et al., 2016).

Clear reporting maintains effective and transparent communication throughout the entire organization. Therefore, nurse managers must be competent at communicating, as they need to discuss difficult issues, listen to different opinions, provide constructive feedback, and share and explain new information to their staff (Rouse & Al-Maqbali, 2014).

Today's nurse managers are increasingly responsible for the management, expenditure, and control of their unit's budget (Townsend et al., 2015). According to Gunawan et al. (2019), competence-based human resource management practices are directly and significantly related to financial outcomes.

The work of nurse managers has been found to be reactive and to consist of fragmented activities because of numerous unplanned disruptions (Bjerregård Madsen et al., 2016; Mintzberg, 1973). Nurse managers also experience time constraints, excessive workloads, and necessary involvement in staffing issues (Rankin et al., 2016). Furthermore, nurse managers in various settings have reported lacking a clear job description (Bjerregård Madsen et al., 2016; Rankin et al., 2016; Sveinsdóttir et al., 2018). Therefore, nurse managers should have a clear, up-to-date job description that includes relevant key performance indicators. The presented POSDCORB theoretical framework is highly compatible with the developed Nurse Managers' Work Content Questionnaire (NMWCQ) instrument, which was tested previously in a pilot study (Nurmeksela et al., 2019). In this article, we describe the further development and testing of this instrument. This study was designed to validate the NMWCQ instrument and analyze the relationships between NMWCQ factors and background variables using structural equation modeling (SEM).

Methods Sample Description and Data Collection

This research employed a descriptive and cross-sectional study design. A convenience sample of nurse managers (N = 756) was recruited from five Finnish university hospitals and three central hospitals located throughout the country. The study hospitals were 390–2,069 beds in size and employed between 1,285 and 10,170 nursing personnel. In Finland, there are five university hospitals and 16 central hospitals. Both types provide specialized medical care. However, university hospitals offer the most specialized medical care and the special competences required to treat difficult and rare illnesses. Data were collected between May and November 2019 using an electronic questionnaire (NMWCQ). The questionnaire was first sent to a contact person at each healthcare organization, who then forwarded the email to nurse directors at the hospital. These nurse directors were responsible for sending the link to the questionnaire to the nurse managers.

The Instrument

The authors of this article started the instrument development process in 2016 with a comprehensive literature review. Next, the instrument was pretested and assessed by a panel of professionals to evaluate the accuracy of the items, the comprehensive suitability of the response options, the usability of the questionnaire, and the amount of time required to complete (Boateng et al., 2018). Thereafter, the questionnaire was validated in a pilot study in 2017. Principal component analysis was used in the pilot study to test the construct validity, with the Cronbach's alpha values for NMWCQ factors ranging from .554 to .890 (Nurmeksela et al., 2019). After the pilot study, the questionnaire was revised to include 87 items across 13 subscales. The subscales were as follows: recruitment (five items), organizing (seven items), work well-being (five items), work atmosphere (three items), communication (five items), clinical nursing (nine items), development of the unit (12 items), personnel development (eight items), development of nursing (four items), financial management (seven items), planning and evaluation of activities (six items), collaboration (10 items), and development with collaborating partners (six items). The original questionnaire was created in Finnish and was later forward–backward translated into English for ease of use in future studies.

Data Analysis

The demographic variables are presented using descriptive statistics. After the pilot study, the developed instrument was revalidated using a larger data set, starting with exploratory factor analysis (EFA) with direct oblimin rotation and followed by modeling to find the optimal factor structure for the instrument (Rencher & Christensen, 2012). The original scale of the instrument (1 = daily, 2 = weekly, 3 = monthly, 4 = 2–4 times a year, 5 = annual, and 6 = never) was reversed (6 = daily, 5 = weekly, 4 = monthly, 3 = 2–4 times a year, 2 = annual, and 1 = never) at the beginning of the analysis to make the results easier to interpret. Because the data included an insignificant number of missing values (i.e., 0–3 missing values per variable), no imputation methods were needed. The Kaiser–Meyer–Olkin measure (> .6) and Bartlett's test of sphericity (p < .001) were used to test sampling adequacy. Those items with communality < .3 and loading < .3 were removed (Watson & Thompson, 2006). The EFA results were used to create a new, 12-factor version of the NMWCQ, which was then validated using confirmatory factor analysis (CFA; Tabachnick & Fidell, 2014). Variables and factors with regression weights below statistical significance (p ≥ .05) were deleted. Several goodness-of-fit measures provided by AMOS were used to confirm model fit. In the SEM, incremental fit index (IFI > 0.90) and comparative fit index (CFI > .95) were used as goodness-of-fit indices to assess model adequacy. Furthermore, the root mean square error of approximation (RMSEA < .05) test was used to estimate the approximation error attributable to model simplification (Musil et al., 1998). The standardized regression weight (β) estimates and standardized total effect values were compared to assess the significance of relationships between variables (Kline, 2016). The statistical analyses were performed in SPSS Statistics Version 27.0 and AMOS Version 27.0 (IBM Inc., Armonk, NY, USA).

Ethical Considerations

Ethics committee approval was obtained from a university (decision date: February 7, 2017, No. 6/2017), and each hospital provided permission for data collection before the research was started. In addition, the questionnaire was supplemented by an information letter that provided information about the study, and the respondents were asked to sign an electronic consent form. Participation in the study and completing the questionnaire were voluntary and anonymous (Finnish National Board on Research Integrity TENK, 2019). The General Data Protection Regulation was followed during all stages of the study (European Commission, 2016).

Results

Two hundred seven nurse managers responded to the study questionnaire (response rate: 27.38%). The participating nurse managers averaged 50.87 years old and worked in five university hospitals and three central hospitals. Most (91.8%) were female and had an average of 26.26 years of total work experience, with an average of 9.41 years of experience as a nurse manager. The participating nurse managers were in charge of 43.52 nurses on average, with 40.1% in charge of < 30 nurses and 5.8% in charge of > 100 nurses. The participating nurse managers reported mean values of 8.96 and 8.15 (on a scale of 0–10) for job satisfaction and quality of care, respectively (Table 1).

Table 1. - Background Variables of Nurse Managers (N = 207) Variable n % M Median SD Hospital  Hospital 1 (UH) 65 31.4  Hospital 2 (UH) 36 17.4  Hospital 3 (UH) 44 21.3  Hospital 4 (UH) 17 8.2  Hospital 5 (UH) 23 11.1  Hospital 6 (CH) 8 3.9  Hospital 7 (CH) 6 2.9  Hospital 8 (CH) 8 3.9 Number of nurses per nurse manager 43.52 33.00 31.76  < 30 83 40.1  30–49 72 34.8  50–99 40 19.3  ≥ 100 12 5.8 Age (years) 50.87 53.00 8.54  < 40 26 12.6  40–49 63 30.4  50–59 82 39.6  ≥ 60 36 17.4 Gender  Female 190 91.8  Male 17 8.2 Total work experience (years) 26.26 27.00 8.96  < 10 3 1.5  10–19 51 24.6  20–29 60 29.0  ≥ 30 93 44.9 Work experience as a nurse manager (years) 9.41 8.50 7.13  < 10 83 40.1  10–19 72 34.8  20–29 40 19.3  ≥ 30 12 5.8 Job satisfaction a 8.96 8.00 1.61  < 7 32 15.5  7–8 123 59.4  9–10 52 25.1 Quality of care a 8.15 8.00 0.99  < 7 9 4.4  7–8 118 57.0  9–10 80 38.6

Note. UH = university hospital; CH = central hospital.

a Job satisfaction and quality of care were scored using a 0–10 scale, with 0 and 10 reflecting the lowest and highest possible ratings, respectively.


Psychometric Characteristics of the Nurse Managers' Work Content Questionnaire

The factor structure of the NMWCQ was first tested using EFA. The Kaiser–Meyer–Olkin measure of sampling adequacy was .711, whereas Bartlett's test of sphericity was < .001. After the EFAs, 10 items were deleted from the instrument (Table 2). The deleted items were as follows: I collaborate in nurse managers' common meetings (communality < .3), I perform statistics related to patient care, I collaborate with other organizations, I organize student orientation, I monitor and evaluate the quality of nursing care, I collaborate with the charge nurse/team leader, I organize and promote coherent practices in my unit, I complete performance appraisals with employees, and I ensure that the organization's instructions are being followed in the unit (all earned Cronbach's α values < .6). Next, the NMWCQ was assessed using CFA, which was conducted separately for each factor because there were a high number of variables relative to the number of respondents. After the CFA, two items were deleted from the instrument: I coordinate beds and I take care of ordering supplies for the unit (both earned regression weight values of p < .05). Notably, the contents of these two variables are not particularly relevant to the work of nurse managers in Finland. After these analyses, the new revised version of the NMWCQ included 75 items across 12 factors. After the deletion of these items and new factor loadings, the factors were renamed to better reflect their content: responsibility for new employees (five items), daily management (six items), human resource management (nine items), decision-making (five items), clinical nursing (eight items), development (eight items), planning of processes (six items), collaboration (six items), ensuring knowledge (six items), evidence-based management (five items), ensuring care quality (four items), and financial management (five items). The Cronbach's alpha values for these factors ranged from .605 to .851 (Table 2). The items showed factor loadings that were either positive or negative and ranged from .314 to .846.

Table 2. - Managers' Work Content Questionnaire Factors, Including Corresponding Cronbach's Alpha Values Factor Cronbach's Alpha Responsibility for new employees .811 Daily management .621 Human resource management .805 Decision making .687 Clinical nursing .789 Development .851 Planning of processes .694 Collaboration .696 Ensuring knowledge .727 Evidence-based management .644 Ensuring care quality .605 Financial management .608
Relationships Between Background Variables and Nurse Managers' Work Content Questionnaire Factors

The SEM results for the NMWCQ factors and background variables of nurse managers are represented in Figure 1. The overall modeling showed acceptable index results (IFI = .954, CFI = .951, and RMSEA = .048).

F1Figure 1.:

Structural Equation Modeling Results for Relationships Between Nurse Managers' Work Content Questionnaire Factors and Background Variables of Nurse ManagersNote. Prerequisites for model: incremental fit index (> 0.90), comparative fit index (> .95), and root mean square error of approximation test (< .05). *p ≤ .05. **p < .01. ***p < .001.

The established model showed 23 direct relationships between the background variables and NMWCQ factors that cover both positive and negative impacts. The number of nurses (β = .17, p = .008) was positively related to the “responsibility for new employees” factor. Furthermore, an increase in the number of nurses that a nurse manager supervised was linked to an increase in human resource management (β = .15, p = .023), decision-making (β = .16, p = .019), collaboration (β = .15, p = .030), ensuring knowledge (β = .17, p < .001), and financial management (β = .16, p = .007) duties. Moreover, this background variable was shown to relate negatively to “daily management” activities (β = −.14, p = .044; Table 3).

Table 3. - Standardized Regression Weight Estimates, Standardized Total Effects, and Regression Weights for Nurse Managers' Work Content Questionnaire Factors and Background Variables Factor Variable Background Variable β STE Est. SE CR p Factor 1  Responsibility for new employees Number of nurses 0.17 0.17 0.16 0.06 2.67 .008**  Responsibility for new employees Age −0.25 −0.25 −0.23 0.09 −2.40 .016* Factor 2  Daily management Number of nurses −0.14 −0.14 −0.12 0.06 −2.02 .044* Factor 3  Human resource management Hospital −0.35 −0.35 −0.10 0.02 −6.38 < .001***  Human resource management Number of nurses 0.15 0.15 0.09 0.04 2.27 .023* Factor 4  Decision making Number of nurses 0.16 0.16 0.17 0.07 2.35 .019*  Decision making Total work experience 0.31 0.31 0.36 0.08 4.53 < .001***  Decision making Work experience −0.15 −0.15 −0.22 0.10 −2.15 .031* Factor 5  Clinical nursing Hospital 0.22 0.22 0.11 0.03 3.51 < .001***  Clinical nursing Total work experience −0.16 −0.16 −0.17 0.06 −2.69 .007** Factor 6  Development Age −0.16 −0.22 −0.14 0.05 −3.12 .002**  Development Hospital −0.39 −0.35 −0.16 0.02 −7.80 < .001***  Development Job satisfaction 0.13 0.13 0.16 0.06 2.49 .013* Factor 7  Planning of processes Age −0.16 −0.21 −0.16 0.05 −3.29 .001** Factor 8  Collaboration Number of nurses 0.15 0.15 0.10 0.04 2.17 .030* Factor 9  Ensuring knowledge Hospital 0.34 0.37 0.12 0.02 6.01 < .001***  Ensuring knowledge Number of nurses 0.17 0.22 0.12 0.04 3.08 .002** Factor 10  Evidence-based management Job satisfaction 0.12 0.12 0.13 0.07 1.96 .050*  Evidence-based man

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