1. Introduction
As the principle of healthcare delivery, medical staff are directly related to the ability and quality of health services, as well as health outcomes [
1,
2]. Nurses are indispensable in all healthcare settings because they care for patients who suffer from illnesses and ensure their quality of life. Nurse managers, as their name implies, are unit administrative leaders responsible for the quality of patient care and using both professional knowledge and administrative power in clinical practice [
3,
4]. The key roles of nurse managers focus on technical, professional, administrative, and fiscal categories. Proper staffing/scheduling, hiring/recruiting, developing staff competencies, role-modeling, retaining staff, and coaching/mentoring professional roles are included in the professional category. The administrative roles are often described as being the types of relational roles that market/champion the hospital, pay attention to the Joint Commission on Accreditation of Healthcare Organizations standards/paperwork reports, cover for other departments, manage admissions, and find beds [
5]. Anthony found that the roles of nurse managers include clinical nursing activities, implementing evidence-based practices and organizational change, budget planning, and ensuring employee satisfaction and retention [
6,
7]. As a result of healthcare system reform, technological innovation, a growing elderly population, and a growing medical burden, a more complex healthcare work environment has placed greater demands on the competence of nurse managers [
8,
9]. Several studies show that nurse managers need to resolve interpersonal conflicts among staff and promote nurse relationship building [
5]. It has been demonstrated that nurse managers play a key role in the establishment of a healthy workplace, the recruitment and retention of clinical nurses, and improvements in the quality of care and patient safety [
10,
11]. As the main body of nursing management, nurse managers are required to master higher levels of education and experience compared with other nurses [
12]. Tertiary general hospitals are associated with the highest healthcare-delivery competence [
13], so nurse managers of tertiary general hospitals are expected to be more proficient in both skills and tasks compared with those of second-tier hospitals. Existing studies suggest that nurse managers of tertiary general hospitals need to be responsible for work organization and administrative management, participate in service-quality supervision and managing the funding budget of the hospital, and improve the efficiency of nursing human resource management and quality of nursing work [
14], which makes a nurse manager’s role unique compared with roles in other healthcare settings.
Most nurse managers in Chinese tertiary general hospitals are selected from clinical nurses based on their explicit characteristics such as their education background, professional knowledge, and nursing skills, without paying much attention to implicit factors such as responsibility, cooperation, and leadership [
15,
16]. However, these implicit characteristics, being undervalued, are inclined to exert considerable influence on nurse managers’ working performance, so the current selection methods are not scientific and rigorous enough. Under this circumstance, a comprehensive nurse manager competency model is needed to measure a nurse manager’s knowledge and skills, as well as their value orientation, competitive consciousness, desire for knowledge, and other potential characteristics. Such a model can act as a selection standard for nurse managers, and hospitals can select candidates with more potential and who fit the job requirements more closely [
17].
The methods for constructing the nurse manager competency model are mainly divided into qualitative and quantitative research, ranging from the Delphi method, job analysis, and the behavioral-event-interview method to the questionnaire-survey method [
18]. Liu constructed a model through the Delphi method including three dimensions: service and help, management characteristics, and personal efficacy and cognition [
19]. Supamanee and Sherman constructed models through the interview method, including six dimensions: self-transcendence, interpersonal communication ability, financial management ability, human resource management, empathy, and systematic thinking ability [
20,
21,
22]. McCarthy and Pillay constructed models by using questionnaire surveys, including professional skills, coordination and communication ability, human resource management, adaptability, innovation ability, and decision-making ability [
23,
24]. McCarthy, Pillay, and Dai constructed models through nuclear inspection tables and the behavioral-event-interview method, including professional learning ability, thinking ability, leadership, communication skills, talent training, team spirit, initiative, self-confidence, and dedication spirit [
23,
24,
25]. Tian constructed a model through focus-group discussions and the online-survey method. The model consisted of five key competency features of high-level community health service management, including interpersonal coordination, communication ability, business resources, administrative and management capability, knowledge of the healthcare environment and organization ability, change leadership and management skills, and the ability to make decisions based on facts [
26].
Despite the above model constructed by domestic and foreign scholars, there are few studies on the competency of nurse managers in tertiary general hospitals [
19]. The existing model studies have not distinguished the research objects, and whether the results are applicable to tertiary general hospitals has not been verified. For example, Dazhi W. applied the established nurse managers’ competency model to the quality assessment of nurse managers through in-tray tests and leaderless group discussions, and drew a conclusion that the assessment results were quite consistent with the reality [
27]. Xianghua X. established a model through behavioral event interviews and questionnaire surveys, designed a training course for nurses according to the competency elements in the model, and evaluated the training effect for head nurses by using the competency assessment questionnaire, which showed that the scores of head nurses in the competency assessment questionnaire improved significantly after training [
28]. Some of the existing models only include competency indicators, and the model structure is incomplete, resulting in a lack of connection between the theoretical framework and practical applications, and its practicality needs to be further explored [
29]. Due to different national conditions and cultures, the application of foreign competency-model methods may not be applicable to China. Therefore, competency research suitable for China’s local conditions is expected to be developed.
2. Materials and Methods
2.1. Sample
In this study, survey samples were selected through two-stage sampling. In the first stage, the study chose Beijing, Jilin, and Hainan based on economic competitiveness through judgement sampling. In the second stage, through simple random sampling, 3 tertiary hospitals in Beijing, 2 tertiary hospitals in Changchun, and 2 tertiary hospitals in Haikou were selected, and 600 questionnaires were distributed.
2.2. Study Design
The research started to obtain nurse managers’ competencies in two ways, which are a literature review and behavioral event interview, and then integrated all the obtained competencies to be preliminary ones for further screening to establish the model. The Delphi method was conducted twice, and the ratio of full scores, mean, and coefficient-of-variation method was adopted to define the number, names, and definitions of competencies; then, the questionnaires containing these competencies were distributed to nurse managers from tertiary general hospitals for further competency screening by virtue of the ratio of full scores, mean, and coefficient-of-variation method. Factor analysis was employed to delineate the dimensions of the competencies, and the competency system was subsequentially tested by using Cronbach’s alpha and the structural equation model. An analytic hierarchy process was consequently utilized for the weights of each dimension and competency. The nurse manager competency model was eventually constructed through the above procedures.
2.3. Study Procedures
The selection of the nurse manager competency model elements for the questionnaire was based on a literature review, a behavioral event interview, and the Delphi method. First, through literature analysis, 10 representative nurse manager competency models were selected as the source of preliminary elements and 20 competency elements were extracted.
The behavioral event interview is an open and behavioral retrospective exploration technique combining the critical event method and thematic apperception test. Through interviews, descriptions of successful and unsuccessful events during the interviewees’ tenure were collected. Based on these descriptions, we could find detailed behaviors that affected the performance in target positions, and then collect, analyze, and code the collected specific events and behaviors to obtain competency elements [
30]. In the behavioral event interview, 14 nurse managers from three tertiary general hospitals in Beijing were selected. All of the 14 nurse managers had more than 2 years of experience in nursing management and had excellent performance appraisals. Moreover, to ensure representativeness, nurse managers were selected from internal medicine, surgery, obstetrics and gynecology, pediatrics, and traditional Chinese medicine departments. Meetings were held to determine the selection criteria for the interview subjects and the compilation and modification of “the Competency Coding Dictionary for Nurse Managers in Tertiary General Hospitals”. By converting the record into text and analyzing key words, we extracted 23 competency elements. After combining the elements from the literature analysis and behavioral event interview, removing the same elements, a total of 31 nurse manager competency elements were obtained.
Second, we screened model elements using the two-round Delphi method with a panel of 20 experts. These experts were selected nationwide according to their education backgrounds, professional titles, years of experience, majors, and positions. All the experts had more than 5 years of working experience in nursing management. The average age was (44.53 ± 10.19) years old, the average working years in nursing management was (18.84 ± 9.11) years, about 60% had obtained a master’s degree or above, and about 70% had obtained titles of deputy senior or above.
The recovery rates for the first and second rounds of consultation were 95% and 100%, respectively. The results showed that the authority degree coefficient for all the factors in the two rounds was higher than 0.8, suggesting that the results of the experts’ evaluation had high reliability. The Kendall coordination coefficient for all the factors was statistically significant (p < 0.05), suggesting that the results of two rounds had high validity. According to the 31 elements collected, the questionnaire on the importance of competency elements was compiled, and two rounds of expert consultation were conducted. After two rounds of Delphi, 27 factors were retained.
Finally, this study finally determined the competency elements through a questionnaire survey of nurse managers in tertiary general hospitals. After two rounds of Delphi, we compiled the Questionnaire on the Importance of Competency Elements for Nurse Managers of Tertiary General Hospitals. The questionnaire asked the participants to rate the importance of each factor on a 5-point Likert scale, ranging from “very important” (5 points) to “very unimportant” (1 point).
Before the formal questionnaire survey began, we conducted a small-scale pre-survey to assess the reliability and validity of the questionnaire. The pre-survey investigated 145 nurse managers from 3 tertiary general hospitals in Beijing. A total of 139 questionnaires were collected. After receiving the completed questionnaires, a preprocessing step was applied to remove incomplete or invalid data. The exclusion criteria were as follows: (1) there were more than three factors unanswered; (2) all the factors of importance were answered the same; and (3) the answers displayed an obvious pattern. A total of 136 of the questionnaires were effective, with a recovery rate and an effective rate of 95.86% and 97.84%, respectively. The analysis results showed that the correlation coefficient for the two tests was 0.83, indicating that the retest reliability coefficient was ideal (a retest reliability coefficient above 0.70 is considered to be optimal). The overall Cronbach α was 0.92, larger than 0.80, indicating that the questionnaire had high reliability. Factor analysis showed that the KMO value was 0.858, indicating that the selected competency elements were suitable for factor analysis, and the questionnaire had high structural validity.
2.4. Statistical Analysis
This study calculated Cronbach’s α to test the reliability of the model and employed the structural equation model to test the structural validity of it. In the structural equation model, since the competency level was an exogenous latent variable and the competency dimension was an endogenous latent variable, the maximum likelihood estimate (MLE) was used for parameter estimation. The evaluation of the model was, to be precise, the evaluation of the fitting degree of the data [
31], as a result of which the goodness-of-fit index of the CMIN (chi-square value)/DF (degrees of freedom) [
32] was used to evaluate the goodness of fit of the model. The data were processed with Microsoft Excel 2017 (Microsoft, Redmond, Washington, DC, USA) and analyzed with SPSS 21.0 (IBM, Armonk, NY, USA).
2.5. Ethical Issues
Informed consent forms had been completed before the survey. All the participants were provided with written and verbal information about the content and gave written informed consent to participate. The experts’ responses were protected throughout the Delphi consultations, and the participants had the right to refuse to answer questions or withdraw from the study whenever they wanted to. The study had no privacy or ethical implications.