INTRODUCTION:

Nursing management is an important component of health care organizations. Executive nurses play a crucial role in ensuring quality, safe patient care and managing care in health care facilities^1,2,3,4. With the rapid evolution of health care systems and changes in the structure of nursing over the past three decades, nursing management has become increasingly demanding. As nurse managers took on more administrative management, their roles underwent a significant change.

Executive nurses have the ability to manage teams, workforce diversity, motivate nurse staff, make decisions, resolve conflicts and problems, manage time, stress, and change processes^5,6,7.

Executive nurses are individuals responsible for the management of all nursing services in a health institution³. Management levels and titles of nurses may vary between health institutions. In this article, the manager nurse refers to those who oversee the general management and administration of the nursing services in the hospital, and the charge nurse refers to the nurses who are the managers of a certain unit or department in the hospital environment.

Nursing leadership is often equated with nursing management⁸. Charge nurses are both clinicians and managers⁵. Charge nurses are responsible for managing the day-to-day operations of nursing units, ensuring the safe and efficient delivery of patient care, and managing nursing staff, including training, and evaluating their performance^7,9,4,10,11.

Restructuring of health institutions has had an impact on the extent of the nurse-in-charge manager role. It has transformed charge nurses into service managers with the autonomy and power to improve the quality and effectiveness of patient care. It has expanded to expect nurses in charge to be leaders alongside management. Added that chief nurse managers have advanced leadership skills and competency to manage people, organization resources, and change^1,12,13,14.

The leadership role of the nurse-in-charge in the hospital aims to manage nursing services effectively, to ensure patient safety, and to increase the quality of care. Therefore, the effective performance of the charge nurse is critical to the successful functioning of the hospital and to ensuring that patients receive good health care¹⁵. The charge nurse has a key role in the implementation of nursing practices in accordance with legal, ethical, and professional standards. She also uses leadership skills such as team management and coordination of patient care^12,13,4,16.

Evaluating the leadership role of charge nurses is an important aspect of nursing management. Various studies have investigated the leadership development and evaluation of charge nurses^{17,18,19,20,21,12,22,23,24}. Charge nurses’ assessment of their own leadership competencies can help them evaluate their skills and leadership styles in the management of nursing services. The evaluation process may include self-evaluation, feedback from peers and subordinates, and feedback from managers¹⁴. Tools used for evaluation may include surveys and performance reviews. Questionnaires allow nurses to assess their leadership skills and obtain other peoples’ views on their leadership skills. Evaluating their own leadership competencies can help nurses identify their own strengths and weaknesses, set goals to develop leadership skills, and fulfill their leadership role more effectively^20,21.

The results of studies on nurses’ self-assessment of leadership competencies show that nurses’ leadership self-efficacy, self-leadership, commitment to work, and authentic leadership have positive correlations with clinical competence, motivation to participate in leadership roles, and quality of nursing care. Self-assessment of nursing executive staff tends to be the guiding style. Nurses’ self-assessment of clinical leadership knowledge and competencies is also an important aspect of assessing leadership competencies^25,26,14.

Evaluation of charge nurses by their managers is important for measuring and improving the work performance of nurses. By objectively evaluating the job performance of charge nurses, administrators can help nurses identify their strengths, identify areas of improvement, and set goals. Evaluation by the manager helps determine whether the nurse’s leadership role meets expectations and contributes to the overall success of the nursing department or unit. Evaluation results are often used to provide feedback, set goals for professional development, and, if necessary, for promotions and performance improvement plans⁶.

When the literature was searched, we could not find any source directly addressing the results of a study on the leadership evaluation of nurses in charge of executive nurses. It is important to consider the perceptions of both charge nurses and executive nurses when assessing charge nurse leadership. Research has shown that leadership development programs for executive nurses can be effective in improving their leadership skills^{27,28,29,17,30,7,31,32,23}.

Charge nurses are the vital link between senior management and clinical nurses. They affect corporate culture and outcomes for patients and staff; therefore, job satisfaction and ultimately retention are important^33,34.

Important leadership qualities of the charge nurse include visibility, accessibility, consultation, recognition, and support. An effective nursing unit manager who consults staff, provides positive feedback, and scores high on various leadership elements is effective in increasing job satisfaction and satisfaction with nursing^35,36.

In the literature, there has been no study examining the self-evaluation of leadership management by charge nurses and their evaluation by executive nurses. It was thought that this study would contribute to the literature on this subject.

AIM:

This study aimed to examine the compatibility between self-evaluations of charge nurses regarding their leadership skills and the evaluations provided by their executive nurses. In addition, the study identified any factors that may influence this compatibility.

MATERIALS AND METHODS:

Design:

This research is a descriptive, cross-sectional (2015-2020) multicenter study. The study included 16 hospitals from a private health group in Turkey, covering the period between January 2015 and December 2020. These hospitals included nine hospitals located in Istanbul and seven hospitals in different provinces of Turkey. The minimum number of beds in these hospitals was 74, and the maximum number of beds was 501. The nursing services in these hospitals comprised 3,381 nurses. Within the hospitals, the study included at least one executive nurse per hospital.

Sample:

The universe and sample of the study consisted of 1200 evaluation forms, including the leadership evaluation form of 600 charge nurses working in a private health group hospitals and 600 charge nurse leadership evaluation forms filled by 53 executive nurses who evaluated them. Because all charge nurse managers were evaluated using this method, no sample selection was made, and the entire universe formed the sample. The distribution of charge and senior nurse managers by years is given in Table 1.

Table 1. Distribution of charge and manager nurses by years

	Charge Nurse Numbers		Manager Nurse Numbers
Year	N	%	N	%
2015	28	4.7	3	5.7
2016	23	3.8	4	7.5
2017	37	6.2	5	9.4
2018	152	25.3	13	24.5
2019	143	23.8	13	24.5
2020	217	36.2	15	28.3
Total	600	100.0	53	100.0

In this study, 600 charge nurses’ self-evaluations related to leadership and 600 charge nurse evaluations of 53 executive nurses were examined in 1200 evaluations. The distribution of the number of nurses by years is given in table 1.

Data collection tools:

"Executive nurse leadership personal evaluation form" consisting of 52 questions prepared in cooperation with the nursing services directorate and human resources in X Health Group, was used to collect the data. The executive nurse leadership personal evaluation form consisted of two parts. In the first part, demographic data 6 items, in the second part, there were 46 items for executive nurses’ leadership evaluations. Executive nurse leadership evaluation form prepared by the institution; communicating (5 items), developing the individual (5 items), managing the unit’s performance (5 items), values (3 items), managing change (5 items), building an effective team (7 items), and cooperation (5 items) were related to individual management (6 items) and strategic planning and decision making (5 items). The 46 items in the evaluation form were evaluated using a five-point Likert scale (1-Strongly Disagree, 2- Disagree, 3-Undecided, 4-Agree, 5-Strongly Agree). In the evaluation of the form, each category was evaluated over 1 to 5 points (Min 46 points, Max 230) and the average was calculated. Expert opinion was taken for the prepared form. The Cronbach’s alpha internal consistency coefficient of the form was calculated as 0.993.

Data collection:

Since 2017, the McKinsey 9-Box Matrix has been used to evaluate the performance and potential of employees in charge of nurse placements at X Health Care Group. The talent management of nurses in the institution includes the management of processes such as developing business skills, planning their careers, and training needed leaders. Nurses who are successful in these processes are brought to the position of charge nurse depending on the evaluations. Charge nurses evaluated themselves once a year using the "Executive Nurse Leadership Personal Evaluation Form, which was prepared in cooperation with the X Health Care Group nursing services directorate and human resources. The director of nursing services also assessed the nurses in charge using the same form. After both sides finished the evaluations, the nurse in charge and the director of nursing services discussed the results of the evaluation through both forms face to face. Because of the different sections between the average scores of the charge and executive nurses and the evaluations made by both managers, development plans were made for the areas needed by the charge nurses. Within the scope of this process, training plans were made within the scope of the X Health Care Group Nursing Leadership Academy according to the requirements of both executive nurses in accordance with the corporate culture and vision.

The completion of forms is a collaborative effort between the charge nurse and the nursing services manager. The original hard copies of these forms are maintained by the nursing services manager within the hospital. Meanwhile, the filled-out forms are electronically transferred to Microsoft Excel and then submitted to the General Directorate's Business Development and Project Directorate through email. This allows for efficient data management and analysis. Lastly, the annual data is archived within the Nursing Services Directorate, ensuring that important records are securely stored for future reference.

Data analysis:

Descriptive statistics, including the mean, standard deviation, minimum, median, and maximum, were calculated to characterize the continuous variables. Spearman’s rho correlation analysis was used to analyze the relationship between two continuous variables that did not fit normally. The Kruskal – Wallis test was used to compare continuous variables belonging to more than two groups that did not fit the normal distribution. Comparison of two independent and non-normally distributed variables was performed using the Mann–Whitney U test. The statistical significance level was determined as 0.05. Intraclass correlation (ICC) analysis was performed to evaluate the concordance of a continuous score between the two raters. Statistical analyzes were performed using IBM SPSS Statistics, version 24 (IBM Corp., Armonk, NY, USA).

Ethical Aspect:

The study was conducted in accordance with the ethical principles stated in the Declaration of Helsinki. As stipulated in the Personal Data Protection Law, all necessary measures were taken to protect the confidentiality and privacy of the participants. Data collection was performed with the utmost care to ensure that the information collected was reliable and accurate. The participants knew that data would be collected for comparison using an evaluation form, and informed consent was obtained. Ethics committee approval was obtained from X University 2/9/2021 and 2021/16-22 for the study.

RESULT:

Table 2 provides information about the characteristics of the nurses who participated in the study. This study focused on both charge and executive nurses. The charge nurses were mostly female (80.10%, n=481) and had less experience as managers (61.84% n= 371) compared with the executive nurses. Many of these nurses held an undergraduate degree (32.62%, n=196). On the other hand, the executive nurses were also female (90.57%, n=48), but held a postgraduate education (81.12%, n=43) and had worked for 61 months or more (20.76%, n=11). The average age of the charge nurses was 37.5 years, and the mean age of the executive nurses was 39 years.

Table 2. Distribution of sociodemographic characteristics of the charge and manager nurses

	Charge nurse		Manager nurse
Gender	N	%	N	%
Female	481	80.17	48	90.57
Men	119	19.83	5	9.43
Education
Vocational	205	34.17	-	-
Prelicensure	50	8.33	-	-
Undergraduate	196	32.67	10	18.87
Graduate	149	24.83	43	81.13
Work years as a manager
0-12 months	371	61.84	-	-
13-36 months	104	17.33	26	49.05
37–60 months	50	8.33	16	30.19
61 months and up	75	12.50	11	20.76
Total	600	100.0	53	100.0

These analyzes aimed to determine whether differences existed in leadership skill evaluations based on gender, education, and seniority of the nurses in charge, as evaluated through self-assessment and administrator evaluation. The results showed that there was no statistically significant difference in the total score distribution of self-assessment and administrator evaluation based on gender (p>0.05), indicating that males and females were evaluated similarly in terms of their leadership skills. Similar results were found in the distribution of self-evaluation and manager evaluation according to the education level of the nurses; no significant difference was observed (p>0.05). However, a statistically significant difference was observed in the distribution of self-evaluation and manager evaluation according to the seniority of the nurses (p<0.05). Post hoc pairwise comparison results revealed a statistically significant difference between all paired comparisons except for the 13-36 months and 37–60 months groups, with nurses with 61 months or above of seniority having a higher average score.

Table 4. Distribution of evaluations of the charge and manager nurses according to average age

Age	Charge Nurse Evaluations		Manager Nurse Evaluations
Age	r	p	r	p
Total points	0,384	<0,001	0,281	<0,001

There was a statistically positive and weak correlation between age and total score average (p<0.05).

Table 5 indicates that the evaluations made by the charge nurses themselves are consistent with those made by their managers. The level of agreement was statistically significant (p<0.05), indicating a high degree of concordance between the two evaluations. There was a significant level of agreement between the self-evaluation of the nurses in charge and the scores evaluated by their managers. This indicates that the evaluations made by the nurses in charge are consistent with those made by their managers. The level of agreement was statistically significant (p<0.05), confirming that there was a reliable homogeneity between the two evaluations. Together, these results indicate that the evaluation forms utilized in the study effectively and accurately assessed the leadership skills of charge and executive nurses.

Table 5. Distribution of the evaluation averages of the charge and manager nurses by years

Years	Charge Nurse Evaluations		Manager Nurse Evaluations
	Mean	Standard Deviation	Mean	Standard Deviation
2015	199	29	170	23
2016	193	27	166	33
2017	190	38	177	44
2018	182	36	167	37
2019	179	40	176	32
2020	187	36	175	34
Total	185,02	36,8	172,5	34,63

Intraclass Correlation ICC: 0.753 p; <0,001

DISCUSSION

In this study, the concordance between charge nurses’ self-evaluations of leadership and their manager nurses’ evaluations and the factors affecting this were investigated. The mean age of charge nurses was 37.5 years, whereas executive nurses had a mean age of 39 years. The nursing workforce globally is generally young, with individuals often beginning their education and entering the profession their 20s or 30s. While it is difficult to provide specific age distribution information for executive nurses due to individual and country variations, it is commonly observed that experienced and skilled nurses are promoted to managerial positions. Age showed a statistically weak correlation with the mean total score (p<0.05), and studies mentioned that leadership qualities tend to increase with age^{15,11,37,38,39,40}.

80% of the nurses in charge and 90% of the executive nurses were women. In Turkey, 25% of nurses are male, which is higher than the global average. In the USA, the proportion of male nurses is 12%⁴¹, whereas while in England, it is 11%⁴². Gender stereotypes in personal qualities and presumed natural differences in attributes affect how people perceive leaders. Culture can influence the differences in leadership style perceived by subordinates²⁵. In both eastern and western cultures, there is a perception that men are more qualified than women to be business leaders⁴³. The gender gap and the difference in education between the charge and executive nurses indicate a possible disparity in opportunities for career growth and advancement within the nursing profession. This disparity may be attributed to the impact of gender on nursing leadership practices and the relevance placed on academic qualifications. Additionally, the average age of the nurses may indicate the need for succession planning in nursing management to maintain a sustainable and effective health care delivery system.

The mean leadership self-evaluation score of the nurses in charge was 185.02 points, while the mean leadership assessment score for the nurses in charge was 172.50 points. Self-evaluation is an appraisal method in which individuals assess their own performance and behaviors. When conducting a self-assessment, it is crucial to maintain objectivity and honesty with oneself. According to various studies, people may find it difficult to analyze themselves objectively enough and to provide accurate information about themselves^{44,19,45,9,26,16,11}. More than half of the charge nurses in this study had been in this job for one year. People tend to overvalue their own performance⁴⁶. Some studies on this effect have revealed different aspects in Western and Eastern cultures. In Eastern cultures, individuals tend to evaluate their own performance lower than that of their superiors, which is referred to as the "humility effect." Conversely, in Western cultures, the results show the opposite^47,34,48.

In this study, individuals also rated themselves higher than executive nurses. Leadership styles between the two groups may differ. The leadership styles of charge nurses may be more operational and team-oriented, whereas those of senior executive nurses may be more strategic and vision-oriented^49,50,51. Therefore, both groups may emphasize different aspects and skills of leaders, which can lead to differences in their assessments. Although the mean scores of the manager nurses in this study were lower than the average scores of the charge nurses to evaluate their leadership, there was a good statistically significant agreement between the self-evaluation of the charge nurses and the manager evaluation (p<0.05). The year with the highest level of compliance was 2019. The results of the evaluation provided the charge nurses with an opportunity to analyze their leadership skills and identify areas for improvement. This information was used to assess the skills of the nurses in charge who received high and low scores and to determine their developmental needs. Necessary support was provided in the areas of training, mentoring, and coaching to increase compliance and assist personal development.

LIMITATIONS:

This research was conducted with the charge and executive nurses working in a private hospital group. Therefore, the results cannot be generalized to all health care professionals. It is recommended that similar studies be conducted in a randomized controlled manner to ensure that the results can serve as a source for evidence-based practices.

CONCLUSION:

This study provides insights into the compatibility between self-evaluations of charge nurses and their managers’ evaluations, along with the factors influencing this compatibility in the field of nursing. Overall, there was a significant level of agreement between nurses’ self-reports on leadership and their managers’ evaluations. However, the correlation with average age was weak. The gender and education level of the nurses in charge did not have a significant impact on the mean scores of leadership self-reports and administrator evaluations. On the other hand, there was a notable difference in the leadership-related self-evaluation and manager evaluation scores based on the nurses’ years of experience, with higher scores observed for those with more years of experience. These findings indicate that nurses’ self-assessments and their managers’ evaluations can provide reliable information, making it beneficial for nurses to identify areas for development and take appropriate steps accordingly.

RELEVANCE FOR CLINICAL PRACTICE:

It is important to ensure compatibility between evaluations conducted by managers and self-evaluations. To achieve this, it is recommended to have clearly defined evaluation criteria and standardized evaluation tools. Regular and ongoing evaluations, along with feedback provided by administrators to charge nurses about their leadership, can help nurses accurately assess their own characteristics. It is advised to incorporate the leadership assessments of charge nurses, both self-reports and manager evaluations, in health care institutions.

CONFLICT OF INTEREST:

The authors declared no potential conflicts of interest regarding the research, authorship and/or publication of this article.

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Received on 12.03.2024 Revised on 15.07.2024

Accepted on 28.10.2024 Published on 20.11.2024

Available online on December 28, 2024

Int. J. of Advances in Nursing Management. 2024;12(4):151-157.

DOI: 10.52711/2454-2652.2024.00033

	Charge Nurse Evaluations			Manager Nurse Evaluations
Gender	Mean	Ss	p	Mean	Ss	p
Female	184,9	37,8	0,582	171,2	34,9	0,216 Mann– Whitney U test
Men	185,14	32,8	0,582	176,2	33,2	0,216 Mann– Whitney U test
Education
Vocational	187,2	31,9	0,990	177,4	30,7	0,148 Kruskal – Wallis Test
Prelicensure	188,3	29,3		172,9	34,4
Undergraduate	184,2	38,7		170,6	34,0
Graduate	181,9	42,4		168,2	39,7
Work years as a manager
0-12 months	153,95	41,9	<0,001	143,02	41,4	<0,001 Kruskal – Wallis Test
13-36 months	174,3	36,7		167,5	30,7
37–60 months	183,3	33,2		176,3	29,9
61 months and up	198,2	30,5		180,2	32,8