Staff Nurses’ Perceptions of Barriers and Facilitators of Effective Nursing Leadership in a Major Saudi Hospital
Ibrahim Alenezi1, *
Identifiers and Pagination:Year: 2022
E-location ID: e187443462207140
Publisher ID: e187443462207140
Article History:Received Date: 31/1/2022
Revision Received Date: 25/3/2022
Acceptance Date: 5/4/2022
Electronic publication date: 03/09/2022
Collection year: 2022
open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Leadership skills on the part of nursing managers are expected to improve care for patients under the care of registered nurses. To do so also requires all Saudi hospital nursing leaders to attract and retain qualified nursing staff during a time of global shortages.
The purpose of this study is to explore and identify the staff nurse perceptions of the barriers to and facilitators of effective nurse leadership for a major Saudi hospital and make recommendations for change.
An interpretative methodology guided by John Kotter’s change theory. Qualitative data were collected from 14 participants using semi-structured interviews in 2016 and analysed using content analysis.
Two main categories have been identified through the data analysis process. The first category was barriers to effective leadership, comprising an inadequate leadership education and skills development; a limited authority and clinical empowerment; an unawareness of the need for change; and poor communication. The second category was facilitators of effective leadership, encapsulated engaging and listening to staff and seeking their ideas; recognizing staff performance, and motivational strategies.
Even though the staff nurses who participated in this study were dissatisfied with the quality of leadership shown by their nurse managers, nevertheless they proffered an abundance of data during the study which accentuated the variety of organizational obstacles encountered by their nursing managers. They also voiced opinions on the workplace factors which might serve to assist nurse managers to improve the efficacy of their guidance. These were included in the study recommendations which were forwarded to all nursing managers employed at the hospital.
The usefulness of how nurse managers lead and supervise their staff nurses is currently a major international concern for all healthcare organizations . Nurse managers commonly encounter difficulties in the areas of finance, improvements in care, medical oversights, and staff shortages. These various problems could be resolved, in part or in full, by proficiency on the part of the nurse managers . This is both crucial for nurses in senior administration and those guiding their junior colleagues. There is a direct correlation between levels of professional contentment in nursing and the degree to which nurse managers can demonstrate effectiveness in terms of leadership and management because they can contribute to the ability to surpass performance targets . Given that the quality of such leadership skills has a direct effect on the level of patient care, many programs have been initiated around the world in pursuit of this idea of which many healthcare organizations have become aware .
At present, the field of nursing leadership could be regarded as in turmoil and, as a result, nursing bodies around the world are burdened by an obligation to work in cooperation to provide operative solutions to this pressing concern. The issue at stake is the future of nursing as a weighty and cherished profession . There is a consensus that nursing managers of all levels must collaborate if they are to discern nascent developments, boost innovation, and make progress toward a collective objective . One of the greatest conundrums encountered by such senior personnel is how they should respond to suboptimal staff performance . Shiery  strongly emphasizes that senior nursing staff face the challenge of enhancing their expertise in a variety of areas. Nursing staff must deal with inconsistencies in the technical arena and elsewhere, along with ever-growing levels of intricacy in modern medicine as well as the use of essential but expensive medicines, the emergence of virtual consultations, technical progress, advances in non-invasive operations and imaging equipment, reductions in expenses, staff shortages, and substantial steps forward in training and procedure. To boost the levels of care offered, there is an obligation by nursing leaders to proffer support to staff. Zakaria, et al  have insisted that managers in the profession must instigate and sustain congenial and reliable professional environments to help subordinate staff cultivate high standards and become more productive.
2. NURSING MANAGEMENT IN SAUDI ARABIA
The backgrounds and educational preparation of nurses employed at health facilities in Saudi Arabia differ considerably  and as Suliman  reported this creates several obstacles and challenges for their ability to manage. Because of this, qualified nurse managers who can successfully lead a variety of staff nurses are greatly prized in the Saudi hospital milieu . Sullivan  added that such managers are acutely perceptive when evaluating dissimilarities between nurses and resolving difficulties that might arise in the workplace among personnel. However, Almalki et al.  pointed out that nurse managers in Saudi healthcare facilities are nevertheless not sufficiently empowered to execute their normal duties nor adequately prepared to participate in the decision-making process, which in turn can lead to the marginalization of their position within their organizations .
In Saudi Arabia, there has been extensive deliberation on the subject of competent leadership and management in the profession, along with the inadequate degree to which nurses have a say in professional decisions associated with working hours and remuneration . Abu Zinada  pointed out that in Saudi Arabia, there are two conflicting views on the subject of management efficacy among nursing managers: the phenomenon has no discernible effect on the quality of patient care; and, conversely, any shortcomings in nursing management will compromise healthcare. An assessment of the existing literature about nursing and healthcare in Saudi Arabia unveiled a dearth of research into the views of staff nurses in terms of what constitutes success on the part of nurse managers’ leadership. More research work is also required to discern what staff nurses regard as obstacles to and facilitators of such success and to unveil any changes which could be applied in pursuit of improvement in this arena.
3. PURPOSE AND SIGNIFICANCE OF THE STUDY
This research study was designed to explore how staff nurses perceive barriers and facilitators in the field of nursing leadership at Saudi hospitals. Any progress in ascertaining these matters should give nurse managers employed at Saudi hospitals a more extensive grasp of the factors needed to enhance their leadership and management approaches. They might also benefit in terms of understanding shortcomings and needs which could encourage motivation in the workplace, with this bringing about improvements in patient care. The findings of such research could also allow managers working at hospitals in the country to view the management through the eyes of the nursing staff, with this subsequently inspiring substantive changes.
3.1. Research Questions
This study aims to answer the following two questions:
- 1- What are the barriers that prevent nurse managers from leading effectively?
- 2- What are the facilitators that would enable nurse managers to lead effectively?
3.2. Theoretical Framework
The foundation framework that guided this study was Kotter’s  change theory. It has been demonstrated that this method can be applied to healthcare to assess leadership and how organizations develop . John Kotter’s eight-part process for transformational advancement has been used to prompt changes in healthcare organizations. In Leading Change, Kotter outlined the eight stages of a system which help people to contemplate new methods, modifications, difficulties, and tactics. He also stressed that leadership is at the core of change, asserting that the first step in the process is the cultivation of a sense of urgency. This leads others to discern the necessity for change and to appreciate the value of prompt action. To bolster the degree of urgency, Kotter claimed that leaders must eliminate anything, which fosters a complacent attitude. Kotter held that  that the subsequent stage is cooperation, with the intention of rendering progress possible.
Sufficient potential to undertake the change required can be attained by assembling a suitable collection of individuals capable of bringing this about, who believe in one another and who are similarly inclined in terms of goals. After forming such a group, the third step is the crafting of a fresh blueprint and new tactics. When this stage has been completed, the group will have an illuminated new path toward progress .
Kotter insisted that once this determination has been made, change can proceed via the next four steps. The fourth stage  consists of conveying the new vision capably and resolutely to the medical facility. During this period, it is considered crucial for leaders to devote attention to short-term gains in pursuit of change in the workplace. Brown and May  portrayed short-term accomplishment as representing progress for any establishment which is seeking to implement wide-ranging modifications. Kotter’s  fifth step consists of the eradication of obstacles to progress. He emphasized that in this part of the process, leaders must encourage their colleagues to bring the new idea to fruition, fostering a creative spirit that embraces an element of risk . During the sixth stage, Kotter accentuated the need to establish incentives for short-term progress as the medical facility takes its initial steps in pursuit of its new aspiration. Kotter  struck a note of caution regarding the seventh step, which involves the securing of previous accomplishments and the cultivation of further progress. He noted that this constitutes a daunting obstacle that presents a fresh degree of difficulty because it prompts more pressing insistence on change in the workplace.
McEwen and Wills  observed that, in the present moment, supervisory staff must continuously gauge the effects of their endeavors and carry out any fine-tuning required. Kotter’s eighth and final step in the process of fostering long-term change consists of an impetus among the staff to make progress. It is essential to uphold the new strategies and to scrutinize the new ethos to ensure that it endures long enough to supplant previously engrained practices .
With Kotter’s blueprint for change acting as a foundation, the opportunity arises for the formation of a well-organized, innovative, and superior work milieu. The formulation and effecting of change at a medical facility involves far-sighted leadership and management. The identification of obstacles and the careful exploitation of methods will assist the author and the staff involved in determining a project plan in the pursuit of progress, with the ultimate goal of developing nursing management in Saudi Arabia.
The theory steered the crafting of interview questions for this research project. The stages proposed by Kotter inspired the formation of the questions. The establishment of apprehension of urgency marks the first stage of progress. The author has observed that resistance to change is widespread across Saudi society and has an adverse effect on the development of the country’s healthcare system. Kotter  stated that the combination of a culture impervious to change and managers who have yet to be schooled in the creation of change is deleterious. Staff attempting to demonstrate leadership at healthcare bodies in Saudi Arabia should, therefore, nurture a sense of urgency if progress is to be effective.
The third section of the change project, which involves the formulation of an overview and associated tactics, will act as a means of steering the assessment of information because the profound change requires far-sighted planning and practical methodologies if progress is to be channeled into an appropriate direction. A cogent vision helps to illuminate the path in terms of such change. It calls staff to action and helps to synchronize the endeavors of a diverse assembly of employees with different qualifications . The first step involved urgency, and the third, which embraces the overall vista and methods of the procedure designed to effect change, constituted part of the research basis. Certain people in a position of leadership have suggested that the substantive challenge lies not so much in the inculcating of a perception of urgency but in the need to inspire junior colleagues to put this into practice . Furthermore, an indistinct vision on the part of nursing leaders could backfire on the planners at the facility by consuming funds and time without any benefit . Conversely, clarity of thought could encourage staff to pursue the changes in question. Consequently, Kotter’s theory lies at the core of this research because it provides a prescribed and well-designed method that could assist in the transformation of the medical body under scrutiny.
An interpretive design was used in this study. This research design encourages participants to deliberate on their past and current circumstances and the events of their lives and use the self-awareness and wisdom which emerges to contribute to the professional changes sought at the workplace [18-20]. It can be instrumental in helping researchers of nursing determine the best ways in which to boost staff recruitment and retention, enhance the quality of nursing, and improve patient care, along with autonomy and job satisfaction also being important goals of this method.
Rooted in perspectives from social sciences, the design highlights the importance in this instance of the views of health care staff including nurses. How they experience, and interpret their employment circumstances. It is not possible to elaborate further on the theoretical underpinnings only to emphasize it is important to be aware that qualitative research is informed by a paradigm that is governed by quantitative clinical research. Qualitative research that uncovers understanding, meanings, and clinical experiences that is relevant to uncovering the complexity inherent in health care leadership of change that can lead to quality improvement .
4.1. Sample and Recruitment
The sample used in this research was a carefully chosen group of staff nurses working at a prominent central hospital in the northern region of Saudi Arabia, who had at least three years of experience as registered nurses in various hospital departments. To attract subjects for the study, the author designed publicity leaflets that were disseminated throughout the hospital. Over the following two weeks, the researcher received only 17 emails from staff nurses who wished to take part. However, three respondents were not then employed as staff nurses and their offers were declined. Therefore, 14 staff nurses provided input for the project.
4.2. Data Collection Procedure
Semi-structured interviews were conducted with study participants following approval from the hospital to recruit participants. As mentioned earlier, participants were recruited via a flyer placed throughout the hospital that briefly explained the study and how to contact the researcher. Voluntary informed consent was obtained from each participant prior to the start of data collection. Before signing the voluntary informed consent form and before beginning each interview session, the researcher verbally explained the study and asked each participant if they had any questions regarding the purpose of this study. Participants were informed that the interview session could be stopped at any time, that they could choose not to answer any of the interview questions, and that they could withdraw from the study at any time. Participants were informed that if they decided to withdraw from the study, all data and study materials involving the participant would be immediately destroyed.
Interviews took place in person in a setting favored by the participant to maximize comfort, privacy, and confidentiality. All interview sessions ran for about one hour. Interviews began with a broad question: “Which obstacles do you think stand in the way of nursing managers becoming successful leaders and managers?” The next step of the inquiry involved further open-ended questions, along with others designed to bring to light the obstacles to effective nursing leadership and any work practices which might facilitate this goal. Field notes were taken by the author as an aide-mémoire of any noteworthy nonverbal reactions or other observations which might bolster and support the research findings. Furthermore, a journal was kept by the researcher to rein in any preconceived views on his part and to ensure objectivity during the data evaluation stage. Data saturation in this study has been achieved after the 11th interview as no new insights were obtained.
4.3. The Protection of Human Participants
Once the hospital had agreed that participants could be recruited for the study, semi-structured interviews took place. As stated above, participants were invited through a flyer placed around the building which succinctly described the study and the researcher’s contact details. Voluntary informed consent was sought from each participant prior to data collection. As a preliminary step, before the consent document was signed, and prior to each interview, the author proffered a verbal outline of the study and enquired whether the person wanted to know any further information about the research objective. The participants were assured that the interview could be terminated at any time, that none of the questions were compulsory, and that they were free to withdraw at any time. In addition, it was made clear that if they did withdraw, all data and research materials pertaining to them would be disposed of immediately.
All digitally recorded interviews were deleted after the interview transcriptions had been verified by the researcher. A master sheet bearing the name of every subject was created along with a dedicated code number, with the latter noted on each participant’s transcribed interview to ensure confidentiality. All consent documents obtained for the purpose of this study, along with all hardcopy interview transcriptions, the journal and field notes preserved by the author in pursuit of the project, and an external computer drive, on which only the research information will be backed up, will spend three years in a sealed drawer at the researcher’s office at Northern Borders University. The master sheet of the study is to be kept in a separate locked filing cabinet drawer at the researcher’s office. Only the author is permitted to use the keys to this drawer. If any part of the research is published, presented, or reported, there will be no means of identifying the participants.
4.4. Data Analysis
Content analysis is a method in which a researcher scrutinizes data or text to expose certain words or patterns in cases in which the research work can be replicated and valid deductions made, to boost knowledge, gain fresh insights, and depict the actual state of affairs . This is designed to describe the phenomenon in a succinct but extensive manner, with the assessment of unearthing notions, classification subgroups, and/or inherent patterns. This method was, therefore, favored in the search for common ideas which typify how staff nurses view the obstacles standing in the way of successful nursing leadership, along with the factors which might assist progress. Content analysis is, as a research method, a methodical and empirical means of defining and measuring the phenomena in question [21, 22].
For an academic researcher, analysis of this kind makes it possible to trial these theoretical concepts in pursuit of a firmer grasp of the data. The application of the process to written text, or other data, can boil words down into a less daunting group of content-oriented classifications. There is a supposition that, when broken down into the same categories, words and phrases can be considered to boast the same meaning . As the information was evaluated, most nascent concepts were discerned and grouped into two principal categories: a) barriers to effective leadership and b) facilitators of effective leadership. These will be the subject of further deliberation in the following section. These findings constituted the foundation of a set of recommendations designed to tackle the obstacles and facilitators to effective nursing management cited by staff nurses. The author resumed contact with the participants in an attempt to validate the suggested recommendations. Once this had been approved and completed, the author perused the literature to ascertain whether this study’s findings matched those of previously published papers.
The analysis of the collected data (14 interview transcripts) revealed two main categories. The first category was “barriers to effective leadership”, which encapsulated four sub-categories: 1) inadequate leadership education development and skills; 2) limited authority and empowerment; 3) unawareness of a need for change, and 4) poor communication. The second category was “facilitators of effective leadership”, with three sub-categories: 1) engaging and listening to staff and seeking their ideas; 2) recognizing staff performance, and 3) motivational strategies. Based on these findings and the wider literature reviewed recommendations were developed for this hospital.
5.1. Barriers to Effective Leadership
It was notable from the collected data that the participants had a clear idea regarding the challenges that their managers face regularly. Such challenges hinder the nurse managers in maximizing their leadership effectiveness.
5.1.1. Inadequate Education and Leadership Skills
Participants believe that their nurse managers need to advance their education and improve their leadership skills to be able to lead effectively and bring about change. In addition, they believe that a dearth of leadership knowledge and skills interferes with effective nursing leadership. Participant (P-R8) described this barrier as follows,
“I believe that our bosses here at this hospital are requested to do tasks that are above their qualifications.” He also added, “a lack of leadership knowledge and skills gets in the way of effective nursing leadership.”
Another participant (P-R11) stated,
“All of our managers, even at top management, hold associates’ or diploma degrees in nursing. So, they are not qualified enough to be managers, I believe.”
Another participant (P-G 6) went further and emphasized the importance of having a professional ladder to occupy leadership positions:
“…leadership among nurse managers is very limited because they are not qualified, I think, I mean they shouldn’t be in leadership positions in the first place. You know, I would say we need a clear ladder that all nurses should go through if they want to be promoted to a leadership post.”
5.1.2. Limited Authority and Empowerment
On many occasions, participants pointed out that their nurse managers have no authority and are dependent on others such as physicians and people at the executive level. They also believe that there are limits on their authority that prevent them from performing efficiently. A participant (P-R8) stated,
“Unfortunately, our nurse managers have no authority and can not make independent decisions at all.”
Another interviewee (P-N 5) added,
“…you know that if I want something like sick leave, I go directly to the medical director who is a physician, and he approves or most likely disapproves my sick leave request!”
Participants also believed that autonomy in their managers’ jobs is totally absent and they are manipulated by others in the hospital administration. For example, a participant (P-R 4) stated,
“umm...I am pretty sure that many of our nurse managers, including our head nurse here in this department, can not make their own decisions independently. You can go and see yourself!”
It was obvious from the collected data that many participants do not directly blame their managers as they believe that all managers are disempowered and are not in a proper position to lead effectively. One participant (P-L 15) commented on this:
“…you know, sometimes when I think about this, I realize we need to be fair – should we only blame our bosses or there is something else that could be blamed. So, so, what about the top management, do they allow our managers to work independently? If not, how can we only blame nurse managers? We need to think more about this in a more critical way…” .
Another participant (P-R8) added:
“I used to work in the department--- as a charge nurse and believe me, I quit after one year because I felt that I can not help my staff and, in my viewpoint, this is due to a lack of autonomy. For instance, I have to get approval from my supervisors and the nursing director if I need to create a work schedule that fits my staff needs. And could you believe that most of the proposed schedules I sent for approval came back with modifications that, most of the time, upset my staff? So, we can not only blame our head nurses because it is bigger than them.”
5.1.3. Unawareness of a need to Change
Many participants believed that their nurse managers were unaware of the need to change. They believed that their nurse managers avoid and ignore any chance to bring about change because they either do not understand why change is important to improve the quality of nursing care or they believe that their management is sufficient and there is no need to change. One participant (P-L 7) stated,
“Bringing about change scared our managers, they want things to stay still.” This could be, according to another participant (P-R 4), due to maintaining their status within the hospital:“…they want to keep their positions, we know that our managers do what they have been told, thus, 90% of them believe that they are just fine and doing great and there is no need to change.”
Other participants linked this to a lack of opportunities for post-qualifying education. One participant (P-L2) explained this:
“I don’t think, I mean, there is no way for deep change if our nurse managers don’t advance their education.” Another one (P-N 5) added, “Because our nurse managers here are not educated enough for leadership roles, I think, they simply use ignorance to overcome challenges and pretend that everything is fine.”.
A participant (P-R 11) tried to talk to her head nurse to improve their department:
“When I started my work here, the nursing director asked me to work in this department because I have a bachelor’s degree in nursing, and I was the only one holding this qualification in our hospital. So, I tried to somewhat take the initiative, and I talked to my boss who is an assistant nurse technician, which means she is less qualified than me, but anyway, I advised her to make some changes in the way we communicate and deliver care to our patients. You know what she did? She stopped me and told me not to give her a headache and waste her time with this rubbish… She said we’re here to deliver care, not to make changes!”
5.1.4. Poor Communication
With no exception, all participants saw poor communication as the most critical issue. They believe that it can lead to a huge misunderstanding between managers and their employees which eventually leads to underperformance.
One participant (P-G 3) explained this as a huge hindrance:
“In fact, open communication and enhanced teamwork are really important. The nursing job is very hard, so, effective communication between nurse managers and staff nurses is extremely required to make our job more exciting. Unfortunately, there is a huge gap between us. Our nurse managers give us little feedback and some of them do not give feedback at all. And, by the way, if you need to speak to one of them about, you know, things like everyday issues, you need to make an appointment ahead of time.”
Another participant (P-L 7) pointed out that having communication with the managers is mostly not helpful and this might be due to their busy work schedule:
“… I should tell you this, we all agree that good communication is a key leadership attribute, but we should keep in mind that they are already busy with other managerial tasks and nursing shortages make it even worse for our managers to have time to communicate effectively with us; we need to be fair enough here.”
However, some participants disagreed with those who believe that nurse managers have an excuse not to communicate effectively with their staff and think that their managers tend to underestimate the importance of communication. One participant (P-R 4) commented,
“I believe that communication is the key to effective management. But our nurse managers don’t see that. I will give an example, you know I never received useful feedback from my current head nurse, umm… I am not sure if they value my work or not, I just don’t know.” Another participant (P-N 1) added, “There is a problem in their communication skills, and I want them to improve it.”
This seems to have an impact on some staff nurses willing to meet with their supervisors, as one of the participants (P-R 11) stated,
“…could you imagine, I swear to god, you know that sometimes I hate to meet with them because I know that this meeting is going to be useless and just waste of time.”
5.2. Facilitators of Effective Leadership
Staff nurses were also aware of the needed skills that would be helpful for their managers to become effective leaders. This category captures three sub-categories that were developed from the analysis of the participants’ transcripts. During the interviews, most of the participants highlighted three ideas as essential components of effective leadership.
5.2.1. Engage and Listen to your Staff and Seek their Ideas
The participants were willing to see their managers more openly and accept them as co-workers. They also wanted them to utilize their ideas to improve the work environment, which is significant for high-quality healthcare and staff retention .
For instance, a participant (P-N7) commented
“…they should be humble, we, we are in fact working together, so we have common goals, I believe all of us want things to get better…”. Another participant (P-G 6) added:
“This attitude should be changed, and nurse leaders should be more open to others’ thoughts and ideas. I think there is no chance for any one of us to play a part in any kind of development at this hospital because our ideas are ignored by our superiors. Therefore, our nurse managers should listen and allow us to share our ideas with them if they really want to bring about change”.
5.2.2. Recognize Staff Performance
There was a common agreement among the participants around the importance of giving credit to the staff nurses for their everyday hard work. One of the participants (P-L 15) stated, “…with this extreme shortage, I and my colleagues here are expected to work as hard as we can to cover the shortage. But the problem is no recognition is given to us, no thank you, nothing at all; this is really unhealthy.” Another participant (P-N 5) highlighted how she felt when her supervisors recognized her work:
“To be honest with you, when my nurse managers acknowledge my work or my efforts, I feel energized and willing to do more.” She added, “I believe if our nurse managers show some interest in what we do and give us some feedback, that would be very helpful in terms of our performance development and job satisfaction.”
5.2.3. Motivational Strategies
The participants agreed that if their nurse managers were more able to motivate them, they would be able to be creative and deliver a high-quality care. One participant (P-R 4) explained it this way:
“…imagine that we have leaders who, who have a plan or a strategy to keep us motivated. Personally, I don’t think this is difficult, they just need to take care of us and motivate us so we can keep going with our duties…”. This, according to the participants, does not require huge effort; it is doable and could be achieved through a few motivational words. One participant (P-L 15) stated,“…I don’t know but I am pretty sure that good words from my charge nurse will inspire us and make our workplace environment healthier, believe me”.
Another participant (P-G 6) went beyond this and suggested that the hospital administration have a clear incentivized plan to improve the workplace by motivating all staff working in the hospital:
“What about the hospital administration? I believe they should play their role, I don’t see incentives for us, I believe, you know, I believe they, how can I say this, I mean if they really want to make a positive difference they should use the financial incentive, they have the budget we all know that – but they don’t use it…In my viewpoint, this will make a big difference, yes”.
6. RECOMMENDATIONS FOR AN ORGANIZATIONAL CHANGE
In the wake of the analysis of the data, the findings acted as a foundation for constructing a change plan later forwarded to the subjects. This plan was designed to diminish or remove obstacles that block the path of efficacy among nurse managers. The identified facilitators were added to the document in pursuit of this. Suggestions from the nursing staff were, along with clues in the literature, assimilated into the plan, which was evaluated in cooperation with the subjects, who took the view that this reflected their experiences and that it could minimize or overcome the obstacles which had been encountered.
Inadequate education and leadership skills development was identified as an obstacle. This demonstrates the need for nurse managers to pursue their training and adopt certain leadership skills to be able to lead with conviction. The participants here discerned a correlation between the efficacy of nursing managers and the level of nursing care. One way of addressing this would be the acknowledgment by managers of the requirement to continue their training and/or boosting their leadership skills. The study supports this conclusion that managing nurses at a hospital must further their training and skills in these vital areas. Nursing managers are entitled to apply for bursaries and training offered by the Health Ministry in this field. Two methods will be used to realize these objectives. Firstly, the managers in question will be informed of the procedures for applications for the government scholarship program. Secondly, they will be shown proof of the correlation between training and professional standing which can place the person in a position to lead effectively.
The participants claimed that their limited authority and empowerment constituted a significant barrier. Staff nurses believe that nursing managers have no independence at work and that they are not permitted to make their own decisions and, in addition, that this pertains to all areas, including staff holidays, work agendas, and performance assessments. They also suspect that deficiencies in leadership prevent nursing managers from providing support or help to their staff nurses. One possible way to resolve this difficulty would be for managers to develop arbitration and resolution skills, defend the needs of their staff, and boost efficacy within the existing system. Another resolution is training nursing managers in negotiation skills and ways to boost self-assurance. This would also help nursing managers to encourage cooperation and, in turn, cause staff nurses to become better organized and enthused. Another factor that was claimed to be able to expedite matters was engagement and the capacity to listen to colleagues and ask them to contribute. Nursing managers have much to learn in the arena of relating to their junior staff to encourage them and render them more productive.
Unawareness of the need to change constituted another barrier. The study participants claimed that many nursing supervisors at the hospital overestimated their abilities, thought that no problems existed, and viewed change as unnecessary. This might be addressed by fostering an apprehension of urgency and removing the causes of complacency. Kotter (1996) lauded the sense of urgency for its capacity to communicate the requirement for change and to realize the value of prompt action. One way might be to design a plan to provide nursing management with evidence that supports the need for changes, which would create a sense of urgency. One source of such evidence might be the stated opinions and ideas of the staff nurses themselves. Measures in this area might include allowing senior nurses to come into contact with the work environments of more advanced hospitals and giving them room to cooperate and form relationships with successful nursing management personnel from other such facilities inside the Kingdom and beyond. They could then learn to apply this experience to the encouragement of change in their workplaces.
Poor communication posed the final barrier identified by the staff nurses. This encompassed a failure to engage with, heed, or request ideas. The participants hinted that many nurse managers were detached and aloof. They stated that communication between themselves and the managers was usually a struggle. Several solutions were cited by the participants as a means of rendering communication less onerous. Involving staff nurses in, for example, exchanging ideas with their managers and arranging meetings regularly were suggested as methods of boosting productive dialogue. It was also proposed that managers should cultivate more solid professional relationships with their staff nurses. Supervisory nursing personnel could come up with tactics to make possible respectful communication with colleagues. The objectives could be furthered if managers were to formulate a monthly meeting timetable and allow their staff to express themselves and openly proffer their opinions and suggestions. They should also be made aware of the importance of acknowledging staff nurse performance and providing constructive criticism. Furthermore, supervisors should be cognizant of the role played by motivational tactics. The participants agreed that if they were consulted by managers, this would cause them to feel more valued and that a subsequent positive effect on productivity would be observed.
This study was designed to detect staff nurse perceptions of obstacles in the way of, and factors that might encourage, more emphatic leadership in nursing by favoring a qualitative approach. An evaluation of the data demonstrates that staff nurses have a clear perception of the obstacles encountered by supervisors, and they proposed several factors which would expedite improvements in the leadership attributes of nursing managers. The positive and negative mechanisms suggested seemed to match the inferences of the pertinent academic literature. Almalki, et al  emphasized Health Ministry overseas scholarship programs which can be undertaken by nurses at Saudi hospitals, claiming that such schemes are designed to ensure rarefied levels of training and certification for Saudi nurses aspiring to senior positions in the country’s profession. Potential managers at the training hospital must become familiar with such bursaries and how they might apply for and profit from them. This was echoed by the research participants, who hinted that their managers exhibited room for improvement in terms of leadership expertise and aptitude.
Most participants claimed that their supervisors did not wield authority and could not function independently. Consequently, staff nurses were not optimistic about receiving encouragement and support from such personnel. However, this might affect the level of patient care and impede job satisfaction [25, 26]. It should be observed, further, that efforts to assist staff nurses in preserving a robust professional life constitute a crucial element in terms of reining in turnover, boosting the quality of work, and making a positive difference for healthcare in general [27, 28]. How nurses view those facets of leadership which can encourage them were strongly associated with professional areas such as proximity to opportunity, assets, and support, along with formal and informal power . It would also seem that managers can offer support to junior staff and that the employment milieu itself can render how nurses perceive their jobs – either positively or negatively. Several studies have concluded that work environments and administrative processes are crucial factors in terms of how nurses perform at work, and the studies in question demonstrate how vital it is that nurses are kept well-informed, possess appropriate assets, are extensively supported, and can discern prospects for progress and promotion .
An uncongenial work environment can adversely affect staff, the quality of their work, and the extent to which they attain work-related goals. Employers are, therefore, warned to assess the work ambiance constantly and change course if necessary, an approach that is crucial for survival and adjustment. Inventive measures are sine qua non in terms of growth for an employer organization . In addition, supervisors at healthcare organizations must heed the role of necessary adjustments in the arena of boosting levels of patient care at any facility. The research participants claim that management nurses are, in general, ignorant of the importance of change and that they would benefit from observing how ordinary hospitals achieve prominence. They also regard the healthcare system as being in a state of flux and feel part of this state of flux. Most healthcare personnel are prompted to work in this field by a desire to be responsible for an affirmative change and to make a difference . It should, therefore, be brought to the attention of nursing managers that staff nurses are eager to assist in improving the professional milieu and accomplishing change.
Poor communication was extensively cited by subjects as a significant impediment to successful leadership. This conclusion is conducive to other literature which accentuates the crucial nature of clear communication among managers and their staff nurses. It is important, therefore, for the former to foster work environments that promote and encourage such communication and help nurses to make progress in this field . As a further incentive, it should be noted that the level of engagement and work satisfaction has been observed to be correlated with how supervisors communicate and that this can have a knock-on effect on patient care . Supervisors in the nursing profession can nurture communication by rendering themselves accessible and by crafting a system for extensive cooperation. For example, this might include an open-door policy to allow nurses to feel confident when contacting managers whenever they have an issue to discuss, irrespective of the cause . The supervisors can also arrange regular team meetings to enable consistent communication and improve staff interaction .
In conclusion, the participants in this project were disenchanted with the existing management. Staff appreciate management's acknowledgment of their views and suggestions and were confident that this would prompt them to attain greater accomplishments. Furthermore, clear communication is greatly prized and the staff nurses involved in this project anticipated that their managers would recognize the importance of communication through regular consultations. Participants reported that they are eager to enjoy full involvement in decision-making, which would have immediate consequences for their work.
The author was unable to ascertain whether the staff nurse standpoint observed in this study reflected a recent change in leadership or a truthful reflection of the ineptness of the existing leadership. The subjects had strong feelings about the need for their superiors to make use of the scholarships and training programs initiated by the Health Ministry to augment their training and enhance their leadership attributes. In any case, there are serious questions to be asked about the efficacy of leadership in this organization.
This research study shows the need for nurse managers to gain greater awareness of the potential for training to boost their status at the hospital. Following the recommendations molded in the wake of this study, managers should be urged to work toward the relevant goals to overcome obstacles and use the more affirmative aids to progress that have been observed at their workplaces.
The research also revealed that subjects hold the view that their managers should expand their leadership skills, with arbitration and problem-resolution standing as stark examples, with the objective of boosting leadership efficacy. The suggested recommendations might make it possible for managers to lead the way more capably and to ameliorate the overall quality of nursing care at the facility. In addition, supervisors should follow developments in the constantly evolving healthcare industry, working with colleagues, junior and otherwise, to keep up with this relentless change. Finally, managers should listen carefully to staff and ensure their involvement to encourage clear communication and create a congenial work environment.
STRENGTHS AND LIMITATIONS
Qualitative research is a practical way for researchers to explore the perceptions and nature of leadership in practice and to explore what is necessary to improve it. It encourages nurse managers to become knowledge-makers rather than users .
However, it is as in this case small-scale and time-consuming and could not be considered a replacement for quasi-experimental research. It must be regarded as simply a means of examining an ongoing leadership situation in a Saudi Arabia hospital environment where other research paradigms may not be effective . The main disadvantage is the inability to generalize the results as they can only apply to the participants and organization under study. The selection of participants may be problematic as they may be self-selected or exposed to coercion .
Nevertheless, the recommendations in this study were founded on the unique data collected using rigorous research processes. Along with the associated academic literature, it inculcates change and how to overcome the obstacles detected it makes sensible use of any supportive factors which could enhance leadership competence among managers in Saudi’s nursing profession. To ensure the validity of the data, the recommendations were presented to and appraised by, the study subjects. Given the constraints on fieldwork time, nursing managers were not invited to take part in this study, and the findings might, as a result, may be biased in favor of the staff nurses’ perspective.
ETHICS APPROVAL AND CONSENT TO PARTICIPATE
Ethical approval was first sought by the General Directorate of Health Affairs in the north region of Saudi Arabia, which was a mandatory step in applying for ethical approval from the hospital.
HUMAN AND ANIMAL RIGHTS
No animals were used in this research. All human research procedures followed were in accordance with the ethical standards of the committee responsible for human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2013.
CONSENT FOR PUBLICATION
Participants are aware of the publication of this study; thus, informed consent was obtained from all of them.
AVAILABILITY OF DATA AND MATERIALS
The author only used primary data that were collected from the participants for the sake of this study.
This study has been funded by the Deputyship for Research and Innovation, Ministry of Education in Saudi Arabia.
CONFLICTS OF INTEREST
The author declares no conflict of interest, financial or otherwise.
The author expresses his gratitude to the Deputyship for Research and Innovation, Ministry of Education in Saudi Arabia for funding this research work through the project number (IF-2020-NBU_226). Also, to all nurses who participated in this study and thanks to the hospital administration where this study was conducted.
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