1. Background
As the most significant professional group directly engaged with patients, nurses have the potential to improve health services and contribute to innovative policies. To optimally impact health improvement and policy development, nurses require leadership abilities. Traditionally, it was believed that only nurses in management roles needed leadership skills. However, the ability to influence changes at all levels of clinical nursing practice has established new essential prerequisites (1).
Transformational management (TM) focuses on leadership features and behaviors necessary to empower and motivate team members (2). Transformational management has evolved into a desirable leadership style in various fields, including nursing. Extensive research across different domains has underscored the advantages of TM. Within the nursing environment, transformational managers can develop trust and respect among nurses by displaying positive and inspirational behaviors (3).
Transformational management revolves around advancing an organization by engaging and empowering its staff. Transformational leaders and managers aim to foster development by harnessing the abilities of their colleagues and leveraging their unique traits to enhance the team’s performance (1). Haoyan highlights TM as a crucial factor in improving organizational commitment and nurse retention. Haoyan identifies 4 characteristics of transformational leadership (TL): Idealized influence, inspirational motivation, intellectual stimulation, and individual attention. He also underscores the importance of increasing nurses’ organizational commitment to enhance the overall performance of healthcare organizations (4).
Leadership features pertain to behavioral and action patterns that leaders utilize to achieve desired outcomes (5). By comprehending the four distinct characteristics of TL, managers can participate as influential leaders within their organization. Using this management approach, managers and colleagues undergo a “change” to enhance job performance and collectively contribute to augmenting the productivity and success of the organization (6).
Nursing managers and leaders who practice and exhibit TM demonstrate transformational characteristics to varying degrees, contingent upon their experience and context (3). The emergence and development of these characteristics assist managers and leaders in creating trust and credibility among their followers. It is the manager’s responsibility to learn and develop these characteristics and employ them in serving others (7).
Due to the extensive appeal of TM, a considerable volume of literature on this topic has emerged in various fields and industries since the inception of TL about 30 years ago (3). However, most studies on managerial attributes have primarily focused quantitatively on competencies and described characteristics in the context of management learning activities (8-10). However, limited attention has been devoted to debatable aspects, such as the ambiguous interrelationships of transformational characteristics, the clarity of how to attain them, and a more comprehensive depiction of their extensive organizational applications. These aspects necessitate further research to advance knowledge in TL (11).
Notable variations are evident across different countries regarding the performance and responsibilities of nursing managers in hospitals. The multifaceted responsibilities of nursing managers necessitate extensive characteristics and expertise, thereby requiring managers to utilize their capabilities to foster the essential features required for achieving organizational objectives (5). To the best of our knowledge, no qualitative study was found that explained the characteristics of nursing managers in TM.
2. Objectives
It was decided to design this qualitative study to elucidate the characteristics needed in TM through the experiences of nursing managers.
3. Methods
3.1. Study Design and Setting
Qualitative content analysis (QCA), a valuable analytical method, is being increasingly employed by researchers across a diverse range of disciplines, including nursing and applied linguistics. This method enables researchers to interpret the contents of qualitative data subjectively in a structured and contextually relevant manner (12). To enhance the credibility of qualitative content analyses, particular attention is given to the process of abstraction and interpretation (13). In this study, we used conventional content analysis to elucidate the characteristics of nursing managers in TM. In conventional content analysis, coding categories are directly derived from the textual data (14).
3.2. Participants
Within April 2022 to September 2023, a purposive sampling technique was utilized to select nursing managers from educational hospitals in Birjand, Iran, for participation in the study. The nursing managers included head nurses, supervisors, and matrons. They were selected to achieve maximum variety in terms of age, gender, and work experience. To participate in the interview, the participants must have at least 5 years of work experience and 2 years of management experience and agree to participate in the study. Otherwise, they were excluded from the study.
3.3. Data Collection
Face-to-face semi-structured interviews and field notes were used to collect the data. The interviews were conducted in a peaceful and private environment after participants’ working hours and at their workplace (hospital). The average time of the interviews was approximately 50 minutes. At the beginning of each interview, the participant’s demographic information, including age, gender, educational attainment, current organizational position, and managerial work experience, was documented (Table 1). The interviews were initiated with an opening inquiry that requested the participants to expound on their experiences of a typical workday and continued with the question, “What goals do you follow in the organization?”. Further exploratory questions were then presented to obtain a more profound understanding of their experiences. For example, “Please explain more”, and “Please talk about an experience”. Data collection concluded when all data and categories were exhaustively explored, and no new data categories emerged. All interviews were transcribed using MAXQDA 2020. A total of 25 interviews involving 22 participants were conducted.
Table 1.Demographic Characteristics of the Participants
| Participant/Current Position | Gender | Experience (y) | Management Experience (y) | Degree of Education |
|---|---|---|---|---|
| P1. Supervisor | F | 23 | 18 | MSN |
| P2. Head nurse | M | 18 | 7 | BSN |
| P3. Supervisor | F | 17 | 10 | MSN |
| P4. Head nurse | F | 19 | 16 | BSN |
| P5. Head nurse | M | 17 | 15 | BSN |
| P6. Head nurse | F | 20 | 8 | MSN |
| P7. Supervisor | M | 16 | 4 | MSN |
| P8. Hospital matron | M | 24 | 14 | PhD |
| P9. Supervisor | F | 18 | 11 | MSN |
| P10. Head nurse | M | 21 | 19 | BSN |
| P11. Head nurse | F | 15 | 4 | BSN |
| P12. Supervisor | F | 22 | 9 | MSN |
| P13. Head nurse | F | 23 | 16 | MSN |
| P14. Head nurse | M | 18 | 7 | BSN |
| P15. Supervisor | M | 17 | 17 | MSN |
| P16. Head nurse | F | 19 | 15 | BSN |
| P17. Head nurse | M | 25 | 19 | BSN |
| P18. Head nurse | F | 18 | 18 | MSN |
| P19. Hospital matron | F | 19 | 10 | PhD |
| P20. Supervisor | M | 13 | 5 | MSN |
| P21. Hospital matron | M | 11 | 3 | MSN |
| P22. Supervisor | M | 9 | 6 | MSN |
Abbreviations: F, female; M, male; BSN, bachelor of science in nursing; MSN, master of science in nursing; PhD, doctor of philosophy.
3.4. Data Analysis
The current study employed conventional QCA management to describe and analyze the data. This systematic methodology is commonly utilized for analyzing qualitative data and has evolved from its original straightforward form to more interpretive management. It is worth noting that all analytical procedures, regardless of their management, entail varying degrees of abstraction and interpretation in their description (13).
Following Graneheim and Lundman’s established guidelines for conventional content analysis, a five-stage procedure was utilized to analyze the conducted interviews. Initially, the interviews were transcribed from their recorded format. Subsequently, the transcripts underwent thorough scrutiny through repeated listening to discern meaningful segments. Thirdly, the identified meaning units were the foundation for generating initial codes. Fourthly, similar codes were grouped based on their conceptual resemblance. Lastly, the process, as mentioned above, was systematically applied to all units of analysis until distinct categories and themes were established (13, 15).
3.5. Trustworthiness
To guarantee the trustworthiness of the data, this study utilized the Kyngas et al. criteria (16), which encompassed five aspects: Credibility, dependability, conformability, authenticity, and transferability. To ensure credibility, the researchers devoted approximately nine months to collecting data and ensuring the inclusion of participants from various age groups and genders. The study’s dependability was ensured through a rigorous process of subjecting the interview process, coding, and analysis to peer checking and external expert review. Conformability was verified through long-term engagement, multiple readings of interviews, and members’ checks, in addition to the verification of codes by participants.
For the authenticity of the data, systematic employment of citations was executed throughout the text, wherein each identified category included at least one pertinent citation. In addition, diverse quotations from distinct participants were incorporated. To identify participants, their current position in the organization was used. Furthermore, to enhance transferability, the study engaged in maximum diversity sampling and member checks. It provided a comprehensive breakdown of participant features and the study context, allowing readers to evaluate the applicability of the findings in their respective environments. Finally, the study’s results were presented to two nursing managers (supervisor and hospital matron) outside the study, who attested that the results of the present study are in close alignment with their experiences.
3.6. Ethical Considerations
This study was registered with the Ethics and Research Committee of Birjand University of Medical Sciences, Birjand, Iran (IR.BUMS.REC.1401.177).
4. Results
In this study, 11 nursing managers were male (50%). Most of them had a master’s degree (n = 11, 50%). In addition, 11 participants (50%) were supervisors. The average professional experience of the participants was about 18 years, with 11 years of management experience.
After analyzing the data, 423 open codes, seven subcategories, and three categories were created. The 3 main categories include (1) the creation of a transformational culture; (2) an ethics-oriented approach; and (3) institutionalization of the changes (Box 1).
Box 1.Categories and Subcategories of Study
| Categories and Subcategories |
|---|
| Creation of a transformational culture |
| Transformational attitude and thinking |
| A different view of the organization’s capital |
| Ethics-oriented approach |
| Modeling moral cases |
| Improvement of clinical ethics of nursing |
| Institutionalization of the changes |
| Synergy of interaction - participation |
| Supportive atmosphere |
| Emphasis on the permanence of changes |
4.1. Creation of a Transformational Culture
Nursing managers believe that change and transformation in work environments are necessary, and to create positive changes and continuous improvement, an organizational culture should be created following that transformation. In the characteristic of transformational culture creation, managers consider change and transformation as a forward and growing process, and instead of resisting change, they use it for development and transformation. In the present study, this category includes two subcategories of transformational attitude and thinking and different views on organizational capital.
4.1.1. Transformational Attitude and Thinking
Nursing managers with a transformational attitude and thinking look at nursing issues and challenges with a newer attitude and provide innovative and forward-looking solutions for the nursing profession. This type of thinking requires extensive interaction with the treatment team. Because new ideas and solutions are formed based on different information and experiences of staff in different situations, the best result can be achieved by interaction and cooperation among the members of the treatment team.
“During management meetings and visits, I always talk about the change in our thinking and ask all personnel to look at issues with different and fresh thinking. I tell the staff that they also need to have the perspective that we are here not only to care for the patient but also to make a difference and progress (head nurse).”
“I am always thinking about improvement and progress in the organization. I also use the thoughts and ideas of staff to improve processes and care. I always review in my mind how I can improve in providing services (hospital matron).”
4.1.2. Different Views on Organizational Capital
Different views on organizational capital mean seeing organizational capital with new and innovative management. Instead of being limited to the usual and common views about organizational capital (financial resources, technical equipment, human resources, and substructure), this new view emphasizes the less common or intangible aspects of these capitals. Most nursing managers acknowledge that nursing staff are the main capital of the organization and refer to them as the principal owners of the processes. They believe that, with this view, nurses feel that they have an influential role in the realization of organizational goals.
“Here, I have valued my personnel. I tried to win their trust ... I used their suggestions to solve problems. When I do this, and the personnel see that their opinions are valuable, they are also motivated to cooperate (head nurse).”
“My most important capital is human resources. I value personnel and other capital of the organization from the lowest to the highest level and rely on the abilities of each one of them (head nurse).”
4.2. Ethics-Oriented Approach
An ethics-oriented approach means paying attention to moral values and principles in the nursing community, which are essential factors in forming ethical behaviors and decisions in personnel. Nursing managers who adhere to ethical principles show ethical values in their behaviors and decisions. The two subcategories of modeling moral cases and improving clinical ethics create the characteristics of an ethics-oriented approach in the study.
4.2.1. Modeling Moral Cases
Nursing managers believe that moral and good behavior should be modeled and repeated in subsequent behaviors. Modeling moral behaviors is one of the learning methods in the nursing environment.
“In the work environment, each of us has weaknesses and strengths. Let’s work on our weaknesses; let us learn from people who have experience and have good morals with patients and companions and patients are satisfied with them (hospital matron).”
“We should learn from the moral situations that arise ... We should learn from the experiences of people who have good relationships and are praised by patients. Let’s observe their behavior and learn from them (head nurse).”
4.2.2. Improvement of Clinical Ethics of Nursing
Clinical ethics means ethical values, principles, and behaviors in the clinical environment. The improvement of clinical ethics means increasing awareness and sustainability about ethical values and principles that lead to better ethical practice in the nursing environment.
“Our staff are weak in ethics. The ethics workshop is held during the service so that the staff can better understand the issues of clinical ethics. It is repeated so that they can use their moral intelligence in interactions, behaviors, and practice effectively and that morality becomes stronger at the nursing practice (supervisor).”
4.3. Institutionalization of Changes
Nursing managers believe that making changes in nursing plays an essential role in the process of improvement and transformation of nursing. Institutionalizing the changes in nursing means reducing the resistance, stabilizing the changes in the organization, and then guiding and improving the values and moral principles and the productivity of the health services. In this category, there are subcategories of synergy of interaction-participation, supportive atmosphere, and emphasis on the permanence of changes.
4.3.1. Synergy of Interaction-Participation
The synergy of interaction-participation of the personnel and manager means creating practical cooperation between managers and personnel, which leads to the improvement of the quality of care, the professional growth and development of personnel, and the achievement of organizational goals. When managers and nurses participate in the organization with active cooperation and interaction, an atmosphere of participation is formed in the organization and can give direction to changes.
“I participate in the procedures, and I have a good relationship with the personnel there. For example, I go and start the dressing, and they also come. I tried to constantly cooperate with my colleagues, the nurses, doctors, and other staff. When they see this sense of cooperation in the department, they are more involved in the work (supervisor).”
“At the clinic, on my first day, I observed colleagues informing patients that visits were no longer available. In response, I initiated direct interaction with patients, assuring them that I would endeavor to arrange a doctor’s visit for them. This behavior swiftly became a model for colleagues, resulting in an increased level of their active and spontaneous participation in various processes (supervisor).”
4.3.2. Supportive Atmosphere
In a supportive atmosphere, treatment team members support and encourage each other. Establishing a supportive atmosphere in the workplace helps create favorable environmental conditions to support changes and improve quality.
“Now in our country, if you pay attention, the changes, if any, become less in the first and second year, why? Because there is no support. If there is no support from the staff and superior managers, success in the changes will certainly not be achieved, so I try to get the support of different people so that everyone supports the changes (head nurse).”
4.3.3. Emphasis on the Permanence of Changes
The permanence of the changes has been mentioned and emphasized in the interviews. The permanence of change means the acceptance of changes by stakeholders and the reduction of resistance to changes, which can help institutionalize changes in the organization. In this case, nursing managers consider it essential to involve personnel and explain and clarify the change process.
“If I want to make a change, I am in no rush; some changes may take a month, and I like the change that is made to permanence for years. In the Emam Reza hospital (South Khorasan, Iran), if you remember, we changed some processes, such as the informatics system, and it is still standing. Now, in the Razi hospital, we changed the processes again and integrated the old and new systems (hospital matron).”
“We apply the changes gently and gradually. In this way, the resistance is reduced ... The emphasis is on permanent changes rather than immediate and unplanned changes. In this regard, we gain the support and trust of the personnel; the changes are designed and implemented with the help of the personnel in the organization (head nurse).”
5. Discussion
About 40 years have passed since Bass and Avolio introduced TL characteristics. They introduced the main TL characteristics, including ideal influence, intellectual stimulation, inspirational motivation, and individual considerations (17). After that, other studies were performed on the structure of TL characteristics, and other features have been added to these items. For example, Allison et al. and Lashari and Rana conducted studies on the structure of transformational characteristics, to which they added another dimension named “risk acceptance” (18, 19). Edirisooriya, Allison et al., and Magasi also proposed the characteristic of “change from self to collective interest” (19-21). Therefore, the transformational characteristics are not fixed and are changing.
In this study, we explained the characteristics of nursing managers in TM. The creation of a transformational culture, an ethics-oriented approach, and institutionalization of changes are the three characteristics of nursing managers identified in this study. Najafi et al., in a qualitative study about the characteristics of effective leadership, reached the following results: “Professional characteristics” with 2 subcategories (creating motivation and support), “communication characteristics” with 2 subcategories (the ability to establish appropriate interpersonal communication and empathy in the correct manner), “scientific characteristics” with two subcategories (scientific model and practicality and situation management), and “ethical characteristics” with two subcategories (responsibility and observance of justice) (22).
In the present study, creating a transformational culture is presented with two subcategories of transformational attitude and thinking and a different view of organizational capital. Creating a transformational culture considers change and evolution in work environments as necessary. It recommends that to create positive change and continuous improvement, an organizational culture that fits it must first be created. The nursing managers of the present study believe that instead of resisting change and transformation, it should be used for development. By raising this characteristic in nursing, we assume that nursing managers and health organizations can create positive changes and use them for their development.
In their study, Doody and Doody emphasized the vital role of future nursing leaders in recognizing and valuing employee participation in work environments (23). Grealish and Henderson found that investing in staff capacity can improve the culture of learning in care settings and benefit nursing students (24). These findings are consistent with the characteristics of a different view of the organization’s capital in the present study.
In an integrated review, Lechasseur et al. state that even if ethical competence represents a necessary characteristic in nursing practice, there is no consensus in the literature regarding its definition. He introduces moral sensitivity, moral knowledge, moral reflection, moral decision-making, moral action, and moral behavior as the most widely used terms that are used concerning moral competence in nursing (25). Vanlaere and Gastmans believes that to achieve ethics, nurses need to think critically about their practices, which can be facilitated through ethics education that integrates a sound practical approach with an ethical approach and virtues (26). In the category of ethics-oriented approach, we discussed modeling ethical cases and promoting clinical ethics, which is consistent with moral action, moral behavior, and teaching ethical values in the 2 above-mentioned studies.
In the present study, the institutionalization of changes was achieved with three items: Synergy of interaction-participation, supportive atmosphere, and emphasis on the permanence of changes. However, Kodama and Fukahori identified four characteristics of nursing managers, including “having a micro and macro view”, “respecting external beliefs and standards”, “being proactive”, and “empathy with nursing staff” as essential factors in promoting change in their departments (27).
Maassen et al., in a Delphi study, emphasized the importance of creating a positive work environment in healthcare institutions. According to the aforementioned study, fostering a positive work environment requires creating an encouraging, healthy, and motivating atmosphere, which fosters mutual respect and trust among employees, receives adequate management support, promotes a supportive organizational climate, enables open communication, instills a sense of worth, shows innovation and readiness for change, and ensures workplace safety (28). The aforementioned study has similarities to the present study in the dimensions of encouraging work environment and gaining support in the characteristic of institutionalization of the changes and a different view of the organization’s capital in the characteristic of creating a transformational culture.
5.1. Conclusions
It seems necessary to recognize and use the characteristics needed for TM in nursing. By applying the characteristics required in TM, nursing managers can take steps toward valuable changes and transformations, and by culturizing valuable changes in nursing, they can bring about transformations in their management, nurses, and the nursing profession, improving health services, patient outcomes, and organization.
5.2. Limitations
In this study, we referred to experienced nursing managers who might show a higher age of experience and management (mean years of experience: About 18 years, the mean years of management: About 11 years). Another limitation of this study was the lack of sufficient motivation for the interview among some participants.
