The challenges that head nurses confront on financial management today: A qualitative study

International Journal of Nursing Sciences 4 (2017) 122e127 Contents lists available at ScienceDirect H O S T E D BY International Journal of Nursing Sciences journal homepage: http://www.elsevier.com/journals/international-journal-ofnursing-sciences/2352-0132 The challenges that head nurses confront on financial management today: A qualitative study Yang Bai, RN, BA, Can Gu, RN, PhD, Qirong Chen, RN, BA, Jinnan Xiao, RN,

The challenges that head nurses confront on financial management
today: A qualitative study
Yang Bai,RN, BA, Can Gu,RN, PhD, Qirong Chen,RN, BA, Jinnan Xiao,RN, BA,
Dan Liu,RN, MSc *
, Siyuan Tang,PhD **
Xiang Ya School of nursing,Central South University,PR China
a r t i c l e i n f o
Article history:
Received 8 October 2016
Accepted 13 March 2017
Available online 31 March 2017
Keywords:
Financial management
Nursing administration
Head nurse
Nursing staff
Hospital economics/distribution
Challenges
Qualitative research
a b s t r a c t
Aim: To explore challenges thatChinese head nurses confronton financial managementfrom the
perspective of different levels of nursing and non-nursing managers and to provide contemporary nurse
managers with suitable supports.
Methods:Eighteen nursing leaders in different levels were divided into two groups: Junior Leadership
Group (head nurses) and Senior Leadership Group (nurse coordinator,nurse executive,and vice-
president of the hospital).All the subjects were invited to participate in a semi-structured interview.
The interviews were audio-taped and transcribed,and data were analyzed using a comparative content
approach.
Results:The four following challenges that head nurses confront on financial management practice were
identified from the research findings: 1) lack of intrinsic motivation; 2) insufficient training and edu-
cation on financial management and nursing economics; 3) desires for cross-uniting communication and
cooperation; 4) insufficient reference managerial tool.
Conclusions:The confusion confronted by head nurses in Changsha include three aspects: managerial
roles, managerialtraining, and managerial tools. Cooperative managementmodel, evidence-based
management training,and data-driven tools will contribute to improving the financialmanagement
capacity of nurse managers.
© 2017 Chinese Nursing Association. Production and hosting by Elsevier B.V. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
A new round of health care reform in China was released by the
Chinese governmentin 2009 [1]. The goal of this reform is to
establish a system that provides safe,effective,convenient,and
affordable services that can satisfy the basic health care needs of
the 1.3 billion people [2,3]. Public hospitals in China are expanding
clinical services and improving delivery efficiency while controlling
costs to keep pace with modernized health care delivery system [4].
Nurses are often seen as one of the largest cost components of any
health care system because of their large numbers compared with
other staff [5].According to Shi et al.[6], nursing activity funding
accounts for approximately one-third ofthe total budget of the
hospital.Head nurses,who are the leaders of each nursing unit,
control labor costs, which are the largest part of the labor budget of a
hospital.Therefore,as middle managers of nurses,the head nurse
plays a defining role in achieving cost savings and contributing to the
financial stability of hospitals [7]. Consequently, hospital nurses are
being increasingly confronted with business administration tasks.
Currently, in the top three general public hospitals (all hospitals
are ranked as 1,2, 3B, and 3A progressively),relevant institutions
are going to conduct physician multi-site profession pilot policy
(physicians work on medical treatment activities in more than two
medical establishments) because of insufficiency in general prac-
titioners and basic medical institution staff [8]. With the advent of
doctor multi-sited license, the reform of hospital cost accounting is
imperative [9]. Head nurses, as active or key team members
involved to deal with financial management, are being increasingly
confronted with business administration tasks [10].
In the 1990s,Flarey [11] and Sullivan [12] forecasted that the
role and responsibility of the nurse manager will be expanded to
confront future developments in nursing and management prac-
tice.Financial management and business skills are gradually seen
* Corresponding author.Xiang Ya Nursing School, Central South University,
No.172,Tong Zi Po Road,Changsha 410013,PR China.
** Corresponding author.Xiang Ya Nursing School, Central South University,
No.172,Tong Zi Po Road,Changsha 410013,PR China.
E-mail addresses: [e-mail] (D.Liu), [e-mail] (S.Tang).
Peer review under responsibility of Chinese Nursing Association.
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International Journal of Nursing Sciences
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n u r s i n g - s c i e n c e s / 2 3 5 2 - 0 1 3 2
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creativecommons.org/licenses/by-nc-nd/4.0/).
International Journal of Nursing Sciences 4 (2017) 122e127

as crucial competencies that are necessary to be a successful leader
[13e15]. Fennimore et al. [16] reported that frontline managers are
often the least prepared to handle these challenges. A considerable
amount of research emerged in the early 21st century in the United
States,focusing on the nursing financial management component
and relevant supports,such as leadership development programs
and information system [17].
However,a few studies focused on the perceptions concerning
the financial managementof the nurse manager population in
China. Yuan [18] summarized the roles of the nurse manager in cost
accounting ranging from resource manager, charge supervisor, cost
inspector, to bonuses member. Zhao [19] reported that a number of
nurse managers in China stillview financialmanagement as the
work of the financial management office.Data,research evidence,
and actions are scarce to close the gap with regard to Chinese nurse
managers confronted by financial management work; hence, more
information is necessary.
In this study,the qualitative methodology is chosen to obtain
data from two separate groups,which could provide a compre-
hensive examination of the issue in a unique cultural context.The
aim of this study is to explore the challenges that Chinese head
nurses deal with today and provide potential solutions to develop
financial competencies for them.The findings of this study are
expected to provide evidence for data-driven,evidence-based
management tools and training programs in the future.
1. Method
1.1.Research design
The study was a part of a large research project, which collected
qualitative and quantitative data on financial management among
the nursing and non-nursing administrators who are working in
centralsouth China.The financial management practice of front-
line head nurses was one of the themes of this large research
project. The semi-structured individualinterview was used to
collect qualitative data.
In Chinese medical system,nursing administrators are divided
into three levels: head nurse,nurse coordinator,and nurse execu-
tive. Head nurses are the direct managers of units and nursing staff.
Nurse coordinators are responsible for several departments, such as
the management of surgical departments system. Nurse executives
manage the entire nursing work in the hospital.
Participants of the individual interviews were divided into two
groups: junior leadership group (J group), which comprised re-
spondentswho were head nurses; senior leadership group (S
group),which included respondents with the following job titles:
nurse coordinator,nurse executive,and vice-president of the hos-
pital. The interviews of the two groups were conducted to obtain
the perceptions offinancial management from different nursing
administration levels.
1.2. Participants
Participants were recruited using purposive sampling,and 18
participants from the top three hospitals of Changsha were iden-
tified. The junior leadership group comprised 11 head nurses,
numbered from 1 to 11.Meanwhile,the senior leadership group
included 3 nurse coordinators,2 nurse executives,and 2 vice
presidents,which were numbered from 12 to 18.The participants
were all female with age ranging from 36 to 56. The mean age of the
junior group is 42, and the mean age of the senior group is 49. The
work time in a leadership position varied from 3 years to 20 years,
with a mean 7 years for the J group and 11 years for the S group. The
professional education time of the informants varied from 3 years
to 10 years,with a mean of 4.8 years for junior leaders and 7.6 for
senior leaders.
1.3. Data collection
Data were collected by an in-depth interview in a two-month
period from December 2015 to January 2016.
The participants of the two groups were individually inter-
viewed in the office of their workplace, wherein confidentiality and
privacy were ensured,with an alternating cross order (e.g.,one
participant from the J group, then one participant from the S group,
then one participant from the J group). The interviews lasted
30e60 min for the J group and 20e30 min for the S group.Two
different semi-structured interview schedules were employed to
separately collect data from the Jand S groups (see Table 1 for
examples of the questions used).During the interview, the in-
vestigators adjusted the questions related to the responses of the
participants and the information provided by the other group. The
interviews were all audio-taped and immediately transcribed.
1.4. Data analysis
Data analysis immediately commenced after the first interview
and continuously proceeded with data collection using conven-
tional content analysis [20].Analytic process (see Fig. 1) is repre-
sented as three main phases: preparation, organization, and
reporting [21].
In the process of coding,the first author and another investi-
gator independently read and reread the transcriptions to conduct
open coding and compared them to come to an agreement of codes.
Chinese research literature on financial management are limited;
therefore,we followed the inductive approach to develop the cat-
egories to describe the phenomenon in a conceptualform [22].
Then, the various codes of the junior nursing leadership group and
senior leadership group were compared,and the differences and
similarities (concepts) between the two groups were analyzed and
sorted into four challenges themes.All the authors participated in
this process and discussed the development of the categories and
sub-categories.After several modifications,the categories were
finally mapped on the conceptual system.
1.5. Ethical considerations
Each participant was provided with an information sheet that
explained the objectives and procedures ofthis study. Written
consents were obtained from all participants. They were informed
that participating in this study was voluntary and refusing to
participate would have no impact on their work and daily life. The
anonymity of the participants was maintained by removing all
names from our record. All data were locked and only accessed by
the researchers.
2. Results
The present report focused on Jand S group perceptions on
working experiences,viewpoint, and attitude regarding financial
managementwork, and they confronted four challenges: in-
sufficiencies in intrinsic motivation,training and education,coop-
eration and communication,and reference managerial tool.
2.1.Challenge one: lack of intrinsic motivation
2.1.1.Junior leadership group
Most of the participants in the J group perceived that financial
managementpractice is of great importance in managing a
Y. Bai et al./ International Journal of Nursing Sciences 4 (2017) 122e127 123

department; however, the feeling always comes from the hospital.
When talking regarding financial management, they tend to define
themselves as performers under the leadership of the department
head:
“Hospitals always attach great importance to this part. Economics
is always a focus of attention.” (05, junior member)
“I do think financial management is very important for department
development.” (03,junior member)
Table 1
Example questions of individual interviews.
Example interview questions for junior nursing leaders Example interview questions for senior nursing and non-nursing
leaders
*How do you think about financial management competencies of nurse managers? *How do you and our hospital about economic administration ability of
nurse managers?
*What contents associated with financial management are involved in your
work?(material management/utility bills/human resource/nursing accident control)
*If nurse manager has a high level ability to manage economic,what
benefit can this bring?
*Do you have some ways to increase revenue/reduce cost? *What kinds of supports have our hospital provided to nurse managers
in economic administration?
*How do you think about your ability to manage economic in your department? *How do you think the level of nursing economic administration ability
in you your hospital? Do you have some evaluation system to evaluate
the ability of nurse managers?
*How do you think about staff nurses' ability to manage economic in your department? *Is there any need to add Nursing Economics course in the study career
of nurses? If necessary,which stage is appropriate? (Non-university
tertiary/undergraduate course/postgraduate course/continue education
course)
*Do you need some help/study in the process of nursing economic administration? If
you have chance learn about the course of nursing economics, when do you think is
appropriate? (Non-University tertiary/undergraduate course/postgraduate course/
continue education course)
*Do you think there it is necessary to set up a full-time stuff to manage/
assist economic administration?
Fig. 1. Analysis process.
Y. Bai et al./ International Journal of Nursing Sciences 4 (2017) 122e127124

“In the financial management aspect,I am mainly responsible for
cost management,including consumable items plan making and
managing, water and electricity bills, and equipment maintenance.
I think I play the performer role in the department managerial
group.” (06, junior member)
“The management authority of the head nurse is limited.I need to
do these details management to avoid wasting under the depart-
ment head leadership.” (08,junior member)
While a few provided different voices,such as:
“Financialmanagementis not that importantfor us; maybe
management by the full-time staff is more appropriate.” (04, junior
member)
2.1.2.Senior leadership group
All senior nursing leaders argued that financial management is
one of the key competencies to be a successfulnursing leader.
Moreover,they defined the role of the head nurse in department
financial management work as follows:
“Head nurse isa key decision-making team member in the
department, and financial management is one of the essential skills
for them.” (12,senior member)
“If a nurse manager can do an excellent job of financial manage-
ment, not only can they provide economic benefits, such as increase
the salary ofthe staffbut they can also make indirect adminis-
tration benefits, such as improving the initiative and positivity.” (17,
senior member)
2.2. Challenge two: insufficient training and education on financial
management and nursing economics
2.2.1.Junior leadership group
Participants in the J group argued that nearly no chance exists
for them to attend training or education programs on financial
management. For example, two participants mentioned:
“We already have many clinicalnursing managementtraining;
however,no existing courses focused on financialmanagement.”
(09,junior member)
“I think I need the further training on financial. Actually, when I do
some nursing research,I do not know from whom I could obtain a
few advices on financial indicators.” (11, junior member)
2.2.2.Senior leadership group
One respondent offered the reason why hospitals only provided
one-time lectures or training administered by the finance section:
“The hospital can only provide poorly designed training because of
the limitation of time and expenditure.” (13,senior member)
A few participants explained why the requirements ofhead
nurses cannot be satisfied.A shortage ofteachers who have the
interdisciplinary background in nursing and economics exists.In
addition,a few of them suggested that nursing economics courses
should be added into degree programs.
“Nursing schools should add related courses.Through these cour-
ses,nursing staff can cultivate their cost management conscious-
ness and ability.” (18,senior member)
2.3. Challenge three: desires for cross-uniting communication and
cooperation
2.3.1.Junior leadership group
Most of the participants had no idea regarding their financial
management performance because communication among parallel
clinical departments is deficient:
“I do not know whether I did well or not on financial management
work because I do not know the performance of other head nurse
We lack communication among parallelclinicaldepartments for
exchanging experience on financialmanagement.”(10, junior
member)
Head nurses expressed their desires for cross-unity cooperation
and data support.
“Advanced managementshould be positive.For example,the
property sector takes responsibility for electricity bills and knows
the electricity consumption of different departments in the hospit
There are three gynecology departments in our hospital.If the
property sector could provide the electricity bills and show differ-
ences ofour three departments,then finding the problems and
avoiding wasting time are beneficial for us.” (02, junior member)
“The positive communication between the ward and the assistant
management department can help the administrator take advan-
tage of the original data and effectively manage the cost.” (11,ju-
nior member)
“Related authorities who are in charge of the data of all departme
should provide the results of the data analysis.For example,if the
equipmentsection can provide the data regarding differentde-
partments in using machines,then we can determine whether we
still have a few problems on maintenance ofequipment,which
would invisibly increase our costs.” (03, junior member)
2.3.2.Senior leadership group
Currently,we have not developed an assessmentsystem of
nursing financialmanagement competencies.Also, one executive
nurse supplied additional information as follows:
“Although we have notformulated the evaluation standard on
financialmanagement competencies ofhead nurses,the perfor-
mance ofthe department can actually reflect the financialman-
agement competencies of nurse managers.” (16,senior member)
In addition, a few punishment indicators can be the guidance of
the financial management practice.
“We have a few punishment indicators regarding financialman-
agement.For example,the surgical consumable is one of these in-
dicators. If consumables were excessively used in the operation o
patient,then this means over-treatment,and we willhave corre-
sponding punishments on this department.” (13, senior member)
2.4. Challenge four: insufficient reference managerial tool
2.4.1.Junior leadership group
In addition,several participants were aware of their need of a
few assistant tools,such as reference books and finance applica-
tions in their study and clinical management work.For example,
when asked regarding how the nurse manager promotes their
competency of financial management, one respondent argued that
Y. Bai et al./ International Journal of Nursing Sciences 4 (2017) 122e127 125

when she was appointed as head nurse,she felt stranded and
concluded:
“I cannot find relevant reading materialsregarding financial
management when I cannot solve a few problems.I can only have
some communication with theother nurse leaderswho had
experience of that problem.” (01,junior member)
3. Discussion
In this study, we finally selected four challenges through the
contrast between the perceptions of two groups concerning
financial management.The main challenges were concluded as
follows: 1) lack of intrinsic motivation; 2) insufficient training and
education on financialmanagementand nursing economics;3)
desires for cross-uniting communication and cooperation; 4)
insufficient reference managerial tool.
Intrinsic motivation significantly affects job performance [23].
Participants in J group were more inclined to describe financial
management as an essentialcomponent in department manage-
ment. This kind of value is originated from outside forces.For
example,“hospitals highly value financial management” or “under
the leadership of the department head.” They define themselves as
performers in finishing these financial tasks, lacking intrinsic
motivation that can positively inspire head nurses to make progress.
By contrast,financialmanagement was emphasized as a very
important component in leadership development of head nurses in
the S group. In the entire department, the head nurse is a key factor
in making organizational decisions that balance quality patient care
and sound financial management [24]. In addition, senior leaders in
the S group argued that head nurses act as the decision maker in
the financial management team work, thereby motivating the head
nurse to pursue self-improvement and make a change on their own
initiative.
This difference of the role definition showed different concerns
of different leadership levels.Moreover,this difference is also a
good explanation why a few different voices exist in the J group,
stating that financialmanagement work is not that important to
head nurses. Even financial management is of great importance to
the department because administration authority is limited and
their sense of job control related to finance is weak.Head nurses
did not correspond their financial management competency with
the financial condition of the department; thus,they were unable
to positively seek personaldevelopmentsupport. The role of a
decision maker can increase the inherent capacity of the head nurse
to critically think and make autonomous and informed decisions
regarding the improvement oftheir financial management com-
petency.Hospital and department leaders should use a variety of
empowerment strategies that are important to the intrinsic moti-
vation of head nurses and potentially to the quality offinancial
management work.
Chinese nurse managers are always selected from front-line
staff nurse based on their clinical expertise [25].The head nurses
that we interviewed argued that they did not receive related
finance courses before transitioning into their first leadership roles.
Previous studies on the approach for developing nurse manage-
ment had described the same resultin which nurse managers
frequently felt less prepared and unequipped to manage the busi-
ness activities than the clinical activities [26].
Participants in the J group showed a strong desire to acquire a
few in-service training on financialmanagement.However,one
study [27] (n ¼ 424) assessing the requirements of nurse managers
for managerialtraining found that the demand for health eco-
nomics is relatively small (9.8%).The completely different results
showed that even head nurses showed a strong will to participate
in financial managementtraining. When faced with diverse
training,their will appeared slightly weak.This phenomenon also
reflected that financialmanagement skills have not been consid-
ered as essentialcomponents in leadership development among
head nurses.The design of training and degree courses should be
more incentive.
In the 2000s, severalresearchers have asserted the necessity
and possibility of combining nursing economics into Chinese
traditional undergraduate and graduate courses [28,29].However,
only a few colleges are currently offering nursing economics cour-
ses in their degree programs.Preparing nurses to influence the
financial performance of organizations on a daily basis is essential
[30] because financial management not only promotes department
benefit but also effectively reduces medical cost and alleviates the
shortage of medicalresources.Good training and degree courses
not only help head nurses gain insight on using leadership skills to
manage budgets,formulate business plans,and write grant pro-
posals but also help in ensuring the delivery of quality and
affordable health care.
Our findings showed that head nurses were not satisfied with
the current communication and cooperation of teamwork in hos-
pital institutions.A few felt the need to communicate more with
parallel nursing departments.Hospital institutions should provide
departments with a platform to study the success ofoptimizing
resources across units and promote experience communication
among parallel nursing departments.A few highlighted the
necessary data cooperation.Nursing must be responsible for and
manage its own financial performance,thus making the relation-
ship between nursing and finance to be independent but collabo-
rative [31]. Head nurses argued that they want to know their water
and electricity bills, usage of equipment, cost, and benefit
compared with other nursing departments. If finance departments,
property sections,facility sections,and other administration as-
sistant departments provide horizontal and longitudinal compari-
son feedback data,then this can help head nurses develop a
broader view of financial management.We should provide the
necessary analyticalsupport to nursing to sustain data-driven
discussions by building strong relationships between the nursing
and finance departments to promote data cooperation.Nursing
staffs must learn the language of finance and be seen as credible
financial managers to achieve this.Finance education on key con-
cepts related to the delivery of care is also a necessity.
A few head nurses stated their needs regarding information
system or APPs for supporting financial management work.Infor-
mation technology in health care can have a strong impact on the
process and the quality of health outcomes and can assist hospital
managers in financialmanagement,resource allocation,and ac-
tivity planning [32,33]. These supportive managerial tools can offer
opportunities to develop big data set and support big data analytics,
evaluating the effectiveness of nursing services for cost and quality.
4. Conclusion
Head nurses in a pivotal position contribute to the financial
management work.Qualitative description of their attitude,prac-
tice, and evaluation provided a picture of the current demands and
challenges ofnursing financialmanagement.The results of this
study will serve as a basis for further K-A-P research regarding the
financial management of head nurses.
Funding
This research was funded by CMB Seed Grand.Grant number:
740010006.
Y. Bai et al./ International Journal of Nursing Sciences 4 (2017) 122e127126

Conflict of interest
No conflicts of interest had been declared by authors.
Author contributions
Study design: BY,CQR,GC,TSY,LD.
Data collection: BY,CQR,XJN, LD.
Data analysis: BY,CQR.
Study supervision: TSY,LD.
Manuscript writing: BY,GC,CQR,XJN, LD, TSY.
Critical revisions for important intellectual content: GC,LD.
Appendix A. Supplementary data
Supplementary data related to this article can be found at http://
dx.doi.org/10.1016/j.ijnss.2017.03.007.
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