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

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 that Chinese head nurses confront on financial management from 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, managerial training, and managerial tools. Cooperative management model, evidence-based
management training, and data-driven tools will contribute to improving the financial management
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 government in 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 of the 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. H O S T E D BY Contents lists available at ScienceDirect
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
http://dx.doi.org/10.1016/j.ijnss.2017.03.007
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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 management of 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 still view financial management 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
central south China. The financial management practice of front-
line head nurses was one of the themes of this large research
project. The semi-structured individual interview 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-
spondents who 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 of financial 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 J and 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 conceptual form [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 of this 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 J and S group perceptions on
working experiences, viewpoint, and attitude regarding financial
management work, 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
management practice 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